1. Antepartal hemorrhagic Disorders
Chapter 28

2. Learning Objectives
Differentiate among causes of early pregnancy bleeding, including miscarriage, ectopic pregnancy, reduced cervical competence, and hydatidiform mole.
Discuss signs and symptoms, possible complications, and management of miscarriage, ectopic pregnancy, cervical insufficiency, and hydatidiform mole.

3. Learning Objectives (Cont.)
Compare and contrast placenta previa and placental abruption in relation to signs and symptoms, complications, and management.
Discuss the diagnosis and management of disseminated intravascular coagulation.

4. Antepartum Hemorrhagic Disorders
Bleeding in pregnancy jeopardizes maternal and fetal well-being
Maternal blood loss decreases oxygen-carrying capacity, increases risk for:
Hypovolemia
Anemia
Infection
Preterm labor
Adverse oxygen delivery to the fetus

5. Antepartal Hemorrhagic Disorders (cont.)
Fetal risks from maternal hemorrhage
Blood loss, anemia
Hypoxemia
Hypoxia
Anoxia
Preterm birth

6. Early Bleeding Miscarriage
Spontaneous abortion- a pregnancy that ends before 20 weeks of gestation
Types of miscarriages
Threatened- include spotting of blood but with cervical os closed.
Inevitable and incomplete-miscarriages involve a moderate to heavy amount of bleeding with an open os
Complete- all fetal tissue is passed, the cervix is closed
Threatened-Mild uterine cramping may be present
Inevitable-Tissue may be present with the bleeding
Mild to severe uterine cramping may be present
Complete-Mild uterine cramping may be present

7. Early Bleeding (Cont) Missed- a pregnancy in which the fetus has died
Recurrent early (habitual )- is the loss of three or more previable pregnancies
Prostaglandin medications-Cytotec
Dilatation and Evacuation (D&C)- commonly performed to treat inevitable and incomplete miscarriage
Missed-but the products of conception are retained in utero for weeks
Incomplete miscarriage involves the expulsion of the fetus with retention of the placenta
Cytotec given orally or vaginally for 7 days
Side effects nausea vomiting, and diarrhea
D&C-a surgical procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents

9. Early Bleeding (cont)
Incompetent Cervix (Recurrent Premature Dilatation of the Cervix)
Passive and painless dilatation of the cervix during the second trimester
Cervical Funneling
Bed rest, pessaries, antibiotics an anti-inflammatory,
And progesterone supplementation
Cervical cerclage
Electively removed when the
woman reaches 37 weeks of
gestation
Cervical Cerclage-band of homogous fascia, or nonabsorbable ribbon (Mersilene) may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix Prophylactic cerclage is placed at 11 to 15 weeks of gestation, after which the woman is told to refrain from intercourse, prolonged (more than 90 –minute) standing, and heavy lifting. She is monitored during the course of her pregnancy with ultrasound scans to assess for cervical shortening and funneling. Tocolytic medications information on preterm labor and labor.
Risk of the procedure include premature labor, rupture of membranes (ROM) and chorioamnionitis.
A short cervix (less than 25 mm) in indicative of reduced cervical competence. Often the short cervis is accompanied by cervical funneling (beaking) or effacement of the internal os.

11. Early Bleeding Ectopic Pregnancy
One in which the fertilized ovum is implanted outside the uterine cavity
Pain may be unilateral, bilateral, or diffuse over the abdomen
Dark red or brown abnormal vaginal bleeding
Referred shoulder pain
Removal of the ectopic pregnancy
by salpingostomy is possible before
rupture
Approximately 95% of ectopic pregnancies occur in the uterine (fallopian) tube.
Other sites include the abdominal cavity, ovary, and cervix
Leading pregnancy-related cause of first trimester maternal mortality
The reported incidence of ectopic pregnancy is increasing as a result of improved diagnostic techniques, such as more sensitive beta-hcG assays and the availability of transvaginal ultrasound.
An increased incidence of sexually transmitted diseases, better treatment of pelvic inflammatory diseases, and surgical reversal of tubal sterilizations also have resulted in more ectopic pregnancies
A missed period, adnexal fullness, and tenderness may suggest an unruptured tubal pregnancy. The tenderness can progress from a dull pain to a colicky pain when the tube stretches.
If the ectopic pregnancy ruptures pain increases.
This pain may be generalized, unilateral, or acute deep lower quadrant pain caused to blood irritating the peritoneum.
Referred shoulder pain can occur as a result of diaphragmatic irritation caused by blood irritating the peritoneum.
Laboratory screening includes determination of serum progesterone, and beta hcG.
Any woman with complaints of abdominal pain, vaginal spotting or bleeding, and a positive pregnancy test should undergo screening for ectopic pregnancy.
Pre operative laboratory tests include determination of blood type, RH factor, CBC. Serum quantitative beta-hcG assay. Ultrasound is used to confirm an extrauterine pregnancy.
Leading cause of infertility
A contraceptive method should be used for at least three menstrual cycle allow women’s body time to heal

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14. Early Bleeding Hydatidiform Mole (molar pregnancy)
Complete mole results from fertilization of an egg with a lost or inactivated nucleus
Resembles a bunch of white grapes
Contains no fetus, placenta, amniotic membranes or fluid
Partial mole often has embryonic or fetal parts and an amniotic sac
20 % of cases of complete mole, progression toward choriocarcinoma occurs
Hydatiform mole (molar pregnancy) is a gestational trophoblastic disease.
Compete mole results from fertilization of an egg with a lost or inactivated nucleus. The nucles of a sperm duplicates itself (resulting in the diploid number, 46, XX ) because the ovum has no genetic material is inactive.
The hydrophic (fluid-filled) vesicles grow rapidly causing the uterus to be larger than expected for the duration of the pregnancy.
Maternal blood has no placenta to receive it, hemorrhage, into the uterine cavity and the vaginal bleeding therefore occurs. In about 20% of cases of complete mole, progression toward choriocarcinoma occurs.
Partial mole-occurs as a results of two sperm fertilizing an apparent normal ovum

16. Early Bleeding Hydatidiform mole Vaginal bleeding
Early in pregnancy the uterus is significantly larger than expected from menstrual dates
Most moles abort spontaneously
Woman should reframe from getting pregnant for 6 months to a year
Vaginal discharge may be dark brown (resembling prune juice) or bright red, either scant or profuse, continuing for only a few days or intermittent for weeks.
The percentage of women with an excessively enlarged uterus increases as length of time since LMP increases
Anemia from blood loss, excessive nausea and vomiting, and abdominal cramps caused by uterine distention are common.
Preeclampsia occurs in about 15% of cases, usually between 9 and 12 weeks. Any symptoms of gestational hypertension before 24 weeks of gestation may suggest hydatidiform mole
D&C
Diagnosis- ultrasound and serial beta-hcG immunoassays
A beta-hcG titer will remain high or increase above normal peak after the time which it normally decreases
Follow-up- frequent physical and pelvic examinations
Biweekly measures of beta-hcG until the levels decrease to normal and remain normal for three weeks
Monthly measures are taken for 6 weeks and then every 2 months for a total of one year.
A rising titer and enlarging uterus may indicate choricaricnoma
A characteristic pattern of multiple diffuse intrauterine masses, often called a snowstorm pattern, is seen in place of, or along with an embryo or fetus

19. Late Bleeding Placenta Previa
Condition in which the placenta is implanted in the lower segment near or over the internal cervical os
Three types of placenta previa
Incomplete (or partial)- if the internal os is entirely covered by the placenta when the cervix is fully dilated
Marginal placenta previa-implies incomplete coverage of the internal os

20. Late Bleeding (cont)
Marginal placenta previa-indicates that only an edge of the placenta extends to the internal os
Painless vaginal bleeding
Previa should be suspected whenever vaginal bleeding occurs during the second or third trimester (after 20 weeks)
Vaginal bleeding is bright red
Low-lying placenta is used when the placenta is implanted in the lower segment but does not reach the os.
Bleeding is associated with the stretching and thinning of the lower uterine segment that occurs during the third trimester
Placental attachment is gradually disrupted, and bleeding occurs when the uterus is not able to contract adequately and stop blood flow from open vessels.
Initial bleeding is usually small amount and stops as clots form

21. Late Bleeding (cont) Placenta Previa
Standard diagnosis for previa is a transvaginal ultrasound
Lab studies include:
H &H
, blood type and RH factor, coagulation profile, and type and crossmatch

22. Late Bleeding (cont) Placenta previa
Expectant management consists of rest and close observation for women less than 36 weeks gestation
Ultrasound
NST
Pad counts
H&H and coagulation values monitored closely
C/S vs. vaginal delivery
Once placenta previa has been diagnosed, a management plan is developed based on gestational age, amount of bleeding, and fetal condition.
If the woman is tern (longer than or equal to 37 weeks of gestation) and I labor or bleeding persistently, immediate delivery by C/S is almost always indicated.
In a woman with partial or marginal previa who have minimal bleeding vaginal birth may be attempted.
Ultrasounds are performed every 2 to 3 weeks
Fetal surveillance may include NST or biophysical profile once or twice weekly

23. Late Bleeding (cont)
Maternal hypertension is probably the most consistently identified risk factor for abruptio
Types of abruptio placenta
Partial ( concealed hemorrhage)- woman has uterine tenderness and tetany, but neither the mother nor baby is in distress
10 to 20% of the total placental surface is detached Abruptio Placentae- is the detachment of part or all of the placenta from its implantation site .
Separation occurs in the area of the decidua basalis after 20 weeks of pregnancy and before the birth of the baby.
Maternal hypertension is probably the most consistently identified risk factor for abruption

24. Late Bleeding (cont)
Partial separation (apparent hemorrhage)- woman has uterine tenderness, and tetany with or without external evidence of bleeding
Complete separation (concealed hemorrhage)-uterine tetany is severe; the woman is in shock; and the fetus is dead
Classical symptoms include: vaginal bleeding, uterine tenderness and contractions, and abdominal pain
Grade 2- Approximately 20 to 50% of the total surface area is detached
Grade 3- Greater than 50% of the total placental surface area is detached. If more than 50 % of the placenta is involved, fetal death is likely to occur
Vaginal bleeding is present in as many as 70 to 80% of women with abruption
Extensive myometrial bleeding damages the uterine muscle. If blood accumulates between the separate placenta and the uterine wall, it may produce a Couvelaire uterus. Uterus appears purplish and copper colored, it is ecchymotic, and contracility is lost. Shock may occur and is out of proportion tp blood loss.
Lab test include: APT test results of blood in the amniotic fluid
Decrease in H&H
Decrease in coagulation factor levels (DIC)
KLeinhauer-Betke stain may be order to determine the presence of fetal-maternal bleeding (transplacental hemorrhage)

25. Late Bleeding (cont) Abruptio placentae
Treatment depends on the severity of blood loss and fetal maturity and status
Woman is hospitalized and observed closely for signs of bleeding and labor
C/S delivery
If the abruption is mild and the fetus is less than 36 weeks of gestation and not in distress, expectant management may be implemented.
Fetal status also is monitored with intermittent fetal heart monitoring and NST or biophysical profile unto fetal maturity is determined or until fetal maturity is determined or until the woman’s condition deteriorates and immediate birth is indicated.
Vaginal birth is usually feasible and is desirable especially in cases of fetal death
Labor induction or agumentation may be intiated so long as the mother and fetus are closely monitored for any evidence of compromise. C/S birth should be reserved for cases of fetal distress or other obstetric complications.

28. Late Bleeding (cont) Velamentous insertion of the cord
Rare placental anomaly associated with placenta previa and multiple gestation
Cord vessels begin to branch at the membranes
Course onto the placenta
Fetus may rapidly bleed to death
ROM and then course onto the placenta or traction on the cord may tear one or more of the fetal vessels.
Battledore (marginal) insertion of the cord-increase the risk of fetal hemorrhage, especially after marginal separation of the placenta.