2. Bleeding in Pregnancy

3. Obstetrics is "bloody business."
Death from hemorrhage still remains a leading cause of maternal mortality.
Hemorrhage was a direct cause of more than 18 percent of 3201 pregnancy-related maternal deaths.

5. DEFINITIONS
ABORTION : Up to 24 weeks of gestation or less than 500 gms (WHO – 20 weeks)
Ante-partum haemorrhage : From 24 weeks gestation until the onset of labour
Intra-partum haemorrhage : From onset of labour until the end of second stage
Post-partum Haemorrhage : from third stage of labour until the end of the puerperium

6. EARLY BLEEDING - CAUSES
Implantation bleeding
Threatened Abortion
Inevitable Abortion
Incomplete Abortion
Complete Abortion
Missed Abortion
Molar pregnancy
Ectopic pregnancy
Local causes

7. Abortion Common – 25% of all pregnancies
Do NOT forget Ectopic Pregnancy
( have Ectopic mind, think Ectopic)

8. Abortion Common – 25% of all pregnancies
Do NOT forget Ectopic Pregnancy
( have Ectopic mind, think Ectopic)
50% due to chromosomal abnormality

9. SYMPTOMS Bleeding Pain Passage of tissue (products of conception)
Haemorrhage / spotting

10. DIAGNOSIS History and examination Vaginal or speculum
Cervix (OS) open, products lying in cervix or vagina
Ultrasound – very helpful, widely available and used
Serum BHCG in doubtful cases

11. MANAGEMENT Depends on diagnosis and patient’s CHOICE
Threatened : continue, reassure
Inevitable / incomplete : conservative, medical or surgical evacuation
Missed : conservative, medical or surgical
Complete: support, explanation
Not sure : WAIT and WATCH, follow with scan and BHCG
RULE OUT ECTOPIC

12. Conservative – leave to nature, do nothing
Medical – Misoprostal, prostaglandins
Surgical – evacuation of retained products
-General Anaesthesia
-Dilatation of cervix if not open
-Suction
-Curettage

13. ANTI - D
Do not forget

14. Molar pregnancy Bleeding, passage of vesicles
Large for gestational age
High BHCG
Hyperthyroidism
Ultrasound – snow storm appearance
Suction Evacuation, rarely hysterectomy
Persistence, chorio-carcinoma (1%)
Methotrxate

15. ECTOPIC PREGNANCY Pain, bleeding, fainting
Examination – abdominal, vaginal
Tenderness, cervical excitation tenderness
Ultrasound – TVS
IU sac seen with Bhcg >1500IU
Serial BHCG – doubling up in normal pregnancy
Laparoscopy

16. Tubal Pregnancy Commonest site of ectopic pregnancy (99%)
The ampulla is the most frequent location of
implantation (64%)
Symptoms:
Onset occurs ~7 weeks after LMP
Abdominal pain
Vaginal bleeding
Signs:
Abdominal tenderness (91%)
1st trimester bleeding (79%)
Common associated findings:
Adnexal tenderness (54%) , Amenorrhea
Early pregnancy symptoms
Cullen’s sign (Periumbilical bruising)
Nausea, vomiting, diarrhea, dizziness

17. Symptoms & Signs: Ectopic Pregnancy
In a woman of child bearing age with pelvi-abdominal pain and/ or vaginal bleeding …… ALWAYS….think
Ectopic Pregnancy

19. Ectopic pregnancy – complication of pregnancy where fertilized ovum implants outside the uterine cavity. Most of ectopic pregnancies are not viable. Heterotopic pregnancy Localizations of ectopic pregnancy: -Fallopian tube 95% (ampullary section 80%) cervix -ovaries -abdomen ….

20. 1.Acute
2.Subacute (75-80%)
3.Asymptomatic
Signs and symptoms- clinical presetnation occurs about 7 weeks after the last normal menstrual period Early signs: -pain in the lower abdomen -vaginal bleeding (falling levels of progesterone from the corpus luteum causes bleeding) Signs of late ectopic pregnancy: -low blood pressure -dizziness -lower back, abdominal or pelvic pain -shoulder pain -external bleeding/internal bleeding

21. Diagnosis: -ultrasound - the most reliable method of verification of ectopic pregnancy -levels of β-hCG - more often levels are lower than in normal pregnancy -laparascopy -laparatomy -culdocentesis (a less commonly performed test that may be used to look for internal bleeding)

22. Treatment: -metotrexate (if the mass is less then 3
Treatment: -metotrexate (if the mass is less then 3.5 cm in diametar) -laparascopy, laparatomy (if the mass is greater than 3.5 cm in diametar, internal bleeding, cardiovascular colapse) SALPINGOSTOMY SALPINGECTOMY

23. Antepartum & Postpartum Hemorrhage (APH &PPH)

24. Antepartum & Postpartum Hemorrhage
Causes of 763 Pregnancy-related Deaths Due to Hemorrhage
Causes of Hemorrhage
Number (%)
Abruptio placentae
141 (19)
Laceration/uterine rupture
125 (16)
Uterine atony
115 (15)
Coagulopathies
108 (14)
Placenta previa
50 (7)
Placenta accreta / increta / percreta
44 (6)
Uterine bleeding
47 (6)
Retained placenta
32 (4)

25. 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.

26. What are the most common causes of Antepartum Hemorrhage ?

27. COMMON CAUSES Placenta Previa Placental Abruption Uterine Rupture
Vasa Previa
Bloody Show
Coagulation Disorder
Hemorrhoids
Vaginal Lesion/Injury
Cervical Lesion/Injury
Neoplasia

28. Key point to Remember
The pregnancy in which such bleeding occurs remains at increased risk for a poor outcome even though the bleeding soon stops and placenta previa appears to have been excluded by sonography.

29. Placenta Previa
Defined as a placenta implanted in the lower segment of the uterus,
presenting ahead of the leading pole of the fetus.

30. Placenta Previa
Total placenta previa. The internal cervical os is covered completely by placenta.
Partial placenta previa. The internal os is partially covered by placenta.
Marginal placenta previa. The edge of the placenta is at the margin of the internal os.
Low-lying placenta. The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it.
Vasa previa

31. Placenta Previa
Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment

34. Placenta Previa Incidence about 1 in 300
Perinatal morbidity and mortality are primarily related to the complications of prematurity, because the hemorrhage is maternal.

35. Placenta Previa Etiology: Advancing maternal age Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa

36. Placenta Previa
The most characteristic event in placenta previa is painless hemorrhage.
This usually occurs near the end of or after the second trimester.
The initial bleeding is rarely so profuse as to prove fatal.
It usually ceases spontaneously, only to recur.

37. Placenta Previa
Placenta previa may be associated with placenta accreta, placenta increta or percreta.
Coagulopathy is rare with placenta previa.

39. شکل 20-35

40. Placenta Previa Diagnosis.
Placenta previa or abruption should always be suspected in women with uterine bleeding during the latter half of pregnancy.
The possibility of placenta previa should not be dismissed until appropriate evaluation, including sonography, has clearly proved its absence.
The diagnosis of placenta previa can seldom be established firmly by clinical examination. Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage.

41. Placenta Previa
The simplest and safest method of placental localization is provided by transabdominal sonography.
Transvaginal ultrasonography has substantively improved diagnostic accuracy of placenta previa.
MRI
At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of the lower uterine segment.

42. Placenta Previa Management
Admit to hospital
NO VAGINAL EXAMINATION
IV access
Placental localization

43. Placenta Previa Management
Severe bleeding
Caesarean section
Resuscitate
>34
Moderate bleeding
Gestation
<34
Resuscitate
Steroids
Unstable
Stable
Mild
bleeding
<36
Gestation
Conservative care
>36

44. Placenta Previa Management
Delivery is by Caesarean section
Occasionally Caesarean hysterectomy necessary.

45. Placental Abruption
Defined as the premature separation of the normally implanted placenta.
Occurs in 1-2% of all pregnancies
Perinatal mortality rate associated with placental abruption was 119 per 1000 births compared with 8.2 per 1000 for all others.

46. Placental Abruption external hemorrhage concealed hemorrhage Total
Partial

48. Placental abruption after delivery

49. Placental Abruption
What are the risk factors for placental abruption?

50. Placental Abruption
The primary cause of placental abruption is unknown, but there are several associated conditions.
Increased age and parity
Preeclampsia
Chronic hypertension
Preterm ruptured membranes
Multifetal gestation
Hydramnios
Cigarette smoking
Thrombophilias
Cocaine use
Prior abruption
Uterine leiomyoma
External trauma

51. Placental Abruption Pathology
Placental abruption is initiated by hemorrhage into the decidua basalis.
The decidua then splits, leaving a thin layer adherent to the myometrium.
development of a decidual hematoma that leads to separation, compression, and the ultimate destruction of the placenta adjacent to it.

52. Placental Abruption
Bleeding with placental abruption is almost always maternal.
Significant fetal bleeding is more likely to be seen with traumatic abruption.
In this circumstance, fetal bleeding results from a tear or fracture in the placenta rather than from the placental separation itself.

53. Placental Abruption
The hallmark symptom of placental abruption is pain which can vary from mild cramping to severe pain.
A firm, tender uterus and a possible sudden increase in fundal height on exam.
The amount of external bleeding may not accurately reflect the amount of blood loss.
Importantly, negative findings with ultrasound examination do not exclude placental abruption. Ultrasound only shows 25% of abruptions.

54. Placental Abruption Shock Consumptive Coagulopathy Renal Failure
Fetal Death
Couvelaire Uterus
Sheehan syndrom

55. Placental Abruption Admit Management:
Treatment for placental abruption varies depending on gestational age and the status of the mother and fetus.
Admit
History & examination
Assess blood loss (Nearly always more than revealed)
IV access, X match, DIC screen
Assess fetal well-being
Placental localization

56. Uterine Rupture
Reported in % of all delivering women, but % among women with a history of a uterine scar (from a C/S for example)
13% of all uterine ruptures occur outside the hospital
The most common maternal morbidity is hemorrhage
Fetal morbidity is more common with extrusion

57. Uterine Rupture
Classic presentation includes vaginal bleeding, pain, cessation of contractions, absence/ deterioration of fetal heart rate, loss of station of the fetal head from the birth canal, easily palpable fetal parts, and profound maternal tachycardia and hypotension.
Patients with a prior uterine scar should be advised to come to the hospital for evaluation of new onset contractions, abdominal pain, or vaginal bleeding.

59. What are the risk factors associated with uterine rupture?

60. Uterine Rupture Excessive uterine stimulation Hx of previous C/S
Trauma
Prior rupture
Previous uterine surgery
Multiparity
Non-vertex fetal presentation
Shoulder dystocia
Forceps delivery

61. Uterine Rupture
Management:
Emergent laparotomy

62. A 40-year-old woman, 29 weeks pregnant, presented to the emergency room with painless vaginal bleeding. This is the patient's fourth pregnancy (G4 P3), and three prior births were by cesarean section.
What’s the Diagnosis??

63. 30-year-old woman, gravida 3, para 2 presented at 32 weeks' gestation with a history of dull aching pain in the abdomen radiating to her back There was no history of vaginal bleeding. Fetal movements were normal Patient has a history of cocaine abuse.
What’s the diagnosis??

64. Questions?

65. Summary: remember 4 Ts
“THROMBIN”
Check labs if suspicious.