Late pregnancy bleeding.pptx

7/29/2019 Late pregnancy bleeding.pptx

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LATE-PREGNANCY BLEEDING


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ETIOLOGY

The most common cause of late-pregnancy bleeding is aproblem with the PLACENTA : Placenta Praevia

Abruptio Placentae Vasa Praevia

Less common causes of late-pregnancy bleeding include : Uterine Rupture

Injuries or lesions of the CERVIX and VAGINA,

Polyps, cancer, and Varicose

Inherited bleeding problems, such as : HEMOPHILIA, are very rare, occurring in 1 in 10,000 women.


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PLACENTA PRAEVIA The placenta, can PARTIALLY or COMPLETELYcover the

cervical opening

Late in pregnancy called the cervix, THINS ANDDILATES (widens) in preparation for labor, some blood

vessels of the placenta stretch and rupture. This causes about 20% OF THIRD-TRIMESTER

BLEEDING and happens in about 1 in 200 pregnancies.

Risk factors for placenta previa include these

conditions: Multiple pregnancies

Prior placenta previa

Prior Cesarean delivery


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CLASSIFICATION

COMPLETE PLACENTA PREVIArefers to the situation in which the placentacompletely covers the opening from the womb to the cervix.

PARTIAL PLACENTA PREVIArefers to the placenta that partially covers thecervical opening (since the cervical opening is not dilated until time fordelivery approaches, this type of placenta previa occurs after the cervix

has begin to dilate). MARGINAL PLACENTA PREVIA refers to a placenta that is located adjacent

to, but not covering, the cervical opening.

The term LOW-LYING PLACENTA or LOW PLACENTAhas been used to referboth to placenta previa and marginal placenta previa.

The terms ANTERIOR PLACENTA PREVIA and POSTERIOR PLACENTA PREVIAare sometimes used after ULTRASOUND EXAMINATION to further define theexact position of the placenta within the uterine cavity.


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PLACENTA

PREVIA


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PLACENTA PREVIA SYMPTOMS

VAGINAL BLEEDING after the 20th week of gestation is the primary

symptom of placenta previa. Although the bleeding is typically PAINLESS and

Recurrent and the more intense

Can be associated with other complications of pregnancy including:

PLACENTA ACCRETA occurs when the placental tissues grows too deeplyinto the womb, attaching to the muscle layer,

Can cause LIFE-THREATENING BLEEDING and commonly requires

HISTERECTOMY.

Placenta accrete occurs in 5% to 10% of women with placenta previa.

PRETERM PREMATURE RUPTURE OF THE MEMBRANES (PPROM)

Other abnormalities of the placenta or umbilical cord

BREECH or ABNORMAL PRESENTATION OF THE FETUS.

a REDUCTION IN FETAL GROWTH associated with placenta previa.


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PLACENTAL ABRUPTION

A normal placenta separates from the wall of

the uterus prematurely and blood collects

between the placenta and the uterus. Such separation occurs in 1 in 200 of all

pregnancies.

The cause is unknown.


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CLASSIFICATION OF PLACENTAL ABRUPTION

Classification of placental abruption is based on :

EXTENT OF SEPARATION (ie, partial vs complete) and

LOCATION OF SEPARATION (ie, marginal vs central).

Clinical classification is as follows: Class 0 - Asymptomatic

Class 1 - MILD (represents approximately 48% of all cases)

Class 2 - MODERATE (represents approximately 27% of all

cases) Class 3 - SEVERE (represents approximately 24% of all

cases)


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DIFFERENTIAL DIAGNOSIS

ABDOMINAL TRAUMA

ACUTE APPENDICITIS

DISSEMINATED INTRAVASCULAR

COAGULATION

TORSION OVARIAN CYST

PLACENTA PREVIA

ECTOPIC PREGNANCY


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A DIAGNOSIS OF CLASS 0 IS MADERETROSPECTIVELY BY FINDING AN:

ORGANIZED BLOOD CLOT OR A

DEPRESSED AREA

ON A DELIVERED PLACENTA.


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CLASS 1 : MILD

CHARACTERISTICS

1. No vaginal bleeding to mild vaginal bleeding

2. Slightly tender uterus

3. Normal maternal BP and heart rate

4. No coagulopathy

5. No fetal distress


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CLASS 2 : MODERATE

CHARACTERISTICS

1. No vaginal bleeding to moderate vaginal

bleeding2. Moderate to severe uterine tenderness with

possible tetanic contractions

3. Maternal tachycardia with orthostatic changes in

BP and heart rate

4. Fetal distress

5. Hypofibrinogenemia (ie, 50-250 mg/dL)


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CLASS 3 : SEVERE

CHARACTERISTICS

No vaginal bleeding to heavy vaginal bleeding

Very painful tetanic uterus

Maternal shock

Hypofibrinogenemia (ie, < 150 mg/dL)

Coagulopathy

Fetal death


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A. CONCEALED BLEEDING B. REVEALED BLEEDING C.MIXED BLEEEDING


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COMPLICATION

Potential MATERNAL COMPLICATIONS include thefollowing:

1. Hemorrhagic shock

2. Coagulopathy/disseminated intravascularcoagulation (DIC)

3. Uterine rupture

4. Renal failure5. Ischemic necrosis of distal organs (eg, hepatic,

adrenal, pituitary)


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COMPLICATION

Potential FETAL COMPLICATIONS include the

following:

1. Hypoxia

2. Anemia

3. Growth retardation

4. CNS anomalies5. Fetal death


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LAB STUDIES IN

ABRUPTIO PLACENTAE

Hemoglobin

Hematocrit

Platelets Prothrombin time/activated partial

thromboplastin time

Fibrinogen Fibrin/fibrinogen degradation products

Blood type


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ULTRASONOGRAPHY and MRI

Ultrasonography helps to determine the location of the placenta inorder to EXCLUDE PLACENTA PREVIA.

Ultrasonography is NOT VERY USEFUL in diagnosing placentalabruption (and normal ultrasonographic findings do not exclude the

condition).[4]

RETROPLACENTAL HEMATOMA may be recognized in 2-25% of allabruptions.

This recognition depends on the degree of hematoma and on theoperator's skill level.

MRI is DIAGNOSTICALLY EFFECTIVE and can ACCURATELY depictplacental abruption. Consider using MRI in cases where ultrasonography findings in the

presence of late pregnancy bleeding are negative, but positivediagnosis of abruption would change patient management.[7]


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MANAGEMENT

Initial Management of Abruptio Placentae

1. Begin continuous external fetal monitoring for thefetal heart rate and contractions.

2. Obtain intravenous access using 2 large-boreintravenous lines.

3. Institute crystalloid fluid resuscitation for the patient.

4. Type and crossmatch blood.

5. Begin a transfusion if the patient is hemodynamicallyunstable after fluid resuscitation.

6. Correct coagulopathy, if present.


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VAGINAL DELIVERY

This is the preferred method of delivery for afetus that has DIED secondary to placentalabruption.

The ability of the patient to undergo vaginaldelivery depends on her remainingHEMODYNAMICALLY STABLE.

Delivery is USUALLY RAPID in these patientssecondary to increased uterine tone andcontractions.


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CESAREAN DELIVERY

Is often necessary for fetal and maternal stabilization.

While cesarean delivery facilitates rapid delivery and direct access to the

uterus and its vasculature, it can be complicated by the patient's coagulation

status.

Because of this, a vertical skin incision, which has been associated with less blood loss, is

often used when the patient appears to have DIC.

The type of uterine incision is dictated by the GESTATIONAL AGE of the fetus, with a vertical

or classic uterine incision often being necessary in the preterm patient.

If hemorrhage cannot be controlled after delivery, a CESAREAN

HYSTERECTOMY may be required to save the patient's life.

Before proceeding to hysterectomy, other procedures, including correction of coagulopathy,

ligation of the uterine artery,

administration of uterotonics (if atony is present),

packing of the uterus, and

other techniques to control hemorrhage,

may be attempted.


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UTERINE RUPTURE

An abnormal splitting open of the uterus, causing the baby to be partially

or completely expelled into the abdomen.

About 40% of women who have uterine rupture had prior surgery on their

uterus, including Cesarean delivery.

The rupture may occur before or during labor or at the time of delivery. Other risk factors for uterine rupture are these conditions:

More than four pregnancies (MULTIPARITY)

Trauma

Excessive use of OXYTOCIN (Pitocin), a medicine that helps strengthen

contractions A baby in any position other than head down

Having the baby's shoulder get caught on the pubic bone during labor

Certain types of forceps deliveries


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FETAL VESSEL RUPTURE

Occurs in about 1 of every 1,000 pregnancies.

The baby's blood vessels from the umbilical

cord may attach to the membranes instead ofthe placenta.

The baby's blood vessels pass over the

entrance to the birth canal. This is called VASA PREVIA and occurs in 1 in

5,000 pregnancies


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PLACENTA BILOBATA


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PLACENTA SUCCENTERIATA


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DIAGNOSIS

The classic triad of the vasa praevia is:

Membrane rupture,

Painless vaginal bleeding and

Fetal bradycardia. This is rarely confirmed before delivery but may be suspected when

antenatal sono-gram with color-flow Doppler reveals a vesselcrossing the membranes over the internal cervical os.[2][3]

The diagnosis is usually confirmed after delivery on examination ofthe placenta and fetal membranes

MOST OFTEN THE FETUS IS ALREADY DEAD when the diagnosis ismade; because the blood loss (say 300ml) constitutes a major bulkof blood volume of the fetus (80-100ml/kg i.e. 300ml approx for a3kg fetus)[citation needed].
http://en.wikipedia.org/wiki/Vasa_praeviahttp://en.wikipedia.org/wiki/Vasa_praeviahttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Vasa_praevia


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THANK YOU

dr.Bambang Widjanarko, Sp OGDept.Obstetri Gynecology

School of Medicine & Health

Muhammdiyah University of Jakarta

Documents

Late pregnancy bleeding.pptx