Abnormal Bleeding in Pregnancy and Labour Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Abnormal Bleeding in Pregnancy and Labour

Dr. Chitra Setya MD

Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida

Definition

Antepartum haemorrhage---It is bleeding from the genital tract after the 28th week of pregnancy and before the end of the second stage of labour .

Postpartum haemorrhage– haemorrhage following delivery.

Antepartum Bleeding

Causes• Abruptio Placentae • Placenta praevia • Rupture of uterus • Carcinoma of cervix • Trauma • Cervical polyp • Unknown origin

Placenta praevia

• Definition : The placenta is partially or totally attached to the lower uterine segment.

• Incidence : 0.5% , more common in multiparas and in twin pregnancy due to the large size of the placenta.

Placenta praevia

Types: 1. Total : internal os completely

covered. 2. Partial : internal os partially

covered 3. Marginal : edge of placenta

at the margin of int. os 4. Low lying placenta

Placenta praevia

Placenta praevia

Placenta praevia

Risk factors • Chronic hypertension • Multiparity (second or succeeding pregnancy) • Multiple gestations (i.e., twins, etc.) • Older maternal age • Previous cesarean delivery • Tobacco use • Prior uterine curettage (D&C)

Placenta praevia

Diagnosis

Symptoms: • Causeless, painless and recurrent bright-red

vaginal bleeding; • It is causeless, but may follow sexual

intercourse or vaginal examination. • It is painless, but may be associated with

labour pains . • It is recurrent, but may occur once in slight

placenta praevia lateralis.

Placenta praevia

Signs: • General examination: Depends on extent of blood loss• Abdominal examination:

•The uterus is corresponding to the period of amenorrhoea, relaxed and not tender.

Placenta praevia

•The foetal parts and heart sound (FHS) can be easily detected.

•Malpresentations, particularly transverse and oblique lie and breech presentation are more common as well as non-engagement of the head.

Placenta praevia

TreatmentAt Home• Arrange for immediate transfer

to the hospital. • No vaginal examination and no

vaginal pack, only a sterile vulval pad is applied.

Placenta praevia

• No oral intake as anaesthesia may be required.

• Antishock measures as pethidine IM, fluids and blood transfusion may be given in the way to the hospital if bleeding is severe.

Placenta praevia

At Hospital• Assessment of the patient's condition,

general and abdominal examination and resuscitation if needed.

• At least 2 units of cross matched blood should be available.

Placenta praevia

If the patient is not in labour•If the bleeding is severe, continue

antishock measures and do immediate caesarean section .

•If the bleeding is slight, look to the gestational age :

Placenta praevia

− If completed 37 weeks (36 weeks by some authors) or more, pregnancy is terminated by induction of labour or caesarean section

− If less than 37 weeks (36 weeks by others), conservative treatment is indicated till the end of 37 (or 36) weeks but not more.

Placenta praevia

Conservative treatment: •The patient is kept hospitalized with

bed rest and observation till delivery.

•Anaemia should be corrected if present.

•Observation of foetal wellbeing. •Anti-D immunoglobulin is given for

the Rh-negative mother.

Placenta praevia

If the patient is in labour: •Vaginal examination is done

using precautions. According to the findings, the patient will be delivered either vaginally or by caesarean section.

Placenta praevia

Vaginal delivery is allowed if thefollowing findings are fulfilled:

• Placenta praevia is lateralis or marginalis anterior,

• bleeding is slight, • vertex presentation, • adequate pelvis with no soft tissue

obstruction.

Caesarian section--- normal mode of delivery

Placenta praevia

Complications of Placenta Praevia• Maternal: mortality rate: 0.2%. • Foetal:

• Foetal mortality rate is 20 %. • Prematurity. • Asphyxia. • Malformations (2%).

Abruptio placenta Placental abruption is the premature separation of

a normally-implanted placenta from the uterine wall.

Risk factors :• Older maternal age • Hypertension (high blood pressure) • Tobacco, cocaine, or methamphetamine use • Clotting abnormalities • Abdominal trauma • Previous placental abruption • Uterine fibroids

Abruptio placenta

Signs and symptoms of placental abruption:

• Vaginal bleeding • Sudden onset of labor, with persistent

pain between contractions • Tenderness over uterus • Back pain • Signs of shock if blood loss is significant

Abruptio placenta

Management -- Depends on gestational age and status of mother & fetus

- live& mature fetus– immediate caesarian section with fluid & blood replacement

- maternal condition stable with premature fetus – expectant management under close supervision

- severe placental abruption with a dead fetus – vaginal delivery preferred

Antepartum bleeding

• Rupture of uterus • Carcinoma of cervix • Trauma • Cervical polyp • Unknown origin

Post partum haemorrhage

Defined as the loss of 500ml or more of blood after completion of the third stage of labour

Causes: -- Uterine atony -- Retained placenta -- Genital lacerations- vaginal,

cervical tears


Uterine atony : Causes Large infant, forceps delivery, intrauterine

manipulation, use of anaesthetic agents, multiple fetuses.

Treatment:• Manual removal of the placenta• Oxytocin- 20 units in 1000ml fluid IV• Methylergonovine 0.2 mg IM• Prostaglandins 0.25mg IM


Retained placenta > 30 minutes seen in ~ 6% of deliveries.

• Risk increased with: prior C/S, curettage , uterine infection, increased parity.

• Most patients have no risk factors. • Occasionally succenturiate lobe left behind.• Attempt to remove the placenta by usual

methods. • Excess traction on cord may cause cord tear or

uterine inversion.


Birth trauma• Vaginal, cervical tears --- to be repaired• Hematoma --- drain

Absent fetal movements

Dr. Chitra Setya MD

Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital

Noida

Fetal Movements First fetal movement occurs around 8-9

weeks For primiparas fetal movement often not felt

till 18wks or later For multiparas fetal movement is felt around

15 –16 wks Simplest and oldest form of fetal welfare

assessment

Fetal movements

Procedure:

The test is valid after 30 weeks of pregnancy.

The mother counts the fetal movements in 3 hours during the period of 12 hours e.g. from 9 am to 9 p.m , - The count is multiplied by 4 to get the fetal movements in 12 hours. If count < 10 – further testing

Fetal movements

Count-to -ten Cardiff system : 10 movements in 12 hrs

Cessation of the fetal movement 12-24 hours before stoppage of the heart ---"movement alarm signal".

Fetal movements

Advantages:

- Informative and non-invasive.

- Pregnant woman can monitor herself.

- No cost. - Accurate gestational age not required.

Fetal movementsDrawbacks: - Awareness of the fetal movement differs from

mother to mother. - Cessation of fetal movement may occur due to

intrauterine sleep. - Sedation of the fetus occurs if mother is on sedatives. - Sudden death of the fetus may occur without

preceding slowing of the fetal movement as in abruptio placenta or it may be preceded by increased flurry movements.

Fetal movements

Assessment of fetal activity

1. Maternal perception

2. Tocodynamometer

3. Ultrasound Fetuses have sleep- activity cycles with sleep

cycles extending upto 23 min. Activity decreases with decreased amniotic fluid

volume

Fetal movements

Electronic monitoring

Non Stress test

Done with 2 transducers placed to assess fetal heart

and uterine contractions

Fetal movements

Fetal movementsNSTReactive test: Two or more fetal movements are accompanied by

acceleration of FHR of 15 beats/ minute for at least 15 seconds’ duration. Reactive test means that the fetus can survive for one week, so the test should be repeated weekly.

Non -reactive test: No FHR acceleration in response to fetal movements

so contraction stress test is indicated.

Fetal movements

Ultrasound Doppler monitoringCheck the FHR, Fetal movements and the

blood flow to the uterus and the baby

Pregnancy outcomePregnancy outcome was the same for mothers

who measured fetal movements and those who did not but it is still considered good for early detection of fetal well being as well for mother– baby bonding

Fetal Movements

ACOG recommendations

Daily fetal kick count to be maintained in

the 3rd trimester

Notify the health provider if the count is

decreased

Fetal Movements

Summary- Fetal movement record is a simple ,harmless

& cost effective way to assess fetal well – being

- Pregnancies with decreased fetal movements are at an increased risk of adverse pregnancy outcome

- It also helps in “Bonding” between the mother and fetus

Premature rupture of Premature rupture of membranesmembranes

Dr. Chitra SetyaDr. Chitra Setya MDMD

Sr. Consultant Obstetrician and Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital NoidaGynaecologist, Apollo Hospital Noida

Premature rupture of membranesPremature rupture of membranes

Rupture of membranes before the onset of labourRupture of membranes before the onset of labourat any stage of gestationat any stage of gestation

Occurs in 3% of all pregnanciesOccurs in 3% of all pregnancies

Responsible for 1/3Responsible for 1/3rdrd causes of preterm birth causes of preterm birth

Causes significant fetal complications– sepsis,Causes significant fetal complications– sepsis,prematurity, cord prolapse, abruptio placenta, fetalprematurity, cord prolapse, abruptio placenta, fetaldeathdeath


Risk FactorsRisk FactorsLower socioeconomic classLower socioeconomic classPrevious preterm birthPrevious preterm birthH/O STDH/O STDMultiple pregnancyMultiple pregnancyPolyhydramniosPolyhydramniosProcedures– cervical Procedures– cervical encirclage,amniocentesisencirclage,amniocentesis


DiagnosisDiagnosis

HistoryHistory

ExaminationExamination

Vaginal swabVaginal swab

Ultrasound assessment Ultrasound assessment

-- amniotic fluidamniotic fluid

- fetal assessment- fetal assessment


Treatment ---Treatment --- depends on depends on

- - gestational age, gestational age,

- - amount of amniotic fluidamount of amniotic fluid

- fetal state- fetal state

- infection- infection


Expectant managementExpectant managementAntibiotic therapyAntibiotic therapy -- Ampicillin with Metronidazole -- Ampicillin with MetronidazoleCorticosteroid therapy-Corticosteroid therapy- to accelerate lung maturity to accelerate lung maturity Betamethasone 12mg I/M 24hrs apart –2 dosesBetamethasone 12mg I/M 24hrs apart –2 doses Dexamethasone 5mg 12 hrly - 4 dosesDexamethasone 5mg 12 hrly - 4 dosesTocolyticsTocolytics- to delay onset of- to delay onset of labour labourRisks Risks Maternal risksMaternal risks– infection– infectionFetal risksFetal risks– pulmonary hypoplasia, limb– pulmonary hypoplasia, limbabnormalities,infectionabnormalities,infection


Summary of treatmentSummary of treatment History, examination, USG History, examination, USG

24 – 31 wks 32 – 33 wks 34 – 36 wks24 – 31 wks 32 – 33 wks 34 – 36 wks

Bed rest Bed rest AntibioticsBed rest Bed rest Antibiotics

Antibiotics Antibiotics DeliverAntibiotics Antibiotics Deliver

Steroids SteroidsSteroids Steroids

Deliver 34 wks Deliver 34 wksDeliver 34 wks Deliver 34 wks


ComplicationsComplicationsDelivery within one weekDelivery within one weekRespiratory distress syndromeRespiratory distress syndromeCord compressionCord compressionCord prolapseCord prolapseChorioamnionitisChorioamnionitisAbruptio placentaeAbruptio placentaeAntepartum fetal deathAntepartum fetal death

Molar PregnancyMolar Pregnancy

Dr. Chitra SetyaDr. Chitra Setya MDMD

Sr. Consultant Obstetrician and Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital NoidaGynaecologist, Apollo Hospital Noida


Definition and EtiologyDefinition and Etiology Hydatidiform mole is a pregnancy characterized Hydatidiform mole is a pregnancy characterized

by vesicular swelling of placental villi and usually by vesicular swelling of placental villi and usually the absence of an intact fetus. the absence of an intact fetus.

The etiology -- unclear, but appears to be due to The etiology -- unclear, but appears to be due to abnormal gametogenesis and fertilization abnormal gametogenesis and fertilization

Incidence-- 1 out of 500-600Incidence-- 1 out of 500-600


Risk factorsRisk factors 1. Maternal age > 40 years1. Maternal age > 40 years < 15 years < 15 years 2. Paternal age > 45 years 2. Paternal age > 45 years

3. Previous hydatidiform mole 13. Previous hydatidiform mole 1stst: 1% , 2: 1% , 2ndnd 15-28% 15-28% 4. Vitamin A deficiency 4. Vitamin A deficiency 5. Consanguinous marriages5. Consanguinous marriages 6. Previous spontaneous abortion6. Previous spontaneous abortion 7. More common in orients7. More common in orients


Molar pregnancyMolar pregnancy - Complete- Complete

- Partial- Partial

Complete moleComplete mole - Mass of tissue is completely - Mass of tissue is completely made up of abnormal cells made up of abnormal cells

There is no fetus and nothing can be found at the There is no fetus and nothing can be found at the time of the first scantime of the first scan. .

Partial molePartial mole - Mass may contain both these - Mass may contain both these abnormal cells and often a fetus that has severe abnormal cells and often a fetus that has severe defects.defects.


HistoryHistoryAmenorrhoeaAmenorrhoea

Vaginal bleedingVaginal bleeding

Excessive nausea & vomitingExcessive nausea & vomiting

Passage of vesiclesPassage of vesicles

ExaminationExaminationUterine size> period of pregnancyUterine size> period of pregnancy

Soft boggy feel of uterus- with no fetal parts feltSoft boggy feel of uterus- with no fetal parts felt

Signs of anaemiaSigns of anaemia


Diagnosis of hydatidiform moleDiagnosis of hydatidiform mole

Quantitative beta-HCG – value > 10,000mIU/mlQuantitative beta-HCG – value > 10,000mIU/ml

Ultrasound is the standard criterion for Ultrasound is the standard criterion for identifying both complete and partial molar identifying both complete and partial molar pregnancies. The classic image is of a pregnancies. The classic image is of a “snowstorm” pattern“snowstorm” pattern


Signs and Symptoms of CompleteSigns and Symptoms of Complete

Hydatidiform Mole Hydatidiform Mole Vaginal bleeding Vaginal bleeding Hyperemesis ( severe vomiting)Hyperemesis ( severe vomiting) Size inconsistent with gestational age( with no Size inconsistent with gestational age( with no

fetal heart beating and fetal movement)fetal heart beating and fetal movement) PreeclampsiaPreeclampsia Theca lutein ovarian cysts Theca lutein ovarian cysts


Signs and Symptoms of Partial HydatidiformSigns and Symptoms of Partial HydatidiformMoleMole

Vaginal bleeding Vaginal bleeding Absence of fetal heart tones Absence of fetal heart tones Uterine enlargement and preeclampsia is Uterine enlargement and preeclampsia is

reported in only 3% of patients. reported in only 3% of patients. Theca lutein cysts, hyperemesis is rare.Theca lutein cysts, hyperemesis is rare.


Differential diagnosis Differential diagnosis

Abortion Abortion Multiple pregnancy Multiple pregnancy PolyhydramniosPolyhydramnios


Treatment Treatment

Suction dilation and curettageSuction dilation and curettage : : Complete evacuation of the uterusComplete evacuation of the uterus USG to confirm complete evacuationUSG to confirm complete evacuation Serum Serum ββ-HCG weekly till undetectable & monthly for 6 -HCG weekly till undetectable & monthly for 6

monthsmonths Serum Serum ββ- HCG expected to be undetectable by8-12 wks- HCG expected to be undetectable by8-12 wks Advise contraception till then– condoms, OC pills after Advise contraception till then– condoms, OC pills after

HCG negativeHCG negative


Indications for chemotherapyIndications for chemotherapy Serum B-HCG >20,000IU/L or urinary B-HCG > Serum B-HCG >20,000IU/L or urinary B-HCG >

30,000 IU/L 4 wks post evacuation30,000 IU/L 4 wks post evacuation Rising level of B- HCG anytime post evacuationRising level of B- HCG anytime post evacuation Positive B-HCG levels 6 mths post evacuationPositive B-HCG levels 6 mths post evacuation Evidence of metastasisEvidence of metastasis Persistant vaginal bleeding with +ve B- HCGPersistant vaginal bleeding with +ve B- HCG Methotrexate is the drug usedMethotrexate is the drug used

RCOG RecommendationsRCOG Recommendations

1.1. Ultrasound has limited value in detecting partial molar pregnancies. Ultrasound has limited value in detecting partial molar pregnancies.

2.2. In twin pregnancies with a viable fetus and a molar pregnancy, the In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed. pregnancy can be allowed to proceed.

3.3. Surgical evacuation of molar pregnancies is advisable. Surgical evacuation of molar pregnancies is advisable.

4.4. Routine repeat evacuation after the diagnosis of a molar pregnancy is Routine repeat evacuation after the diagnosis of a molar pregnancy is not warranted. not warranted.

5.5. Registration of any molar pregnancy is essential. Registration of any molar pregnancy is essential.

6.6. The combined oral contraceptive pill and hormone replacement therapy The combined oral contraceptive pill and hormone replacement therapy are safe to use after hCG levels have reverted to normal. are safe to use after hCG levels have reverted to normal.

7.7. Women should be advised not to conceive until the hCG level has been Women should be advised not to conceive until the hCG level has been normal for six months or follow-up has been completed (whichever is normal for six months or follow-up has been completed (whichever is the sooner). the sooner).

Grade C recommendation

Documents

Abnormal Bleeding in Pregnancy and Labour Dr. Chitra Setya MD Sr. Consultant Obstetrician and Gynaecologist, Apollo Hospital Noida