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If you are a doctor

If you are a doctor. In the midnight, the pregnant women awakens to find that they have to sleep in a pool of blood. How to diagnosis ？ How to management ？. You. Antepartum Hemorrhage. Obstetrics & Gynecology Hospital of Fudan University Xu Huan. Rationale (why we care…).

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If you are a doctor

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  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. How to diagnosis？ How to management？ You

  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 • Risk of preterm delivery • 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. Classification Complete placenta previa Partrial placenta previa Marginal placenta previa

  14. Classification

  15. 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

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

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

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

  19. 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)

  20. 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

  21. Limited vaginal examination

  22. 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!

  23. 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

  24. 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

  25. Velamentous placenta vasa previa

  26. vasa previa

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

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

  29. 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

  30. 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???

  31. 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

  32. Cesarean hysterectomy specimens with placenta percreta.

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

  34. 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!)

  35. 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

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

  37. Placental abruption

  38. Definition • abruptio placentae or placental abruption: placental separation from its implantation site before delivery (the normally implanted placenta ) • Incidence • complicates 0.5-1.5% of all pregnancies • recurrence risk • 10% after 1st episode • 25% after 2nd episode

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

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

  41. revealed hemorrhage concealed hemorrhage mixed hemorrhage

  42. Total placental abruption with concealed hemorrhage and fetal death

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

  44. Symptoms • Vaginal bleeding • Abdominal or back pain • Uterine contractions • Uterine tenderness

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

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