Antepartum Hemorraghe

FIRST TRIMESTER BLEEDING  Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women  It may be any combination of light or heavy, intermittent or constant, painless or painful.

FIRST TRIMESTER BLEEDING The four major sources of bleeding in early pregnancy are:  Ectopic pregnancy  Miscarriage (threatened, inevitable, incomplete, complete)  Implantation of the pregnancy  Cervical, vaginal, or uterine pathology (eg, polyps, inflammation/infection, trophoblastic disease

SECOND AND THIRD TRIMESTER BLEEDING Vaginal bleeding is less common in the second and third trimesters. The major causes of bleeding at these times are:  Bloody show associated with cervical insufficiency or labor  Placenta previa  Abruptio placenta  Uterine rupture  Vasa previ

Abruptio Placenta

Definition  Placental abruption is defined as decidual hemorrhage leading to the premature separation of the placenta prior to delivery of the fetus.

Causes  The immediate cause of the premature placental separation is often the rupture of maternal vessels in the decidua basalis, where it interfaces with the anchoring villi in the placenta

Incidence  Placental abruption complicates about 1 in 100 births, and an abruption severe enough to result in stillbirth occurs in about 1 in 830 deliveries

COMPLICATIONS OF PLACENTAL ABRUPTION Maternal  Hypovolemia related to blood loss  Need for blood transfusion  Disseminated intravascular coagulopathy  Renal failure  Adult Respiratory Distress Syndrome  Multisystem organ failure  Death

COMPLICATIONS OF PLACENTAL ABRUPTION Fetal  Growth restriction (with chronic abruption) [1-6]  Fetal hypoxemia or asphyxia  Preterm birth [1,2]  Perinatal mortalit

INITIAL MANAGEMENT  Patients suspected to have a placental abruption should have a rapid initial evaluation  Subsequent management is determined on a case-by- case basis, and will depend upon the severity of the abruption, the gestational age, and maternal and fetal status

INITIAL MANAGEMENT  Continuous fetal monitoring should be initiated immediately, given the high likelihood of diminished placental perfusion  Most serious maternal risks are due to hypovolemia  It is important to immediately secure two wide-bore intravenous lines

INITIAL MANAGEMENT  The mother's hemodynamic status is closely monitored  In severe cases, a Foley catheter should be inserted to monitor maternal urine output hourly. The urine output should be maintained at above 30 ml/hour.

INITIAL MANAGEMENT  A complete blood count, blood type and Rh, and coagulation studies are obtained  A low fibrinogen level is the most sensitive indicator of coagulopathy related to abruption  Prolongation of the prothrombin time (PT) and partial thromboplastin time (PTT) does not occur with small degrees of placental separation

INITIAL MANAGEMENT  Blood loss should be evaluated carefully  It is frequently underestimated since the bleeding may be largely concealed, and the actual loss may be much more than observed  Blood and blood coagulation replacement products should be readily available

INITIAL MANAGEMENT  Ultra Sound should be performed in stable patients, if possible  While some studies have reported poor sensitivity of ultrasound in the diagnosis of placental abruption, others have found that ultrasound can be an accurate tool in diagnosis  The presence of sonographic features of abruption has a very high positive predictive value, and may influence management

Blood and Blood Product Replacement  Maintain the hematocrit above 30 percent  Each unit of 300 mL PRBC’s contains approximately 200 mL of red cells and will raise the hematocrit by roughly 3 to 4 percent  Give six units of platelets to patients with marked thrombocytopenia (<20) or moderate thrombocytopenia (< 50) with serious bleeding or planned cesarean deliver

Blood and Blood Product Replacement  Fresh frozen plasma or cryoprecipitate is indicated for fibrinogen level < 150 mg/dL, with the goal of raising he level to 150 to 200 mg/dL  Fresh frozen plasma provides more volume than cryoprecipitate depending on the patient's cardiovascular status

Blood and Blood Product Replacement  If multiple transfusions are given because of severe bleeding, the coagulation system should be frequently monitored with measurements of the PT, PTT and platelet count, preferably after each five units of blood are replaced  If the PT and PTT exceed 1.5 times the control value, the patient should be transfused with two units of fresh frozen plasma  If the platelet count falls below 50,000/microL, six units of platelets should be given

SUBSEQUENT MANAGEMENT Subsequent management of pregnancies complicated by abruption depends primarily on:  The fetus (alive or dead)  Maternal status

Live fetus at or near term  The fetus should be delivered by the quickest, safest method if it is alive, the pregnancy is at least 34 weeks of gestation, and abruption is suspected

Live fetus at or near term  Vaginal delivery requirements:  Maternal status is stable  Fetal heart tracing is reassuring with continuous monitoring  Preparating for emergency cesarean section

Live fetus at or near term Cesarean delivery indications:  Fetal heart tracing is nonreassuring  There is ongoing major blood loss or other serious maternal complications

Fetal Demise  The mode of delivery should be one that minimizes the risk of maternal morbidity or mortality  Vaginal delivery is preferable unless urgent delivery is needed to enable stabilization of the mother or there are obstetrical contraindications to vaginal birth  Since the patient is often contracting vigorously, amniotomy may be all that is required to expedite delivery  Oxytocin can be given, if needed to augment labor

Fetal Demise  The frequency of coagulopathy is much higher in abruptions in which fetal death has occurred  Blood pressure, pulse, urine output and blood loss should be monitored closely  Blood, fresh frozen plasma, platelets, and cryoprecipitate should be readily available and given liberally.

Placenta Previa

INTRODUCTION The management of pregnancies complicated by placenta previa is best considered in terms of the clinical setting:  Asymptomatic women  Women who are actively bleeding  Women who are stable after one or more episodes of active bleeding

ASYMPTOMATIC PLACENTA PREVIA  Sonographic reassessment to determine placental position (serial transvaginal ultrasound evaluations at four-week intervals beginning at 28 weeks of gestation)  Development of the lower uterine segment over time often relocates the stationary lower edge of a marginal or low-lying placenta away from the internal os

ASYMPTOMATIC PLACENTA PREVIA Sonographic measurement of cervical length  It provides useful information about the risk of hemorrhage  Studis found that a short cervix was associated with a significantly increased frequency of delivery because of hemorrhage  64 percent of women with a cervical length greater than 3 cm had no bleeding episodes and progressed to term

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA  An actively bleeding placenta previa is anobstetrical emergency  These women should be admitted to the Labor and Delivery Unit for maternal and fetal monitoring  Intravenous access should be established (two large bore IV lines)

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Blood Bank and Laboratory Monitoring :  A blood type and antibody screen should be performed  If bleeding is heavy or increasing, or difficulty in procuring compatible blood is anticipated, then we advise cross-matching two to four units of packed red blood cells

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Fetal monitoring  The fetal heart rate is continuously monitored  Loss of reactivity, persistent minimal variability, or fetal tachycardia, recurrent late decelerations are nonreassuring signs suggesting the potential presence of fetal hypoxia or anemia

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Maternal monitoring  Use a cardiac monitor and automated blood pressure cuff to follow maternal heart rate and blood pressure  Urine output is evaluated hourly with a Foley catheter attached to a urimeter

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Maternal monitoring  Vaginal blood loss can be estimated by weighing or counting perineal pads  Visual estimations of blood loss in obstetrics have historically been inaccurate

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Tocolysis  Generally tocolysis is not used with actively bleeding patients  Tocolysis may be considered if contractions are present, bleeding is diminishing or has ceased, and delivery is not otherwise mandated by the maternal or fetal condition

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Indications for delivery  A nonreassuring fetal heart rate tracing unresponsive to maternal oxygen therapy, left-sided positioning, and intravascular volume replacement  Life-threatening refractory maternal hemorrhage  Significant vaginal bleeding after 34 weeks of gestation

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA Anesthesia  General anesthesia is typically administered for emergency cesarean delivery, especially in hemodynamically unstable women or if the fetal status is nonreassuring  However, regional anesthesia is an acceptable choice in hemodynamically stable women with reassuring fetal heart rate tracings

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED  Most women who initially present with symptomatic placenta previa respond to supportive therapy and do not require immediate delivery  Fifty percent of women with a symptomatic previa (any amount of bleeding) are not delivered for at least four  A large bleed does not preclude conservative management

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED  Symptomatic women often remain hospitalized from their significant bleeding episode until delivery  Since recurrent bleeding episodes are unpredictable, keeping close to the hospital minimizes the risk of complications by enabling fast access to transfusion therapy and emergency cesarean delivery when needed  Select women with placenta previa may be discharged if bleeding has stopped for a minimum of 48 hours and there are no other pregnancy complications

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED Candidates for outpatient care should:  Be able to return to the hospital within 20 minutes  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 managemen

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED Correction of anemia  Iron supplementation may be needed for optimal correction of anemia  Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining that might precipitate bleeding

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED Autologous blood donation  Autologous blood donation is acceptable in stable women who meet usual criteria (hemoglobin ≥11.0 g/dL)  A program of autologous blood collection and transfusion can result in a decrease in homologous blood transfusion  Most women who have bled from a placenta previa, however, will not meet standard criteria for autologous donation

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED Antenatal corticosteroids  A course of antenatal corticosteroid therapy should be administered to symptomatic women between 24 and 34 weeks to improve fetal pulmonary maturity  Do not administer steroids to asymptomatic women or those whose first bleed is after 34 weeks of gestation

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED Fetal assessment  There is value of nonstress testing or BPP in the asymptomatic placenta previa patient who has no evidence of uteroplacental insufficiency or other signs of distress  Active vaginal bleeding is an indication for fetal assessment

DELIVERY Timing  Severe persistent hemorrhage is an indication for delivery, regardless of gestational age  The delivery of a pregnancy with uncomplicated placenta previa should be accomplished at 36 to 37 weeks, without documentation of fetal lung maturity by amniocentesis  The rationale behind this is that the risks of continuing the pregnancy were greater than the risks of complications from prematurity

DELIVERY  Women with increasing frequency or volume of bleeding or with signs of imminent labor are delivered at ≤36 weeks if they have received a steroid course  However, women whose first bleed occurred after 34 weeks may not have received a course of betamethasone  If a course of antenatal steroids has not been given, an amniocentesis is performed and deliver the baby at ≤36 weeks if pulmonary indices are mature

Route of Delivery Complete previa  A cesarean delivery is always indicated when there is sonographic evidence of a complete placenta previa and a viable fetus  Vaginal delivery may be considered in rare circumstances, such as in the presence of a fetal demise or a previable fetus, as long as the mother remains hemodynamically stable

Route of Delivery Low-lying placenta  Rates of cesarean delivery and antepartum bleeding decrease as the distance between the placental edge and internal os increases.  There is a reasonable possibility of vaginal delivery when the placenta is more than 2 cm from the internal os, so a trial of labor is appropriate  When this distance is between 1 and 20 mm, the rate of cesarean delivery ranges from 40 to 90 percent

Route of Delivery Marginal previa  Historically, it was believed that vaginal delivery could occasionally be performed safely in women with marginal previa because the fetal head tamponades the adjacent placenta  However most women with marginal previa will end up with a cesarean delivery  Scheduled cesarean delivery is done for these pregnancies to minimize the risk of emergent delivery and hemorrhage

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