Abnormal Bleeding in Pregnancy and Labour Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Definition Antepartum haemorrhage---It is bleeding from the genital tract after the 28th week of pregnancy and before the end of the second stage of labour . Postpartum haemorrhage– haemorrhage following delivery.

Antepartum Bleeding Causes Abruptio Placentae Placenta praevia Rupture of  uterus Carcinoma of cervix Trauma Cervical polyp Unknown origin  

Placenta praevia Definition : The placenta is partially or totally attached to the lower uterine segment. Incidence : 0.5% , more common in multiparas and in twin pregnancy due to the large size of the placenta.

Placenta praevia Types: 1. Total : internal os completely covered. 2. Partial : internal os partially covered 3. Marginal : edge of placenta at the margin of int. os 4. Low lying placenta

Placenta praevia

Placenta praevia

Placenta praevia Risk factors Chronic hypertension Multiparity (second or succeeding pregnancy) Multiple gestations (i.e., twins, etc.) Older maternal age Previous cesarean delivery Tobacco use Prior uterine curettage (D&C)

Placenta praevia Diagnosis Symptoms: Causeless, painless and recurrent bright-red vaginal bleeding; It is causeless, but may follow sexual intercourse or vaginal examination. It is painless, but may be associated with labour pains . It is recurrent, but may occur once in slight placenta praevia lateralis.

Placenta praevia Signs: General examination: Depends on extent of blood loss Abdominal examination: The uterus is corresponding to the period of amenorrhoea, relaxed and not tender.

Placenta praevia The foetal parts and heart sound (FHS) can be easily detected. Malpresentations, particularly transverse and oblique lie and breech presentation are more common as well as non-engagement of the head.

Placenta praevia Arrange for immediate transfer to the hospital. Treatment At Home Arrange for immediate transfer to the hospital. No vaginal examination and no vaginal pack, only a sterile vulval pad is applied.

Placenta praevia No oral intake as anaesthesia may be required. Antishock measures as pethidine IM, fluids and blood transfusion may be given in the way to the hospital if bleeding is severe.

Placenta praevia At Hospital Assessment of the patient's condition, general and abdominal examination and resuscitation if needed. At least 2 units of cross matched blood should be available.

Placenta praevia If the patient is not in labour If the bleeding is severe, continue antishock measures and do immediate caesarean section . If the bleeding is slight, look to the gestational age :

Placenta praevia If completed 37 weeks (36 weeks by some authors) or more, pregnancy is terminated by induction of labour or caesarean section If less than 37 weeks (36 weeks by others), conservative treatment is indicated till the end of 37 (or 36) weeks but not more.

Placenta praevia Conservative treatment: The patient is kept hospitalized with bed rest and observation till delivery. Anaemia should be corrected if present. Observation of foetal wellbeing. Anti-D immunoglobulin is given for the Rh-negative mother.

Placenta praevia If the patient is in labour: Vaginal examination is done using precautions. According to the findings, the patient will be delivered either vaginally or by caesarean section.

Placenta praevia Vaginal delivery is allowed if the following findings are fulfilled: Placenta praevia is lateralis or marginalis anterior, bleeding is slight, vertex presentation, adequate pelvis with no soft tissue obstruction. Caesarian section--- normal mode of delivery

Placenta praevia Complications of Placenta Praevia Maternal: mortality rate: 0.2%. Foetal: Foetal mortality rate is 20 %. Prematurity. Asphyxia. Malformations (2%).

Abruptio placenta Placental abruption is the premature separation of a normally-implanted placenta from the uterine wall. Risk factors : Older maternal age Hypertension (high blood pressure) Tobacco, cocaine, or methamphetamine use Clotting abnormalities Abdominal trauma Previous placental abruption Uterine fibroids

Abruptio placenta Signs and symptoms of placental abruption: Vaginal bleeding Sudden onset of labor, with persistent pain between contractions Tenderness over uterus Back pain Signs of shock if blood loss is significant

Abruptio placenta Management -- Depends on gestational age and status of mother & fetus - live& mature fetus– immediate caesarian section with fluid & blood replacement - maternal condition stable with premature fetus – expectant management under close supervision - severe placental abruption with a dead fetus – vaginal delivery preferred

Antepartum bleeding Rupture of uterus Carcinoma of cervix Trauma Cervical polyp Unknown origin

Post partum haemorrhage Defined as the loss of 500ml or more of blood after completion of the third stage of labour Causes: -- Uterine atony -- Retained placenta -- Genital lacerations- vaginal, cervical tears

Post partum haemorrhage Uterine atony : Causes Large infant, forceps delivery, intrauterine manipulation, use of anaesthetic agents, multiple fetuses. Treatment: Manual removal of the placenta Oxytocin- 20 units in 1000ml fluid IV Methylergonovine 0.2 mg IM Prostaglandins 0.25mg IM

Post partum haemorrhage Retained placenta > 30 minutes seen in ~ 6% of deliveries. Risk increased with: prior C/S, curettage , uterine infection, increased parity. Most patients have no risk factors. Occasionally succenturiate lobe left behind. Attempt to remove the placenta by usual methods. Excess traction on cord may cause cord tear or uterine inversion.

Post partum haemorrhage Birth trauma Vaginal, cervical tears --- to be repaired Hematoma --- drain

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Absent fetal movements Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Fetal Movements First fetal movement occurs around 8-9 weeks For primiparas fetal movement often not felt till 18wks or later For multiparas fetal movement is felt around 15 –16 wks Simplest and oldest form of fetal welfare assessment  

Fetal movements Procedure: The test is valid after 30 weeks of pregnancy. The mother counts the fetal movements in 3 hours during the period of 12 hours e.g. from 9 am to 9 p.m , - The count is multiplied by 4 to get the fetal movements in 12 hours. If count < 10 – further testing

Fetal movements Count-to -ten Cardiff system : 10 movements in 12 hrs Cessation of the fetal movement 12-24 hours before stoppage of the heart ---"movement alarm signal".

Fetal movements - Pregnant woman can monitor herself. - No cost. Advantages: - Informative and non-invasive. - Pregnant woman can monitor herself. - No cost.                                 - Accurate gestational age not required.

Fetal movements Drawbacks: - Awareness of the fetal movement differs from mother to mother. - Cessation of fetal movement may occur due to intrauterine sleep. - Sedation of the fetus occurs if mother is on sedatives. - Sudden death of the fetus may occur without preceding slowing of the fetal movement as in abruptio placenta or it may be preceded by increased flurry movements.

Fetal movements Assessment of fetal activity Maternal perception Tocodynamometer Ultrasound Fetuses have sleep- activity cycles with sleep cycles extending upto 23 min. Activity decreases with decreased amniotic fluid volume

Fetal movements Electronic monitoring Non Stress test Done with 2 transducers placed to assess fetal heart and uterine contractions

Fetal movements

Fetal movements NST Reactive test: Two or more fetal movements are accompanied by acceleration of FHR of 15 beats/ minute for at least 15 seconds’ duration. Reactive test means that the fetus can survive for one week, so the test should be repeated weekly. Non -reactive test: No FHR acceleration in response to fetal movements so contraction stress test is indicated.    

Fetal movements Ultrasound Doppler monitoring Pregnancy outcome Check the FHR, Fetal movements and the blood flow to the uterus and the baby Pregnancy outcome Pregnancy outcome was the same for mothers who measured fetal movements and those who did not but it is still considered good for early detection of fetal well being as well for mother– baby bonding

Fetal Movements ACOG recommendations Daily fetal kick count to be maintained in the 3rd trimester Notify the health provider if the count is decreased

Fetal Movements Summary Fetal movement record is a simple ,harmless & cost effective way to assess fetal well – being Pregnancies with decreased fetal movements are at an increased risk of adverse pregnancy outcome It also helps in “Bonding” between the mother and fetus

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Premature rupture of membranes Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Premature rupture of membranes Rupture of membranes before the onset of labour at any stage of gestation Occurs in 3% of all pregnancies Responsible for 1/3rd causes of preterm birth Causes significant fetal complications– sepsis, prematurity, cord prolapse, abruptio placenta, fetal death

Premature rupture of membranes Risk Factors Lower socioeconomic class Previous preterm birth H/O STD Multiple pregnancy Polyhydramnios Procedures– cervical encirclage,amniocentesis

Premature rupture of membranes Diagnosis History Examination Vaginal swab Ultrasound assessment - amniotic fluid - fetal assessment

Premature rupture of membranes Treatment --- depends on - gestational age, - amount of amniotic fluid - fetal state - infection

Premature rupture of membranes Expectant management Antibiotic therapy -- Ampicillin with Metronidazole Corticosteroid therapy- to accelerate lung maturity Betamethasone 12mg I/M 24hrs apart –2 doses Dexamethasone 5mg 12 hrly - 4 doses Tocolytics- to delay onset of labour Risks Maternal risks– infection Fetal risks– pulmonary hypoplasia, limb abnormalities,infection

Premature rupture of membranes Summary of treatment History, examination, USG 24 – 31 wks 32 – 33 wks 34 – 36 wks Bed rest Bed rest Antibiotics Antibiotics Antibiotics Deliver Steroids Steroids Deliver 34 wks Deliver 34 wks

Premature rupture of membranes Complications Delivery within one week Respiratory distress syndrome Cord compression Cord prolapse Chorioamnionitis Abruptio placentae Antepartum fetal death

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Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida Molar Pregnancy Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Molar Pregnancy Definition and Etiology Hydatidiform mole is a pregnancy characterized by vesicular swelling of placental villi and usually the absence of an intact fetus. The etiology -- unclear, but appears to be due to abnormal gametogenesis and fertilization Incidence-- 1 out of 500-600

Molar Pregnancy Risk factors < 15 years 1. Maternal age  > 40 years              < 15 years  2. Paternal age  > 45 years   3. Previous hydatidiform mole  1st: 1% , 2nd 15-28%  4. Vitamin A deficiency  5. Consanguinous marriages 6. Previous spontaneous abortion 7. More common in orients

Molar Pregnancy Molar pregnancy - Complete - Partial Complete mole - Mass of tissue is completely made up of abnormal cells There is no fetus and nothing can be found at the time of the first scan.  Partial mole - Mass may contain both these abnormal cells and often a fetus that has severe defects.

Molar Pregnancy History Examination Amenorrhoea Vaginal bleeding Excessive nausea & vomiting Passage of vesicles Examination Uterine size> period of pregnancy Soft boggy feel of uterus- with no fetal parts felt Signs of anaemia

Molar Pregnancy Diagnosis of hydatidiform mole Quantitative beta-HCG – value > 10,000mIU/ml Ultrasound is the standard criterion for identifying both complete and partial molar pregnancies. The classic image is of a “snowstorm” pattern  

Molar Pregnancy Signs and Symptoms of Complete Hydatidiform Mole Vaginal bleeding Hyperemesis ( severe vomiting) Size inconsistent with gestational age( with no fetal heart beating and fetal movement) Preeclampsia Theca lutein ovarian cysts

Molar Pregnancy Signs and Symptoms of Partial Hydatidiform Mole Vaginal bleeding Absence of fetal heart tones Uterine enlargement and preeclampsia is reported in only 3% of patients. Theca lutein cysts, hyperemesis is rare.      

Molar Pregnancy Differential diagnosis Abortion Multiple pregnancy Polyhydramnios    

Molar Pregnancy Treatment Suction dilation and curettage : Complete evacuation of the uterus USG to confirm complete evacuation Serum β-HCG weekly till undetectable & monthly for 6 months Serum β- HCG expected to be undetectable by8-12 wks Advise contraception till then– condoms, OC pills after HCG negative

Molar Pregnancy Indications for chemotherapy Serum B-HCG >20,000IU/L or urinary B-HCG > 30,000 IU/L 4 wks post evacuation Rising level of B- HCG anytime post evacuation Positive B-HCG levels 6 mths post evacuation Evidence of metastasis Persistant vaginal bleeding with +ve B- HCG Methotrexate is the drug used

Grade C recommendation RCOG Recommendations Ultrasound has limited value in detecting partial molar pregnancies. In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed. Surgical evacuation of molar pregnancies is advisable. Routine repeat evacuation after the diagnosis of a molar pregnancy is not warranted. Registration of any molar pregnancy is essential. The combined oral contraceptive pill and hormone replacement therapy are safe to use after hCG levels have reverted to normal. Women should be advised not to conceive until the hCG level has been normal for six months or follow-up has been completed (whichever is the sooner). Grade C recommendation

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