1. If you are a doctor
In the midnight, the pregnant women awakens to find that they have to sleep in a pool of blood

2. You
How to diagnosis？
How to management？

3. Antepartum Hemorrhage
Obstetrics & Gynecology Hospital of Fudan University
Xu Huan

4. Rationale (why we care…)
4-5% of pregnancies complicated by 3rd trimester bleeding
Immediate evaluation needed
Significant threat to mother & fetus
(consider physiologic increase in uterine blood flow)
Consider causes of maternal & fetal death
Priorities in management (triage!)

5. Objectives We will be able to:
Describe the approach to the patient with third-trimester bleeding
Compare symptoms, physical findings, and diagnostic methods that differentiate bleeding etiologies
Describe management and delivery options for 3rd trimester bleeding etiologies
Describe potential maternal and fetal morbidity & mortality
Describe management of postpartum hemorrhage
Apply knowledge in the discussion of clinical case scenarios

6. Vaginal Bleeding: Differential diagnosis
Common:
Abruption, previa, preterm labor, labor
Less common:
Uterine rupture, fetal vessel rupture, lacerations/lesions, cervical ectropion, polyps, vasa previa, bleeding disorders
Unknown
NOT vaginal bleeding!!!
(happens more than you think!)

7. Other Etiologies Cervicitis infection Cervical erosion Trauma
Cervical cancer
Foreign body
Bloody show/labor

8. Perinatal mortality and morbidity
Previa
Decreased mortality from 30% to 1% over last 60 years
Now emergent cesarean delivery often possible
Risk of preterm delivery
Abruption
Perinatal mortality rate 35%
Accounts for 15% of 3rd trimester stillbirths
Most common cause of DIC in pregnancy
Massive hemorrhage --> risk of acute renal failure, Sheehan’s, etc.

9. Placenta previa

10. Definition
After 28 pregnant weeks placental implantation over the cervical os or in the lower uterine segment
It constitutes an obstruction of descent of the presenting part
Main cause of obstetrical hemorrhage(20%)
Incidence
0.24%-1.57% (our country).

11. Risk factors Prior cesarean delivery/myomectomy
Prior previa (4-8% recurrence risk)
Previous abortion
Increased parity
Multiple pregnancy
Advanced maternal age
Abnormal presentation
Smoking

12. Etiology Causes Endometrial abnormality
Scared or poorly vascularized endometrium in the corpus.
Curettage, Delivery, CS and infection of endometrium
Placental abnormality
Large placenta (multiple pregnancy), succenturiate lobe
Delayed development of trophoblast

13. Marginal placenta previa
Classification
Complete
placenta previa
Partrial
placenta previa
Marginal placenta previa

14. Classification

16. Symptoms(1) Painless vaginal bleeding (70%) Spontaneous,After coitus
The most characteristic symptom
late pregnancy (after the 28th week) and delivery
Characteristics: sudden, painless and profuse
Contractions
No symptoms
Routine ultrasound finding
The mean gestational age of first bleed: 30 wks
1/3 before 30 weeks

17. Symptoms(2) Anemia or shock repeated bleeding→ anemia
heavy bleeding→ shock
Abnormal fetal position
a high presenting part
breech presentation (often)

18. Physical Findings Bleeding on speculum exam Cervical dilation
Abnormal position/lie
Non-reassuring fetal status
If significant bleeding:
Tachycardia
Postural hypertension
Shock

19. Diagnosis(1) History Painless hemorrhage At late pregnancy or delivery
History of curettage or CS

20. Diagnosis(2) Signs Abdominal findings
Uterus is soft, relaxed and nontender.
Contraction may be palpated.
A high presenting part can’t be pressed into the pelvic inlet. (Breech presentation)
Fetal heart tones maybe disappear (shock or abruption)

21. Diagnosis(3) Speculum examination
Rule out local causes of bleeding, such as cervical erosion or polyp or cancer.
Limited vaginal examination (seldom used)
Palpation of the vaginal fornices to learn if there is an intervening bogginess between the fornix and presenting part.
Rectal examination is useless and dangerous

22. Limited vaginal examination

23. Diagnosis(4) Ultrasound abdominal 95% accurate to detect
transvaginal (TVUS) will detect almost all
consider what placental location a TVUS may find that was missed on abdominal
MRI
Check the placenta and membrane after delivery
remember: no digital exams unless previa RULED OUT!

25. Diagnosis(5)
Before 20 weeks’ gestation,4-6% have some degree of placenta previa on ultrasonic examination
90% of these resolving by the third trimester
Only 10% of complete placenta

26. Differential Diagnosis
Placental abruption
vagina bleeding with pain, tenderness of uterus.
vasa previa
In cases of velamentous cord insertion fetal vessels cover cervical os
Abnormality of cervix
cervical erosion or polyp or cancer

27. Velamentous placenta
vasa previa

28. vasa previa

29. Effects obstetrical hemorrhage Placenta accreta, increta, and percreta
Anemia and infection
Premature labor or fetal death or fetal distress

30. A B
Abnormally adherent placentation. A. Placenta accreta. B. Placenta increta. C. Placenta percreta C

31. Management(1)
Less than 36 wks gestation - expectant management if stable, reassuring
Rest: keep the bed
No vaginal exams (not negotiable)
Steroids for lung maturation (<32 wks)
Controlling the contraction: MgSO4
Treatment of anemia
Preventing infection
70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean

32. Management(2) Initial evaluation/diagnosis
Observe/admit to Labor & Delivery
Intravenous access, routine (maybe serial) labs
Continuous electronic fetal monitoring
Continuous at least initally
May re-evaluate later if stable, no further bleeding
Delivery???

33. Management Termination of pregnancy CS
total placenta previa (36th week), Partial placenta previa (37th week) and heavy bleeding with shock
Preventing postpartum hemorrhage: pitocin and PG
Hysterectomy: Placenta accreta or uncontroled bleeding

34. Cesarean hysterectomy specimens with placenta percreta.
A. Total placenta previa with percreta involving the lower uterine segment and cervical canal. Black arrows show the invading line of the placenta through the myometrium
Cesarean hysterectomy specimens with placenta percreta.

35. B. Lateral fundal percreta caused hemoperitoneum in late pregnancy.
Cesarean hysterectomy specimens with placenta percreta. (Lateral fundal percreta caused hemoperitoneum in late pregnancy )

36. Management 36+ weeks gestation
Cesarean delivery if positive fetal lung maturity by amniocentesis
Delivery vs expectant management if fetal lung immaturity
Schedule cesarean delivery at 37 weeks
Discussion/counseling regarding cesarean hysterectomy
Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why Obstetrics is so much fun!)

37. Other Considerations Placenta accreta, increta, percreta
Cesarean delivery may be necessary
History of uterine surgery increases risk
Must consider these diagnoses if previa present
Could require further evaluation, imaging (MRI considered now)
NOT the delivery you want to do at 2 am

38. Management Vaginal delivery Marginal placenta previa (＞2cm)
Vaginal bleeding is limited

39. Placental abruption

40. Definition
abruptio placentae or placental abruption: placental separation from its implantation site before delivery (the normally implanted placenta )
Incidence
complicates % of all pregnancies
recurrence risk
10% after 1st episode
25% after 2nd episode

41. Risk factors & Associations
Cocaine
maternal hypertension
abdominal trauma
smoking
prior abruption
preeclampsia
multiple gestation
prolonged PROM
uterine decompression
short umbilical cord
chorioamnionitis
multiparity

43. Pathology
Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma
Concealed hemorrhage
Revealed hemorrhage

44. revealed hemorrhage
concealed hemorrhage
mixed hemorrhage

45. Total placental abruption with concealed hemorrhage and fetal death

47. Maternal-fetal risk perinatal mortality: 35% DIC hypovolemic shock
acute renal failure
Sheehan’s syndrome

49. Symptoms Vaginal bleeding Abdominal or back pain Uterine contractions
Uterine tenderness

50. Physical Findings Vaginal bleeding Uterine contractions Hypertonus
Tetanic contractions
Non-reassuring fetal status or demise
Can be concealed hemorrhage

52. Laboratory Findings Anemia DIC
may be out of proportion to observed blood loss
DIC
Can occur in up to 10% (30% if “severe”)
First, increase in fibrin split products
Followed by decrease in fibrinogen

53. Diagnosis Clinical scenario Physical exam Ultrasound
Not digital pelvic exams until rule out previa
Careful speculum exam
Ultrasound
Can evaluate previa
Not accurate to diagnose abruption

54. Management Physical exam Continuous electronic fetal monitoring
Ultrasound
Assess viability, gestational age, previa, fetal position/lie
Expectant management
vaginal vs cesarean delivery
Available anesthesia, OR team for cesarean delivery

55. Partial placental abruption with adhered clot

56. Couvelaire Uterus

57. A bimanual compression
腹壁子宫按摩法
腹部-阴道双手压迫子宫法

58. Packing the uterine cavity

59. B-lynch/Bind suture
正面观
背面观
Flash

61. Cho/patch suture

62. Ligation of the utering arteries

64. Management Careful maternal hemodynamic monitoring Fetal monitoring
Serial evaluation of the hematocrit, coagulation profile,delivery
Blood products for replacement
A large-bore intravenous line

65. Thank you!