Antepartum Hemorraghe. FIRST TRIMESTER BLEEDING Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women

Antepartum Hemorraghe

FIRST TRIMESTER BLEEDING

Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women

It may be any combination of light or heavy, intermittent or constant, painless or painful.

FIRST TRIMESTER BLEEDING

The four major sources of bleeding in early pregnancy are:

Ectopic pregnancy

Miscarriage (threatened, inevitable, incomplete, complete)

Implantation of the pregnancy

Cervical, vaginal, or uterine pathology (eg, polyps, inflammation/infection, trophoblastic disease

SECOND AND THIRD TRIMESTER BLEEDING

Vaginal bleeding is less common in the second and third trimesters. The major causes of bleeding at these times are:

Bloody show associated with cervical insufficiency or labor

Placenta previa

Abruptio placenta

Uterine rupture

Vasa previ

Abruptio Placenta

Definition

Placental abruption is defined as decidual hemorrhage leading to the premature separation of the placenta prior to delivery of the fetus.

Causes

The immediate cause of the premature placental separation is often the rupture of maternal vessels in the decidua basalis, where it interfaces with the anchoring villi in the placenta

Incidence

Placental abruption complicates about 1 in 100 births, and an abruption severe enough to result in stillbirth occurs in about 1 in 830 deliveries

COMPLICATIONS OF PLACENTAL ABRUPTION

Maternal

Hypovolemia related to blood loss

Need for blood transfusion

Disseminated intravascular coagulopathy

Renal failure

Adult Respiratory Distress Syndrome

Multisystem organ failure

Death

COMPLICATIONS OF PLACENTAL ABRUPTION

Fetal

Growth restriction (with chronic abruption) [1-6]

Fetal hypoxemia or asphyxia

Preterm birth [1,2]

Perinatal mortalit

INITIAL MANAGEMENT

Patients suspected to have a placental abruption should have a rapid initial evaluation

Subsequent management is determined on a case-by-case basis, and will depend upon the severity of the abruption, the gestational age, and maternal and fetal status

INITIAL MANAGEMENT

Continuous fetal monitoring should be initiated immediately, given the high likelihood of diminished placental perfusion

Most serious maternal risks are due to hypovolemia

It is important to immediately secure two wide-bore intravenous lines

INITIAL MANAGEMENT

The mother's hemodynamic status is closely monitored

In severe cases, a Foley catheter should be inserted to monitor maternal urine output hourly. The urine output should be maintained at above 30 ml/hour.

INITIAL MANAGEMENT

A complete blood count, blood type and Rh, and coagulation studies are obtained

A low fibrinogen level is the most sensitive indicator of coagulopathy related to abruption

Prolongation of the prothrombin time (PT) and partial thromboplastin time (PTT) does not occur with small degrees of placental separation

INITIAL MANAGEMENT

Blood loss should be evaluated carefully

It is frequently underestimated since the bleeding may be largely concealed, and the actual loss may be much more than observed

Blood and blood coagulation replacement products should be readily available

INITIAL MANAGEMENT

Ultra Sound should be performed in stable patients, if possible

While some studies have reported poor sensitivity of ultrasound in the diagnosis of placental abruption, others have found that ultrasound can be an accurate tool in diagnosis

The presence of sonographic features of abruption has a very high positive predictive value, and may influence management

Blood and Blood Product Replacement

Maintain the hematocrit above 30 percent

Each unit of 300 mL PRBC’s contains approximately 200 mL of red cells and will raise the hematocrit by roughly 3 to 4 percent

Give six units of platelets to patients with marked thrombocytopenia (<20) or moderate thrombocytopenia (< 50) with serious bleeding or planned cesarean deliver


Fresh frozen plasma or cryoprecipitate is indicated for fibrinogen level < 150 mg/dL, with the goal of raising he level to 150 to 200 mg/dL

Fresh frozen plasma provides more volume than cryoprecipitate depending on the patient's cardiovascular status


If multiple transfusions are given because of severe bleeding, the coagulation system should be frequently monitored with measurements of the PT, PTT and platelet count, preferably after each five units of blood are replaced

If the PT and PTT exceed 1.5 times the control value, the patient should be transfused with two units of fresh frozen plasma

If the platelet count falls below 50,000/microL, six units of platelets should be given

SUBSEQUENT MANAGEMENT

Subsequent management of pregnancies complicated by abruption depends primarily on:

The fetus (alive or dead)

Maternal status

Live fetus at or near term

The fetus should be delivered by the quickest, safest method if it is alive, the pregnancy is at least 34 weeks of gestation, and abruption is suspected


Vaginal delivery requirements:

Maternal status is stable

Fetal heart tracing is reassuring with continuous monitoring

Preparating for emergency cesarean section


Cesarean delivery indications:

Fetal heart tracing is nonreassuring

There is ongoing major blood loss or other serious maternal complications

Fetal Demise

The mode of delivery should be one that minimizes the risk of maternal morbidity or mortality

Vaginal delivery is preferable unless urgent delivery is needed to enable stabilization of the mother or there are obstetrical contraindications to vaginal birth

Since the patient is often contracting vigorously, amniotomy may be all that is required to expedite delivery

Oxytocin can be given, if needed to augment labor

Fetal Demise

The frequency of coagulopathy is much higher in abruptions in which fetal death has occurred

Blood pressure, pulse, urine output and blood loss should be monitored closely

Blood, fresh frozen plasma, platelets, and cryoprecipitate should be readily available and given liberally.

Placenta Previa

INTRODUCTION

The management of pregnancies complicated by placenta previa is best considered in terms of the clinical setting:

Asymptomatic women

Women who are actively bleeding

Women who are stable after one or more episodes of active bleeding

ASYMPTOMATIC PLACENTA PREVIA

Sonographic reassessment to determine placental position (serial transvaginal ultrasound evaluations at four-week intervals beginning at 28 weeks of gestation)

Development of the lower uterine segment over time often relocates the stationary lower edge of a marginal or low-lying placenta away from the internal os

ASYMPTOMATIC PLACENTA PREVIA

Sonographic measurement of cervical length

It provides useful information about the risk of hemorrhage

Studis found that a short cervix was associated with a significantly increased frequency of delivery because of hemorrhage

64 percent of women with a cervical length greater than 3 cm had no bleeding episodes and progressed to term

ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA

An actively bleeding placenta previa is anobstetrical emergency

These women should be admitted to the Labor and Delivery Unit for maternal and fetal monitoring

Intravenous access should be established (two large bore IV lines)


Blood Bank and Laboratory Monitoring :

A blood type and antibody screen should be performed

If bleeding is heavy or increasing, or difficulty in procuring compatible blood is anticipated, then we advise cross-matching two to four units of packed red blood cells


Fetal monitoring

The fetal heart rate is continuously monitored

Loss of reactivity, persistent minimal variability, or fetal tachycardia, recurrent late decelerations are nonreassuring signs suggesting the potential presence of fetal hypoxia or anemia


Maternal monitoring

Use a cardiac monitor and automated blood pressure cuff to follow maternal heart rate and blood pressure

Urine output is evaluated hourly with a Foley catheter attached to a urimeter


Maternal monitoring

Vaginal blood loss can be estimated by weighing or counting perineal pads

Visual estimations of blood loss in obstetrics have historically been inaccurate


Tocolysis

Generally tocolysis is not used with actively bleeding patients

Tocolysis may be considered if contractions are present, bleeding is diminishing or has ceased, and delivery is not otherwise mandated by the maternal or fetal condition


Indications for delivery

A nonreassuring fetal heart rate tracing unresponsive to maternal oxygen therapy, left-sided positioning, and intravascular volume replacement

Life-threatening refractory maternal hemorrhage

Significant vaginal bleeding after 34 weeks of gestation


Anesthesia

General anesthesia is typically administered for emergency cesarean delivery, especially in hemodynamically unstable women or if the fetal status is nonreassuring

However, regional anesthesia is an acceptable choice in hemodynamically stable women with reassuring fetal heart rate tracings

CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED

Most women who initially present with symptomatic placenta previa respond to supportive therapy and do not require immediate delivery

Fifty percent of women with a symptomatic previa (any amount of bleeding) are not delivered for at least four

A large bleed does not preclude conservative management


Symptomatic women often remain hospitalized from their significant bleeding episode until delivery

Since recurrent bleeding episodes are unpredictable, keeping close to the hospital minimizes the risk of complications by enabling fast access to transfusion therapy and emergency cesarean delivery when needed

Select women with placenta previa may be discharged if bleeding has stopped for a minimum of 48 hours and there are no other pregnancy complications


Candidates for outpatient care should:

Be able to return to the hospital within 20 minutes

Have an adult companion available 24 hours a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding

Be reliable and able to maintain bed rest at home

Understand the risks entailed by outpatient managemen


Correction of anemia

Iron supplementation may be needed for optimal correction of anemia

Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining that might precipitate bleeding


Autologous blood donation

Autologous blood donation is acceptable in stable women who meet usual criteria (hemoglobin ≥11.0 g/dL)

A program of autologous blood collection and transfusion can result in a decrease in homologous blood transfusion

Most women who have bled from a placenta previa, however, will not meet standard criteria for autologous donation


Antenatal corticosteroids

A course of antenatal corticosteroid therapy should be administered to symptomatic women between 24 and 34 weeks to improve fetal pulmonary maturity

Do not administer steroids to asymptomatic women or those whose first bleed is after 34 weeks of gestation


Fetal assessment

There is value of nonstress testing or BPP in the asymptomatic placenta previa patient who has no evidence of uteroplacental insufficiency or other signs of distress

Active vaginal bleeding is an indication for fetal assessment

DELIVERY

Timing

Severe persistent hemorrhage is an indication for delivery, regardless of gestational age

The delivery of a pregnancy with uncomplicated placenta previa should be accomplished at 36 to 37 weeks, without documentation of fetal lung maturity by amniocentesis

The rationale behind this is that the risks of continuing the pregnancy were greater than the risks of complications from prematurity

DELIVERY

Women with increasing frequency or volume of bleeding or with signs of imminent labor are delivered at ≤36 weeks if they have received a steroid course

However, women whose first bleed occurred after 34 weeks may not have received a course of betamethasone

If a course of antenatal steroids has not been given, an amniocentesis is performed and deliver the baby at ≤36 weeks if pulmonary indices are mature

Route of Delivery

Complete previa

A cesarean delivery is always indicated when there is sonographic evidence of a complete placenta previa and a viable fetus

Vaginal delivery may be considered in rare circumstances, such as in the presence of a fetal demise or a previable fetus, as long as the mother remains hemodynamically stable

Route of Delivery

Low-lying placenta

Rates of cesarean delivery and antepartum bleeding decrease as the distance between the placental edge and internal os increases.

There is a reasonable possibility of vaginal delivery when the placenta is more than 2 cm from the internal os, so a trial of labor is appropriate

When this distance is between 1 and 20 mm, the rate of cesarean delivery ranges from 40 to 90 percent

Route of Delivery

Marginal previa

Historically, it was believed that vaginal delivery could occasionally be performed safely in women with marginal previa because the fetal head tamponades the adjacent placenta

However most women with marginal previa will end up with a cesarean delivery

Scheduled cesarean delivery is done for these pregnancies to minimize the risk of emergent delivery and hemorrhage

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Antepartum Hemorraghe. FIRST TRIMESTER BLEEDING Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women