Antepartum Hemorrhage Lecture Petrenko N., MD, PhD

Introduction Definition: Vaginal bleeding which occurs after fetal viability. Incidence: 2 – 6 %.

ANTEPARTUM HEMORRHAGE Per vagina blood loss after 20 weeks’ gestation. Complicates close to 4% of all pregnancies and is a MEDICAL EMERGENCY! Is one of the leading causes of antepartum hospitalization, maternal morbidity, and operative intervention. 3

Causes Placental: Abruptio placenta. Placenta previa. Non-placental: Vasa previa. Bloody show. Trauma. Uterine rupture. Cervicitis. Carcinoma. Idiopathic.

Abruptio Placenta

Introduction Definition: It is the separation of the placenta from its site of implantation before delivery of the fetus. Incidence: 1 in 200 deliveries.

Risk Factors Increased age & parity. Hypertensive disorders. Preterm ruptured membranes. Multiple gestation. Polyhydramnios. Smoking. Thrombophilia. Cocaine use. Prior abruption. Uterine fibroid. Trauma.

Types Total or partial. Concealed or reveiled.

Placental Abruption external hemorrhage concealed hemorrhage Total Partial 9

Presentation Vaginal bleeding. Uterine tenderness or back pain. Fetal distress. High frequency contractions. Uterine hypertonus. Idiopathic PTL. IUFD.

Diagnosis The diagnosis is primarily clinical, but may be supported by radiologic, laboratory, or pathologic findings. It is generally obvious in severe cases. In milder forms the diagnosis is often made by exclusion.

Diagnosis The echogenic appearance depends upon the onset of symptoms: Acute hemorrhage is hyperechoic to isoechoic compared with the placenta. Resolving hematomas is hypoechoic within one week and sonolucent within two weeks.

Diagnosis Laboratory testing is not useful in making the diagnosis: Kleihauer-Betke test: sensitivity 17%. CA-125: elevated. D-dimer: sensitivity 67, specificity 93% Thrombomodulin: sensitivity 88, specificity 77%. Hypofibrinogenemia < 200 mg/dL. Thrombocytopenia < 100,000/microL.

Diagnosis Gross examination of the placenta often reveals a clot and/or depression in the maternal surface. It may be absent with acute abruption.

Initial Management Stabilization of the maternal cardiopulmonary status. Blood work: - CBC. - Coagulation profile. - Fibrinogen. - Blood type and Rh.

Initial Management Large-bore intravenous lines and continuous fetal monitoring Correction of the intravascular fluid deficit via crystalloid +/- PRBC. If the PT and PTT > 1.5x control  2u FFP. If the platelet count is < 50,000/microL  6u plt.

Initial Management Heparin or other anticoagulants ? Tocolysis is generally contraindicated. Delivery is the optimal treatment. DIC & hemorrhage will resolve over 12 hours when the placenta is removed.

Initial Management Medical treatment of coagulopathy for: Marked thrombocytopenia (< 20,000/microL) Moderate thrombocytopenia(<50,000/microL) &serious bleeding or planned cesarean delivery. FFP or cryoprecipitate if fibrinogen is <100 mg/dL

Mild Abruption Expectant management with short term hospitalization. Corticosteroid. Tocolysis may be of value in mild cases.

Delivery The mode and timing of delivery depend upon: GA. The condition of the fetus. The condition of the mother (eg, hypotension, coagulopathy, hemorrhage). The status of the cervix.

Delivery The term or near term fetus should be expeditiously delivered. Amniotomy with placement of a fetal scalp electrode. Oxytocin may be used to augment uterine activity.

Delivery C/S is performed in the presence of a nonreassuring fetal heart rate pattern & when delay in delivery will endanger the mother or fetus. It should be done after rapid maternal hemodynamic and clotting factor stabilization.

Complications Maternal: Hypovolemia. DIC. Renal failure. Death. Fetal: IUGR. IUFD.

Placenta Previa

Introduction Definition: The presence of placental tissue overlying or proximate to the internal cervical os after viability. Incidence: Complicates approximately 1 in 300 pregnancies.

Risk Factors Increasing parity: incidence 0.2 percent in nulliparas versus up to 5 percent in grand multiparas. Maternal age: incidence 0.03 percent in nulliparous women aged 20 to 29 versus 0.25 percent in nulliparous women 40 years of age. Number of prior cesarean deliveries incidence 10 percent after four or more. Number of curettages for spontaneous or induced abortions.

Independent Risk Factors Maternal smoking Residence at higher altitudes Male fetus Multiple gestation: 3.9 and 2.8 previas per 1000 live twin and singleton births, respectively Gestational age: the prevalence of placenta previa is much higher early in pregnancy than at term

Classification Complete placenta previa: The placenta completely covers the internal os. Partial placenta previa: The placental edge does not completely cover the internal cervical os but partially covers it. Marginal placenta previa: The placenta is proximate to the internal os. Low-lying placenta: in which placental edge lies within 2 to 3 cm of the internal os. (reference)

Maggie Myles: Textbook for Midwives

Clinical Manifestations Painless vaginal bleeding occurs in 70 to 80 percent of patients. 10 to 20 percent present with uterine contractions associated with bleeding. Fewer than 10 percent are incidentally detected by ultrasound.

Associated Conditions Malpresentation. PPROM. Congenital anomalies. IUGR.

Diagnosis The diagnosis is based upon results of ultrasound examination. Clinical findings are used to support the sonographic diagnosis. Placenta previa should be suspected in any woman beyond 24 weeks of gestation who presents with painless vaginal bleeding.

Transabdominal US It has a diagnostic accuracy as high as 95% in detecting placenta previa, with a false negative rate of 7%. Sagittal, parasagittal and transverse sonographic views should be obtained.

Transabdominal US It requires the identification of echogenic placental tissue overlying or proximate to the internal cervical os (a distance >2 cm).

Transvaginal US It has become the gold standard for the diagnosis of placenta previa. It is a safe and effective technique, with diagnostic accuracy greater than 99 percent. The probe does not need to come into contact with the cervix to provide a clear image.

Ultrasound Both the transabdominal and transvaginal US should be used as complementary studies. Initial transabdominal examination, with transvaginal sonography if there is any ambiguity in the placental position. Translabial ultrasound imaging is an alternative technique.

Antepartum Management Avoidance of coitus and digital cervical examination. Counseling to seek immediate medical attention if there is any vaginal bleeding. Women are also encouraged to avoid exercise, decrease their activity, and notify the physician of uterine contractions. Serial ultrasound evaluations every two to four weeks to assess placental location and fetal growth.

Acute Care of Symptomatic Placenta Previa Large bore IV access & administration of crystalloid. Type and cross-match for four units of PRBC. Transfuse to maintain a Hct of 30% if the patient is actively bleeding. Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree of blood loss.

Acute Care of Symptomatic Placenta Previa The fetal heart rate is continuously monitored. Quantitative monitoring of vaginal blood loss. The source of the vaginal blood (maternal versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis. Urine output is evaluated hourly with a Foley catheter & should be at least 30 mL/hour.

Acute Care of Symptomatic Placenta Previa Hb & Hct. Serum electrolytes and indices of renal function. Coagulation profile (fibrinogen, Plt, PT & PTT) are checked especially if there is a suspicion of coexistent abruption.

Delivery Tocolysis is not administered to actively bleeding patients. Delivery is indicated if:           (1) there is a nonreassuring fetal heart rate.          (2) life threatening refractory maternal hemorrhage.

Mode of Delivery Cesarean delivery is the delivery route of choice. Vaginal delivery may be considered in the presence of: a fetal demise previable fetus some cases of marginal previa, as long as the mother remains hemodynamically stable.

Conservative Management of Stable Preterm Patients The patient is hospitalized at bedrest with bathroom privileges. Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining. Periodic assessment of the maternal hematocrit. Ferrous gluconate supplements (300 mg orally three or four times per day) are given with vitamin C to improve intestinal iron absorption.

Conservative Management of Stable Preterm Patients Cross match to provide two to four units of packed red blood cells. Prophylactic transfusions to maintain the maternal hematocrit above 30 percent in stable asymptomatic patients in anticipation of future blood loss.

Conservative Management of Stable Preterm Patients A single course of corticosteroid between 24 and 34 w. Rh(D)-negative women should receive Rh(D)-immune globulin if they bled. Readministration is not necessary if delivery or rebleeding occurs within three weeks, unless a large fetomaternal hemorrhage is detected by KBT.

Conservative Management of Stable Preterm Patients Fetal growth, amniotic fluid volume, and placental location are evaluated sonographically every two to four weeks. Tocolysis may be safely utilized if contractions are present and delivery is not otherwise mandated by the maternal or fetal condition.

Conservative Management of Stable Preterm Patients Amniocentesis can be done at 36 weeks to assess pulmonary maturity. Scheduled abdominal delivery is suggested @ 37w or upon confirmation of pulmonary maturity.

Delivery Abdominal delivery. Two to four units of PRBC should be available for the delivery. Appropriate surgical instruments for performance of a cesarean hysterectomy should also be available since there is a 5 to 10 percent risk of placenta accreta.

C/S The surgeon should try to avoid disrupting the placenta when entering the uterus. If the placenta is encountered upon opening the uterus then it is necessery to cut through the placental tissue to deliver the fetus.

Outpatient Managaement Women who have never bled. Women with placenta previa if bleeding has stopped for more than one week. There are no other pregnancy complications, such as fetal growth restriction.

Outpatient Management Live within 15 minutes of the hospital. Have an adult companion available 24 hours a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding. Be reliable and able to maintain bed rest at home. Understand the risks entailed by outpatient management.

Outcome The maternal and perinatal mortality rates in pregnancies complicated by placenta previa have been reduced over the past few decades because of: The introduction of conservative obstetrical management. The liberal use of cesarean rather than vaginal delivery. Improved neonatal care.

Vasa Previa

Introduction Vasa previa refers to vessels that traverse the membranes in the lower uterine segment in advance of the fetal head. Rupture of these vessels can occur with or without rupture of the membranes and result in fetal exsanguination. The incidence is 1 in 2000 – 3000 deliveries.

Associated Conditions Low-lying placenta. Bilobed placenta. Multi-lobed placenta. Succenturiate-lobed placenta. Multiple pregnancies. Pregnancies resulting from IVF.

Diagnosis The diagnosis of vasa previa is considered if vaginal bleeding occurs upon rupture of the membranes. Concomitant fetal heart rate abnormalities, particularly a sinusoidal pattern. Ideally, vasa previa is diagnosed antenatally by US with color flow Doppler.

Antenatal Management Consider hospitalization in the third trimester to provide proximity to facilities for emergency cesarean delivery. Fetal surveillance to detect compression of vessels. Antenatal corticosteroids to promote lung maturity. Elective cesarean delivery at 35 to 36 weeks of gestation.

Antepartum Management Immediate C/S. Avoid amniotomy as the risk of fetal mortality is 60-70% with rupture of the membranes.

Uterine Rupture

Risk Factors The most common risk factor is a previous uterine incision. The rate is higher with classical & T-shape uterine incision in comparison to low vertical & transverse incisions. The rate increases with the number of previous uterine incisions.

Risk Factors High parity. Labor complications: CPD. Abnormal presentation. Unusual fetal enlargement (hydrocephalus). Trauma. Delivery complications: Difficult forceps. Breech extraction. Internal podalic version.

Presentation Sudden severe fetal heart decelerations. Abdominal pain & PV bleeding ( <10%). Diaphragmatic irritation. Loss of fetal station. Cessation of uterine contractions.

Prognosis Fetal death 50-75%. Maternal mortality is high if not diagnosed & managed promptly. Maternal morbidity: hemorrhage & infection.

Management stabilization of maternal hemodynamics. Prompt C/S with either repair of the uterine defect or hysterectomy. Antibiotics.

A 23-y-o PG, @ 29w comes to A&E for evaluation following a RTA in which a restrained passenger in the back seat. She denies any symptoms & examination is normal with fetal heart rate of 150bpm. Before discharging the patient your recommendation regarding electronic fetal monitoring: Do none. Monitor for 2-6h. Monitor for 6-12h. Monitor for 12-18h. Monitor for 18-24h.

In counseling a woman with a prior C/S regarding IOL, you tell her that the highest risk of uterine rupture is associated with: Osmotic cervical dilator. Transcervical Foley balloon placement. Prostaglandins. Oxytocin.

A 34-y-o woman G3P2, present @38w in early labor A 34-y-o woman G3P2, present @38w in early labor. V/E: 3cm with a firm ridge in the membranes by palpation. U/S: placenta located both anteriorly & posteriorly in the lower uterine segment. There is no placenta previa. A tocolytic is administered. What should be the next step in management? Allow continued labor. Speculum examination. Amniocentesis. Color flow Doppler U/S. Amniotomy.

A 19y-o PG admitted @ 34w with heavy vaginal bleeding & regular contractions. She reports no leakage of fluid. BP:156/98. F Ht 35cm. CTG is reactive. U/S: anterior placenta & no retroplacental sonolucency. V/E: 4cm. The most likely Dx is: Vasa previa. Placental abruption. Chorioangioma. Placenta accreta. Placental succenturiate lob.

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