Vaginal Bleeding in

Late Pregnancy

Presented ByNirsuba Gurung Master in nursing

Women health and development

Obstetric Haemorrhage

Ranks as the First cause of maternal mortality accounting for 25 – 50 % of maternal deaths

APH: Epidemiology & Causes Magnitude: 4% of women may

develop APH. Causes:

placenta previa (1/200) placental abruption (1/100) uterine rupture (<1% in scarred uterus) vasa previa (1/2000-3000) Local causes

Cervical polyp Bloody show Cervicitis or cervical ectropion Cervical cancer

Vasa Previa

Velamentous Insertion of the umbilical cord

ABRUPTIO PLACENTA Definition:

Early separation of the normally implanted placenta after 28/40 and before the end of second stage of labour

Recurrence: The risk of recurrent abruption in a

subsequent pregnancy is high.

Epidemiology of Abruption Occurs in 1-2% of pregnancies

20% of all third-trimester bleeders

Recurrence risk 10% in first pregnancy 25% in second pregnancy

Epidemiology of Abruption It is a significant cause of

perinatal mortality – 15-20%

Maternal mortality- 2-5%

Risk factors

Prevalence is high in Smoking or substance abuse (e.g.

cocaine) History of previous abruption High birth order Advancing maternal age Poor-socioeconomic condition Malnutrition Placental insufficiency

Risk factors

Etiology Hypertension in pregnancy

•Spasm of utero-placental blood vessels

•Anoxic endothelial damage

•Rupture of vessels or•Extravasations' of blood in decidual basalis

Trauma External cephalic version RTA Needle puncture during

amoiocentesis

Sudden uterine decompression

Delivery of first twins Sudden escape of liquor amnii in

hydraminous Premature rupture of membrane

Short cord Supine hypotension syndrome Placental anomaly Sick placenta Folic acid deficiency Uterine anomaly Thrombophilias

Pathogenesis

Umbilical artery (UA)Umbilical vein (UV)

Uterine arteries

Uterine veins

Abruption

Archer TL 2006 unpublished

Placental abruption: fetal asphyxiation (O2 supply is cut off).

Placental abruption with trauma

Elastic myometrium

Liquid placenta

Placenta shears off

Miller’s Anesthesia chap. 58

Occult hemorrhage in abruption

Features of retroplacental clots Depression found in maternal

surface of placenta

Area of infraction with varying degree of organization

Abruptio placenta: Classifications

Are based on1.Extent of separation: Partial vs

complete 2.Location of separation: Marginal Vs

central 3.Clinical presentation: Revealed,

concealed and mixed4.Clinical Severity: Mild, Moderate and

Severe

Grade 1 Mildest form: approx 40 of all cases.

• No vaginal bleeding to mild vaginal bleeding

• Slightly tender uterus

• Normal maternal BP and heart rate

• No coagulopathy (clotting problems)

• No fetal distress

Clinical Severity

Grade 2: moderate -approx

45% of all cases. • No vaginal bleeding to

moderate vaginal bleeding• Moderate-to-severe uterine

tenderness with possible tetanic contractions

• Maternal tachycardia with orthostatic changes in BP and heart rate

• Fetal distress or even death • Low fibrinogen levels present

(causing clotting problems)

Grade 0: no clinical features• Diagnosis made after placental exmaninatio

Grade 3: Severe form: Approx 15% of all cases.

• No vaginal bleeding to heavy vaginal bleeding• Very painful tetanic uterus• Maternal shock• Coagulopathy• Fetal death

Clinical Severity

Abruptio Placenta: Features

Pain and tenderness Initially localized then becomes

generalized due to endometrial injury – extravasations of blood

Vaginal bleeding Maternal distress Often I.U.F.D

Clinical manifestation of hemorrhage Concealed type: blood

accumulates behind placenta Revealed type: blood dissect

downwards between membranes and uterine wall and ultimately escape out through the cervix or may be kep concealed by the pressure of fetal head on the lower uterine segment

Clinical manifestation of hemorrhage Blood may gain access to the

amniotic cavity after rupturing the membrane

Couvelaire uterus : blood may percolate through the layer of myometrium

Couvelaire uterus Naked eye features

Dark port wine color:patchy and diffused

Sub peritoneal petechial hemorrhage

Free blood may be present in peritoneal cavity

Couvelaire uterus Microscopic appearance:

Necrosed uterine muscles in the affected part

Blood infiltration between the muscle bundle

Blood vessels may show acute degenerative changes

Muscular dissociation occurs in middle and outer muscle layer

Clinical features

Revealed Mixed(Concealed features predominate)

Symptoms Abdominal bleeding and discomfort followed by bleeding

Acute, intense abdominal pain followed by slight bleeding

Character of bleeding Continuous dark color Continuous dark color or blood stained serous discharge

General condition Proportionate to the visible blood loss, shock is usually absent

Shock may be pronounced which is proportionate to the visible blood loss

Pallor Related with visible blood loss

Pallor is usually severe and out of proportion to the visible blood loss

Features of pre-eclampsia

May be absent Frequent association

Revealed Mixed(Concealed features predominate)

Uterine height Proportionate to the POG

May be disproportionately enlarged and globular

Uterine feel Normal feel with localized tenderness, contractions frequent and local amplitude

Uterus is tense ,tender and rigid

Fetal parts Can be identified easily

Difficult to make out

FHS Usually present Usually absent

Laboratory test Revealed Mixed(Concealed

features predominate) Hemoglobin Low value proportionate to

the blood loss Markedly lower than vi

Coagulation profile Usually unchanged Variable changes •Clotting time increased(>6min)•Fibrinogen level low(<150mg/dl)•Low platelet count•^ Partial thromboplastin time•^ FDP and D-dimer

Urine for protein Confusion in diagnosis

May be absent Usually present

Confusion in diagnosis Placenta previa Acute obstretrical-gynaecological –surgical complication

Ultrasound - Abruption Abruption is a clinical diagnosis! Placental location and appearance

Retroplacental echolucencyAbnormal thickening of placenta“Torn” edge of placenta

Fetal lie Estimated fetal weight

Large, extensive sonographic preplacental collection beneath the chorionic plate

 Large, retroplacental sonographic abruption between the placenta and uterus.

Sonographic blood collection at the placental margin

Laboratory - Abruption Complete blood count Type and Rh Coagulation tests + “Clot test” Kleihauer-Betke not diagnostic, but

useful to determine Rhogam dose Preeclampsia labs, if indicated Consider urine drug screen

Sher’s Classification - Abruption Grade I

Grade II

Grade III with fetal demise III A - without coagulopathy

(2/3) III B - with coagulopathy

(1/3)

mild, often retroplacental clot identified at delivery

tense, tender abdomen and live fetus

Placental Abruption: Complications Shock Acute renal failure

Cause: ?seriously impaired renal perfusion 2° to ↓CO and intrarenal vasospasm as in preeclampsia

DIC Consumptive coagulopathy 2° to

hypofibrinogenemia along with elevated levels of fibrinogen–fibrin degradation products

Placental Abruption: Complications Fetal distress/demise PPH Couvelaire Uterus:

Widespread extravasation of blood into the uterine musculature and beneath the uterine serosa.

Sheehan syndrome Puerperal sepsis

Placental Abruption: Management Prevention : Aim

Elimination of the known factorsCorrection of anemia Prompt detection and institution

of the therapy to minimize complication

Prevention of known factors Early detection and effective

therapy Needle puncture: USG guided Avoidance of trauma Avoid sudden decompression of

the uterus To avoid supine hypotension Routine administration of folic acid

Placental Abruption: Management Management depends on:

fetal maturity, degree of severity, viability of the fetus/fetal distress

Assessment of case Blood loss Maturity of fetus Whether patient is in labor or not Presence of complication Types and grade of abruption

Emergency measures Sent blood for Hb and hematocrit,

coagulation profile, ABO and Rh grouping

Urine for detection of protein IV RL drip with wide bore cannula

and arrangement for BT Close monitoring of maternal and

fetal well being

Treatment modalities

Expectant management of pregnancy

Definitive management Induction/augmentation of labor

Caesarean section

If patient in labor Low Rupture of membrane Augmentation

Bed site clotting timeDone regularly

Vaginal delivery Limited placental abruption Reassuring FHS Facilities of continous FHS

monitoring Prospect of vaginal delivery is soon Placental abruption with dead

fetus

The patient not in labor Bleeding continues > grade 1 abruption

Delivery either by • Induction of labor• C/S

Placental Abruption: General Management

1. Delivery Resuscitation

FFP, whole blood, IV fluids Monitor BP Catherization - monitor urine

output

Placental Abruption: General Management

2. Caesarean Section Indications for Caesarean Section

salvageable baby, Severe vaginal bleeding,Poor progress,Transverse lie, inadequate pelvis

Post delivery -watch out for PPHMyometrial myofibrin loose contractilityFailure to clot

Expectant management If bleeding stopped Grade 1 Fetus reactive and remote from

term

Goal : prolong pregnancy Meanwhile administer

betamethasone for fetal lung maturity