1. Vaginal Bleeding in Late Pregnancy

2. Objectives
Identify major causes of vaginal bleeding in the second half of pregnancy
Describe a systematic approach to identifying the cause of bleeding
Describe specific treatment options based on diagnosis

3. Causes of Late Pregnancy Bleeding
Placenta Praevia
Abruption
Ruptured vasa praevia
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer
Life-threatening

4. Prevalence of Placenta Praevia
Occurs in 1/200 pregnancies that reach 3rd trimester
Low-lying placenta seen in 50% of ultrasound scans at weeks
90% will have normal implantation when scan repeated at > 30 weeks
No proven benefit to routine screening ultrasound for this diagnosis

5. Risk Factors for Placenta Praevia
Previous caesarean delivery
Previous uterine instrumentation
High parity
Advance maternal age
Smoking
Multiple gestation

6. Morbidity and Placenta Praevia
Maternal haemorrhage
Operative delivery complications
Transfusion
Placenta accreta, increta or percreta
Prematurity

7. Patient History – Placenta Praevia
Painless bleeding
2nd or 3rd trimester, or at term
Often following intercourse
May have preterm contractions
“Sentinel bleed”

8. Physical Exam – Placenta Praevia
Vital signs
Assess fundal height
Fetal lie
Estimated fetal weight (Leopold)
Presence of fetal heart tones
Gentle speculum exam
No digital vaginal exam unless placental location known

9. Laboratory – Placenta Praevia
Haematocrit or complete blood count
Blood type and Rh
Coagulation tests

10. Ultrasound – Placenta Praevia
Can confirm diagnosis
Full bladder can create false appearance of anterior praevia
Presenting part may overshadow posterior praevia
Transvaginal scan can locate placental edge and internal os

11. Treatment – Placenta Praevia
With no active bleeding
Expectant management
No intercourse, digital exams
With late pregnancy bleeding
Assess overall status, circulatory stability
Full dose Rhogam if Rh-
Consider maternal transfer if premature
May need corticosteroids, tocolysis, amniocentesis

12. Double Set-Up Exam
Appropriate only in marginal praevia with vertex presentation
Palpation of placental edge and fetal head with set up for immediate surgery
Caesarean delivery under regional anaesthesia if:
complete praevia
fetal head no engaged
non-reassuring tracing
brisk or persistent bleeding
mature foetus

13. Placental Abruption Premature separation of placenta from uterine wall
Partial or complete
“Marginal sinus separation” or “marginal sinus rupture”
Bleeding, but abnormal implantation or abruption never established

14. Epidemiology of Abruption
Occurs in 1-2% of pregnancies
Risk factors
hypertensive diseases of pregnancy
smoking or substance abuse (e.g. cocaine)
trauma
overdistension of the uterus
history of previous abruption
unexplained elevation of MSAFP
placental insufficiency
maternal thrombophilia/metabolic abnormalities

15. Abruption and Trauma
Can occur with blunt abdominal trauma and rapid deceleration without direct trauma
Complications inculde prematurity, growth restriction, stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease mortality

16. Bleeding from Abruption
Externalized hemorrhage
Bloody amniotic fluid
Retroplacental clot
20% occult
“Couverlaire” uterus
Look for consumptive coagulopathy

17. Patient History - Abruption
Pain = hallmark symptom
Varies from mild cramping to severe pain
Back pain – think posterior abruption
Bleeding
May not reflect amount of blood loss
Differentiate from exuberant blood show
Trauma
Other risk factors (e.g. hypertension)
Membrane rupture

18. Physical Exam - Abruption
Signs of circulatory instability
Mild tachycardia normal
Signs and symptoms of shock represent > 30% blood test
Maternal abdomen
Fundal height
Leopold’s estimated fetal weight, fetal lie
Location of tenderness
Tetanic contractions

19. Ultrasound - Abruption
Abruption is a clinical diagnosis!
Placental location and appearance
Retroplacental echolucency
Abnormal thickening of placenta
“Torn” edge of placenta
Fetal lie
Estimated fetal weight

20. Laboratory - Abruption
Complete blood count
Type and Rh
Coagulation tests
Kleihauer-Betke not diagnostic, but useful to determine Rhogam dose
Preeclampsia labs, if indicated
Consider using drug screen

21. Sher’s Classification - Abruption
Grade I
mild, often retroplacental clot identified at delivery
Grade II
tense, tender abdomen and live fetus
Grade III
III A
III B
with fetal demise
without coagulopathy (2/3)
with coagulopathy (1/3)

22. Treatment – Grade II Abruption
Assess fetal and maternal stability
Amniotomy
IUPC to detect elevated uterine tone
Expeditious operative or vaginal delivery
Maintain urine output > 30cc/hr and haematocrit > 30%
Prepare for neonatal resuscitation

23. Treatment – Grade III Abruption
Assess mother for hemodynamic and coagulation status
Vigorous replacement of fluid and blood products
Vaginal delivery preferred, unless severe haemorrhage

24. Coagulopathy with Abruption
Occurs in 1/3 of Grade III abruption
Usually not seen if live fetus
Etiologies: consumption, DIC
Administer platelets, FFP
Give factor VIII if severe

25. Epidemiology of Uterine Rupture
Occult dehiscence vs. symptomatic rupture
% of all women
% of women with uterine scar
Previous caesarean incision most common reason for scar disruption
Other causes: previous uterine curettage or perforation, inappropriate oxytocin usage, trauma

26. Risk Factors – Uterine Rupture
adenomyosis
fetal anomaly
vigorous uterine pressure
difficult placental removal
placenta increta or percreta
pervious uterine surgery
congenital uterine anomaly
uterine overdistension
gestational trophoblastic neoplasia

27. Morbidity with Uterine Rupture
Maternal
haemorrhage with anaemia
bladder rupture
hysterectomy
maternal death
Fetal
respiratory distress
hypoxia
acidaemia
neonatal death

28. Patient History – Uterine Rupture
Vaginal bleeding
Pain
Cessation of contractions
Absence of FHR
Loss of station
Palpable fetal parts through maternal abdomen
Profound maternal tachycardia and hypotension

29. Uterine Rupture
Sudden deterioration of FHR pattern is most frequent finding
Placenta may play a role in uterine rupture
Transvaginal ultrasound to elevate uterine wall
MRI to confirm possible placenta accreta
Treatment
Asymptomatic scar disruption – expectant management
Symptomatic rupture – emergent caesarean delivery

30. Vasa Praevia Rarest cause of haemorrhage Onset with membrane rupture
Blood loss is fetal, with 50% mortality
Seen with low lying placenta, velamentous insertion of the cord or succenturiate lobe
Antepartum diagnosis
amnioscopy
colour doppler ultrasound
palpate vessels during vaginal examination

31. Diagnostic Tests – Vasa Praevia
Apt test – based on colorimetric response of fetal haemoglobin
Wright stain of vaginal bleed – for nucleated RBCs
Kleihauer-Betke test – 2 hour delay prohibits its use

32. Management – Vasa Praevia
Immediate caesarean delivery if fetal hear rate non-assuring
Administer normal saline cc/kg bolus to newborn, if found to be in shock after delivery

33. Summary
Late pregnancy bleeding may herald diagnoses with significant morbidity/ mortality
Determining diagnosis important, as treatment dependent on cause
Avoid vaginal exam when placental location not known