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Third-Trimester Bleeding Hasan Ismail July 2015

Third trimester bleeding

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  1. 1. Third-Trimester Bleeding Hasan Ismail July 2015
  2. 2. Third-trimester bleeding, ranging from spotting to massive hemorrhage, occurs in 2% to 6% of all pregnancies. The differential diagnosis includes: Bloody show from labor Abruptio placentae (AP) Placenta previa (PP) Vasa previa (VP) Cervicitis, postcoital bleeding, trauma, uterine rupture, and carcinoma. AP, PP, and VP can lead to significant maternal and fetal morbidity and mortality.
  3. 3. ABRUPTIO PLACENTAE AP is the premature separation of the normally implanted placenta from the uterine wall due to maternal/uterine bleeding into the decidua basalis.
  4. 4. Epidemiology One third of all antepartum bleeding is due to AP, with an incidence of 1 in 75 to 1 in 225 births. AP recurs in 5% to 17% of pregnancies after one prior episode and up to 25% after two prior episodes. There is a 7% incidence of stillbirth in future pregnancies after AP leading to fetal death.
  5. 5. Etiology Bleeding does not correlate with abruption size. Blood in the basalis layer stimulates forceful, classically tetanic, uterine contractions leading to ischemic abdominal pain. AP is associated with maternal hypertension, advanced maternal age, multiparity, cocaine use, tobacco use, chorioamnionitis, and trauma. Many cases are idiopathic. Chronic hypertension, superimposed preeclampsia, or severe pre- ec-lampsia have fivefold increased risk of severe abruption compared to normotensive women.
  6. 6. Antihypertensive medications ??
  7. 7. Cigarette smoking increases the risk of stillbirth from AP by 2.5-fold. Rapid changes in intrauterine volume can lead to abruption, such as in rupture of membranes or therapeutic amnioreduction with polyhydramnios or during delivery of multiple gestations. Abruption occurs more frequently when the placenta implants on abnormal uterine surfaces as with submucous myomas or uterine anomalies. Hyperhomocysteinemia, Factor V Leiden, and prothrombin 20210 mutations (thrombophilias) are associated with an increased risk of abruption.
  8. 8. Complications Hemorrhagic shock (if massive loss) Maternal (DIC) can occur and is found in 10% to 20% of AP with stillbirth. Extravasation of blood directly into the uterine muscle (Couvelaire's uterus) can lead to uterine atony and massive postpartum hemorrhage. Fetal hypoxia may occur, leading to acute fetal distress, hypoxic-ischemic encephalopathy,premature delivery, and fetal death. Milder chronic abruption may lead to growth restriction, major malformations, or anemia.
  9. 9. Diagnosis History and Physical Examination Classically presents late in pregnancy with vaginal bleeding and acute severe constantabdominal pain. Immediately : Maternal vital signs, fetal heart rate assessment, and uterine tone Mark or record the fundal height to follow expansion of concealed hemorrhage. Defer digital cervical exam until PP and VP have been R/O Ultrasound is insensitive in diagnosing AP, but large abruptions may be seen as hypoechoic areas underlying the placenta. Perform a speculum exam to evaluate vaginal or cervical lacerations and the amount of bleeding. If discharge or signs of cervicitis are noted, obtain a wet prep, potassium hydroxide slide (KOH), and cervical swabs for gonorrhea and chlamydia testing.
  10. 10. Diagnosis Laboratory Tests CBCD (