1. Preterm Labor and Bleeding in Pregnancy

2. Patient Patient: 25 y.o G3P1011 at 27+5
Vaginal spotting after wiping with urination x 1 day
Lower abdominal cramps every 10 minutes x 12 hours, improving
ROS: +FM, - LOF, - Ctx, - dysuria

3. History Ob/Gyn History
Past gyn history
Menarche at 13
Period was regular
No abnormal pap smear
Past Ob history
1st preg: CS at 36 wk for pre-e
1 SAB s/p D/C
Prenatal care
No complications so far
PMH: none
Soc hx: denies use of alcohol, tobacco
Surg: cholecystectomy
Meds: PNV
Allergy: latex

4. Differentials for 3rd trimester bleeding and cramping
Pre-term labor
Bloody show (cervical insufficiency or labor)
Placenta previa
Vasa previa
Placental abruption
Uterine rupture
Cervical/vaginal/uterine pathology (polyp, inflammation/infection, trophoplastic disease)
UTI

5. Objective findings Vitals T 97.9 P 82 BP 119/64 R 16 O2 97 PE NAD
Lung – CTAB
Heart – RRR
Abd – gravid, soft, NT
LE – warm, NT
Cervical exam
closed/thick/high
Pelvic exam
no pooling
no blood
negative ferning

6. Additional workup Transvaginal ultrasound FHT Tocometer UA
Cervix closed 32mm, no change in Valsalva
FHT
Baseline 135
Moderate variability
Accelerations +
Tocometer
Quiet UA
Negative for infection

7. Assessment and Plan
A: 25 y.o G3P1001 at 27+5 with cramping and spotting P:
Maternal well being:
Low suspicion for premature labor, CL reassuring, cervix closed, no bleeding on exam
UA negative
Fetal well being:
Category I, reassuring for 27 weeks
Discharge home pending
Bleeding/pre-term labor precautions
Pre-term labor precaution
Contractions like mild menstrual cramps lasting 20s-1.5 minutes
Occasional contractions are normal after weeks esp if standing a lot or dehydrated
If have 4+ in a hr – rest and drink water; if persist call your doctor

8. General approach to bleeding in pregnancy
Differential based gestational age and characteristic of bleeding
T1 = wk 1-14
T2 = wk 14-28
T3 = wk 28-40
First trimester (T1) bleeding -r/o ectopic pregnancy
Second, third trimester (T2, T3) – avoid digital examination of cervix
light/heavy, painful/painless, intermittent/, constant), lab and images used to confirm/revise differential. Will go into specifics of T1 and T2/3 bleeding in later slides
b/c ruptured ectopic can result in severe hemorrhage
Placental previa need to be excluded b/c digital exam can cause immediate and severe hemorrhage
T1 wk 1-12
T2 wk 13-27
T3 wk 28-40

9. T2, T3 Bleed Less common than T1 bleeding (3-4% of pregnancies) Causes
Ob causes
Miscarriage (< 20wk)
Cervical insufficiency or labor
Placenta previa
Fetal vessel rupture- velamenous cord insertion, vasa previa
Placental abruption
Uterine rupture
Non ob causes
Cervical, vaginal, uterine pathology – eg. cervicitis, genital laceration, cancer
Hemorrhoid, bleeding disorder, abd/pelvic trauma, hematuria
Avoid digital examination of cervix
Rh (-) + bleeding  give anti-D immunoglobulin to protect against isoimmunization

10. Placenta previa 20% Complete, incomplete, marginal, low lying
Placental migration, Trophotropism
Complications
Vasa previa – vessel run thru membrane over cervix
Placental accreta – abnl attachment to myometrium
Increta vs percreta (bladder, rectum)
Associated w/ premature delivery, PPROM, IUGR, peripartum hysterectomy
Low lying – implanted in the lower uterine segment close to but not extending into internal os
Placental migration – 90% previa detected early will appear to have move away later in pregnancy
Trophotropism – placenta preferentially grow toward better vascularized area; less vascularized area atrophy
Increta – invade myometrium,
Percreta – invade through myo to serosa
Bleeding cause more uterine contraction, further stimulate placental separation and bleeding

11. Placenta previa
Risk factor: things that prevent normal migration/implantation of placenta
Prior previa, uterine surgery, C-section, multiple gestation, multiparity, advanced maternal age, smoking
Classic: sudden profuse PAINLESS vaginal bleeding in T3, usually no contraction
“sentinel bleed” – usually after 28 weeks when lower uterine segment develops and thins, disrupting placental attachment
Accreta – hematuria, rectal bleeding; suspect if previa + prior C-sec
Workup: Transvaginal U/S (95% sensitivity). NO VAGINAL EXAM

12. Placenta previa Mgmt: Stabilize, continuous fetal monitoring
Labs: H&H, type & cross, coagulation labs, D-dimer, fibrininogen, Kleihauer- Betke test
Between wk: steroid, +/- blood transfusion, +/- tocolytics
Schedule delivery at weeks
C-section if unstoppable preterm labor, large hemorrhage, non-reassuring fetal test, or at 36 weeks w/ mature lung indices
Plan for hysterectomy
Vaginal delivery if low lying placenta or marginal previa and stable
Kleihauer-Betke test - estimate degree of fetal-maternal transfusion to dose RhoGAM for RH (-) mother
Prematurity is primary cause of perinatal mortality, want to prolong pregnancy as much as possible, as long as mom and fetus are stable

13. Fetal vessel rupture Associated w/ perinatal mortality up to 60%
Cause: Velamentous cord insertion, +/- vasa previa
Loss of FETAL blood
Risk factor: multiple gestation, abnormal placentation, IVF esp in twin pregnancy
Sx: vaginal bleeding + sinusoidal FHR pattern
Diagnosis: often posthumously; U/S finding membranous cord insertion ; Apt test, Kleihauer- Betke test
Mgmt:
VUC: start FHR monitor at 36 wk
VP: Start semiweekly NST wk; admn betamethasone 28-30; hospitalize 30-32; deliver 35
Emergent C-section
Immediate transfusion
umbilical cord inserts into the fetal membranes (choriamniotic membranes), then travels within the membranes to the placenta (between the amnion and the chorion). The exposed vessels are not protected by Wharton's jelly and hence are vulnerable to rupture. Rupture is especially likely if the vessels are near thecervix,
Apt test – diluting blood, collect supernatant, combine w/ 1% NaOH (pink = fetal blood, yellow-brown = maternal)

14. Placental abruption
30%
Risk factors: cHTN, preeclampsia, cocaine/methamphetamine, hx of abruption, multiple gestation
mechanism? Abnl placental vasculature, thrombosis, reduced perfusion
Classic: T3 vaginal bleeding, severe PAIN, CONTRACTION, uterine tenderness; 20% concealed hemorrhage
Complication: hypovolemic shock, DIC, premature delivery
Diagnosis: clinical, U/S poor sensitivity (retroplacental clot)
Smoking, alcohol, advanced maternal age, multiple gestation, multiparity

15. Placental abruption Mgmt: Stabilize
Prepare for transfusion with FFP and cryoprecipitate
Betamethasone for lung maturity
Labs similar to placenta previa
Deliver if life threatening / non reassuring FHT
Stable, bleeding controlled – vaginal delivery
Unstable pt – C-section
FFP – fibrinogen, VIII, V
Cyroprecipitate – fibrinogen, VIII, vW

16. Uterine rupture
Rare ob catastrophe, but seen in 1/200 in laboring women w/ prior C- section
Risk factors: prior C-sec, uterine surgery, abdominal trauma, grand multiparity, aggressive oxytocin use, abnormal placentation
Sx: sudden intense abdominal pain, vag bleeding, non-reassuring FHT, abnl abdl contour, (-) contraction, (-) fetal heart tone
Mgmt:
Immediate laparotomy
Delivery of fetus
repair/ of rupture or hysterectomy

17. Reference Blueprints Chp 5 Antepartum Hemorrhage
UpToDate Overview of the etiology and evaluation of vaginal bleeding in pregnant woman
Medscape
First Aid for OB/Gyn