bleeding in Early & Late

pregnancy

Dr. Rabi Narayan Satapathy

Asst. Professor

Dept. of Ob. & Gynae.

SCB Medical College, CuttackMob. 09861281510

Causes of early bleeding in pregnancy

Abortion

Ectopic pregnancyHydatidiform mole

Abortion/Miscarriage

Definition: any fetal loss from conception until the time of

fetal viability at 24 weeks gestation.

OR:

Expulsion of a fetus or an embryo weighing 500 gm or less

Incidence: 15 - 20% of pregnancies total reproductive losses

are much higher if one considers losses that occur prior to

clinical recognition.

Classification:

1. spontaneous:

occurs without medical or mechanical means.

2. induced abortion

Pathology

Haemorrhage into the decidua basalis.

Necrotic changes in the tissue adjacent to

the bleeding.

Detachment of the conceptus.

The above will stimulate uterine

contractions resulting in expulsion.

Causes of miscarriage

Fetal causes:

Chromosome Abnormality:

- 50% of spontaneous losses are associated with fetal chromosome

abnormalities.

- autosomal trisomy (nondisjunction/balanced translocation): is the

single largest category of abnormality and → recurrence.

- monosomy (45, X; turner): occurs in 7% of spontaneous abortions

and it is caused by loss of the paternal sex chromosome.

- triploids: found in 8 to 9% of spontaneous abortions. it is the

consequence of either dispermy or failure of extrusion of the

second polar body,

Causes of miscarriage

Maternal causes:

1. Immunological:

- alloimmune response: failure of a normal immune response in the

mother to accept the fetus for a duration of a normal pregnancy.

- autoimmune disease: antiphospholipid antibodies especially lupus

anticoagulant (LA) and the anticardiolipin antibodies (ACL)

2. uterine abnormality:

- congenital: septate uterus → recurrent abortion.

- fibroids (submucus): → (1) disruption of implantation and

development of the fetal blood supply, (2) rapid growth and

degeneration with release of cytokines, and (3) occupation of space

for the fetus to grow. Also polyp > 2 cm diameter.

- cervical incompetence: → second trimester abortions.

Causes of miscarriage

Maternal causes:

3. Endocrine :

- poorly controlled diabetes (type 1/type 2).

- hypothyroidism and hyperthyroidism.

- Luteal Phase Defect (LPD): a situation in which the endometrium is

poorly or improperly hormonally prepared for implantation and is

therefore inhospitable for implantation. (questionable).

4. Infections (maternal/fetal): as TORCH infections, Ureaplasma

urealyticum, listeria

Environmental toxins: alcohol, smoking, drug abuse, ionizing

radiation……

Types of abortion

Threatened abortion.

Inevitable abortion.

Incomplete abortion.

Complete abortion.

Missed abortion

Septic abortion: Any type of

abortion, which is complicated by

infection

Recurrent abortion: 3 or more

successive spontaneous abortions

Clinical features/management

Threatened abortion:

- Short period of amenorrhea.

- Corresponding to the duration.

- Mild bleeding (spotting).

- Mild pain.

- P.V.: closed cervical os.

- Pregnancy test (hCG): + ve.

- US: viable intra uterine fetus.

Management

- reassurance.

- Rest.

- Repeated U/S

Inevitable abortion

Clinical feature:

- Short period of amenorrhea.

- heavy bleeding accompanied

with clots (may lead to shock).

- Severe lower abdominal pain.

- P.V.: opened cervical os.

- Pregnancy test (hCG): + ve.

- US: non-viable fetus and blood

inside the uterus.

Management:

- fluids…..blood.

- ergometrinn & sentocinon.

- evacuation of the uterus

(medical/surgical).

Incomplete abortion

Clinical feature:

- Partial expulsion of

products

- Bleeding and colicky pain

continue.

- P.V.: opened cervix…

retained products may be

felt through it.

- US: retained products of

conception.

Treatment

as inevitable abortion

Complete abortion

- expulsion of all products of conception.

- Cessation of bleeding and abdominal pain.

- P.V.: closed cervix.

- US: empty uterus.

Missed abortion

Feature:

- gradual disappearance of pregnancy Symptoms Signs.

- Brownish vaginal discharge.

- Milk secretion.

- Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus.

- US: absent fetal heart pulsations.

Complications

- Infection (Septic abortion)

- DIC

Treatment- Wait 4 weeks for spontaneous

expulsion

- evacuate if:

Spontaneous expulsion does not occur after 4 weeks.

Infection.

DIC.

- Manage according to size of uterus

- Uterus < 12 weeks : dilatation and evacuation.

- Uterus > 12 weeks : try Oxytocin or PGs.

Vaginal Bleeding in

Late Pregnancy

Objectives

Identify major causes of vaginal bleeding in the

second half of pregnancy

Describe a systematic approach to identifying

the cause of bleeding

Describe specific treatment options based on

diagnosis

Causes of Late Pregnancy

Bleeding

Placenta Previa

Abruption

Ruptured vasa previa

Uterine scar disruption

Cervical polyp

Bloody show

Cervicitis or cervical ectropion

Vaginal trauma

Cervical cancer

Life-Threatening

Prevalence of Placenta Previa

Occurs in 1/200 pregnancies that reach 3rd

trimester

Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks

90% will have normal implantation when scan repeated at >30 weeks

No proven benefit to routine screening ultrasound for this diagnosis

Risk Factors for Placenta Previa

Previous cesarean delivery

Previous uterine instrumentation

High parity

Advanced maternal age

Smoking

Multiple gestation

Morbidity with Placenta Previa

Maternal hemorrhage

Operative delivery complications

Transfusion

Placenta accreta, increta, or percreta

Prematurity

Patient History – Placenta Previa

Painless bleeding

2nd or 3rd trimester, or at term

Often following intercourse

May have preterm contractions

“Sentinel bleed”

Physical Exam – Placenta Previa

Vital signs

Assess fundal height

Fetal lie

Estimated fetal weight (Leopold)

Presence of fetal heart tones

Gentle speculum exam

NO digital vaginal exam unless placental location known

Laboratory – Placenta Previa

Hematocrit or complete blood count

Blood type and Rh

Coagulation tests

While waiting – serum clot tube taped to wall

Ultrasound – Placenta Previa

Can confirm diagnosis

Full bladder can create false appearance of

anterior previa

Presenting part may overshadow posterior previa

Transvaginal scan can locate placental edge and

internal os

Treatment – Placenta Previa

With no active bleeding

Expectant management

No intercourse, digital exams

With late pregnancy bleeding

Assess overall status, circulatory stability

Full dose Rhogam if Rh-

Consider maternal transfer if premature

May need corticosteroids, tocolysis, amniocentesis

Double Set-Up Exam

Appropriate only in marginal previa with vertex

presentation

Palpation of placental edge and fetal head with set

up for immediate surgery

Cesarean delivery under regional anesthesia if:

Complete previa

Fetal head not engaged

Non-reassuring tracing

Brisk or persistent bleeding

Mature fetus

Placental Abruption

Premature separation of placenta from uterine

wall

Partial or complete

“Marginal sinus separation” or “marginal sinus

rupture”

Bleeding, but abnormal implantation or abruption

never established

Epidemiology of Abruption

Occurs in 1-2% of pregnancies

Risk factors

Hypertensive diseases of pregnancy

Smoking or substance abuse (e.g. cocaine)

Trauma

Overdistention of the uterus

History of previous abruption

Unexplained elevation of MSAFP

Placental insufficiency

Maternal thrombophilia/metabolic abnormalities

Abruption and Trauma

Can occur with blunt abdominal trauma and

rapid deceleration without direct trauma

Complications include prematurity, growth

restriction, stillbirth

Fetal evaluation after trauma

Increased use of FHR monitoring may decrease

mortality

Bleeding from Abruption

Externalized hemorrhage

Bloody amniotic fluid

Retroplacental clot

20% occult

“uteroplacental apoplexy” or “Couvelaire” uterus

Look for consumptive coagulopathy

Patient History - Abruption

Pain = hallmark symptom

Varies from mild cramping to severe pain

Back pain – think posterior abruption

Bleeding

May not reflect amount of blood loss

Differentiate from exuberant bloody show

Trauma

Other risk factors (e.g. hypertension)

Membrane rupture

Physical Exam - Abruption

Signs of circulatory instability

Mild tachycardia normal

Signs and symptoms of shock represent >30%

blood loss

Maternal abdomen

Fundal height

Leopold’s: estimated fetal weight, fetal lie

Location of tenderness

Tetanic contractions

Ultrasound - Abruption

Abruption is a clinical diagnosis!

Placental location and appearance

Retroplacental echolucency

Abnormal thickening of placenta

“Torn” edge of placenta

Fetal lie

Estimated fetal weight

Laboratory - Abruption

Complete blood count

Type and Rh

Coagulation tests + “Clot test”

Kleihauer-Betke not diagnostic, but useful to

determine Rhogam dose

Preeclampsia labs, if indicated

Consider urine drug screen

Sher’s Classification - Abruption

Grade I

Grade II

Grade III with fetal demise

III A - without coagulopathy (2/3)

III B - with coagulopathy (1/3)

mild, often retroplacental

clot identified at delivery

tense, tender abdomen and

live fetus

Treatment – Grade II Abruption

Assess fetal and maternal stability

Amniotomy

IUPC to detect elevated uterine tone

Expeditious operative or vaginal delivery

Maintain urine output > 30 cc/hr and hematocrit > 30%

Prepare for neonatal resuscitation

Treatment – Grade III Abruption

Assess mother for hemodynamic and

coagulation status

Vigorous replacement of fluid and blood

products

Vaginal delivery preferred, unless severe

hemorrhage

Coagulopathy with Abruption

Occurs in 1/3 of Grade III abruption

Usually not seen if live fetus

Etiologies: consumption, DIC

Administer platelets, FFP

Give Factor VIII if severe

Epidemiology of Uterine Rupture

Occult dehiscence vs. symptomatic rupture

0.03 – 0.08% of all women

0.3 – 1.7% of women with uterine scar

Previous cesarean incision most common

reason for scar disruption

Other causes: previous uterine curettage or

perforation, inappropriate oxytocin usage,

trauma

Risk Factors – Uterine Rupture

Previous uterine surgery Adenomyosis

Congenital uterine

anomaly

Fetal anomaly

Uterine overdistension Vigorous uterine

pressure

Gestational trophoblastic

neoplasia

Difficult placental

removal

Placenta increta or

percreta

Morbidity with Uterine Rupture

Maternal

Hemorrhage with anemia

Bladder rupture

Hysterectomy

Maternal death

Fetal

Respiratory distress

Hypoxia

Acidemia

Neonatal death

Patient History – Uterine Rupture

Vaginal bleeding

Pain

Cessation of contractions

Absence of FHR

Loss of station

Palpable fetal parts through maternal abdomen

Profound maternal tachycardia and hypotension

Uterine Rupture

Sudden deterioration of FHR pattern is most frequent finding

Placenta may play a role in uterine rupture

Transvaginal ultrasound to evaluate uterine wall

MRI to confirm possible placenta accreta

Treatment

Asymptomatic scar disruption – expectant management

Symptomatic rupture – emergent cesarean delivery

Vasa Previa

Rarest cause of hemorrhage

Onset with membrane rupture

Blood loss is fetal, with 50% mortality

Seen with low-lying placenta, velamentous insertion

of the cord or succenturiate lobe

Antepartum diagnosis

Amnioscopy

Color doppler ultrasound

Palpate vessels during vaginal examination

Diagnostic Tests – Vasa Previa

Apt test – based on colorimetric response of

fetal hemoglobin

Wright stain of vaginal blood – for nucleated

RBCs

Kleihauer-Betke test – 2 hours delay prohibits its

use

Management – Vasa Previa

Immediate cesarean delivery if fetal heart rate is

non-reassuring

Administer normal saline 10 – 20 cc/kg bolus to

newborn, if found to be in shock after delivery

Summary

Late pregnancy bleeding may herald diagnoses

with significant morbidity/mortality

Determining diagnosis important, as treatment

dependent on cause

Avoid vaginal exam when placental location not

known