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Antepartum Hemorrhage/ Third trimester Bleeding

Vaginal Bleeding occurring from 24 weeks gestation to delivery

Incidence: ~2-5 % of all Pregnancies

Placental Abruption 40% ~1% of all Pregnancies Unclassified 35% Placenta Previa 20% ~.5% all pregnancies Lower Genital Tract Lesion 5% Other

Etiology Cervical:

Contact bleed Inflammation Effacement and dilatation

Placentalo Abruptiono Previao Marginal Sinus rupture

Vasa Previa Other: abnormal coagulation

Diagnostic Procedure

1. H & P : NO digital exam2. U/S3. Fetal monitoring4. Speculum5. Labs: non-diagnostic but beneficial for management

I. Placental abruption:a. Premature separation of normally implanted placenta tearing of placental blood

vesselshemorrhage into separated spaceb. Risk Factors

Maternal HypertentionAbdominal traumaCocaine use Previous abruptionOverdistended uterusSmoking Increased 2nd trimester MSAFP

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Subchronic hematomac. Classification:

Totalfetal deathPartial: fetus tolerate up to 30-50% abruption

i. Class 0: diagnosed retrospectively- organized blood clot or depressed area on delivered placenta

ii. Class 1: mildiii. Class 2: moderateiv. Class 3: severe

b. Presentation:

i. Painful unremitting vaginal bleeding

ii. Contractions

iii. fetal distress

iv.tender uterus, irritability or tetanic uterus

Concealed: blood within uterine cavity (more likely to be complete)

Complications: DIC; uterine tetany; fetal hypoxia; fetal death; Sheehan syndrome

External: blood drains through cervix

Usually smaller with minimum complications

Treatment:

Cesarean Delivery:

Uncontrollable Maternal hemorrhage

Rapidly expanding concealed hemorrhage

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Fetal distress

Rapid placental separation

Vaginal deliveries:

Placental separation limited

Reassuring FHR

Seperation extensive and fetus is dead

2. Placenta Previa: Abnormal implantation over the cervical os

Risk factors:

Previous C/S

Previous uterine surgery

Multiple gestations

Previous placenta previa

Large number of D&C

High Parity

Presentation: Painless vaginal bleeding

Sentinal bleed: first bleed and is usually very mild

Subsequent bleeds are usually much heavierhypovolemic shockDeath

Physical Exam: Soft uterus with readily palpable fetal parts

Abnormal lie with high presenting parts (if engangement of fetal head is just about pubic symphysis—previa can be ruled out)

Diagnostic test: Transabdominal U/S

False +ve associated with distended bladder

Marginal: covers margin of the os

Vaginal delivery possible if Maternal hemorrhage not too great and fetal head exerts enough pressure on placenta to push out of way and tamponade bleeding

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Complete: covers entire osimpossible for fetal passage thru canal without maternal hemorrhageC/S

Low-lying: located near the internal os

Treatment:

Reserved for large volume bleeding or drop in hematocrit

Strict pelvic rest and nothing put into vagina

Immediate C/S:

Unstoppable labor; severe hemorrhage; fetal distress

Prepare for life threatening bleed by type and screen of blood, CBC and prothrombin time

Associated with placental invasion

Complications: Hemorrhage, Placental acretta, malpresentation, & PPROM, septicemia, thrombophlebitis

3. Vasa Previa: fetal vessels running through the membranes over cervical os and under fetal presenting part

Velamentous insertion: cord running through the membrane

May insert in a possible accessory placental lobe

Rupture of fetal vesselsfetal exsanguination and death

Fetal blood volume ~80-100mL/kg i.e. loss of even small amouts of blood can be disasterous

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Risk Factors: Low lying placenta (if low lying in 2nd trimester ~20% remain so in 3rd trimester)

Accessory lobes

Multiple gestations

IVF

Diagnosis:

Rupture of membrane vaginal bleeding and fetal distress or death

U/S

Management: C/S prior to ROM

4. Previa Acretta

Adherence of placenta to endometrial cavity

Increta-Myometrium

Percreta-myometrium and serosa

Incidence/ Risk Factors:

5% occur with unscarred uterus

25% with 1 prior C/S

64% with 3 prior C/S (prior C/S with previa)

Diagnostic test:

U/S or MRI

U/S: “moth eaten” or “swiss cheese” appearance

Increased levels of MSAFP during 2nd trimester

Suspect in patient with previa and history of C/S

Management:

Abdominal total hysterectomy

Embolization

Methotrexate

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Complications: Bladder involvement (predelivery hematuria)

DIC

Need for hysterectomy

Surgical injury of ureters, bladder

ARDS

Renal Failure

Spontaneous Uterine rupture

5.Uterine Rupture

Life threat to fetus and mother (usually occurs during labor)

Risk factors:

Previous C/S

Trauma (esp MVA)

Uterine myomectomy

Uterine over distention

Placenta previa

Presentation:

Sudden onset of extreme abdominal pain

Abnormal bump in abdomen

No Uterine contractions

Regression of fetus

Management:

Immediate laparotomy with delivery of fetus

C/S not done because baby may be located outside of uterus

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