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Bleeding in early & late pregnancy
1. bleeding in Early & Late
pregnancy
Dr. Rabi Narayan Satapathy
Asst. Professor
Dept. of Ob. & Gynae.
SCB Medical College, Cuttack
Mob. 09861281510
2. Causes of early bleeding in pregnancy
Abortion
Ectopic pregnancy
Hydatidiform mole
3. Abortion/Miscarriage
īŽ 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
īŽ Incidence: 15 - 20% of pregnancies total reproductive losses
are much higher if one considers losses that occur prior to
clinical recognition.
īŽ Classification:
1. spontaneous:
occurs without medical or mechanical means.
2. induced abortion
4. Pathology
īŽ Haemorrhage into the decidua basalis.
īŽ Necrotic changes in the tissue adjacent to
the bleeding.
īŽ Detachment of the conceptus.
īŽ The above will stimulate uterine
contractions resulting in expulsion.
5. Causes of miscarriage
īŽ Fetal causes:
īļ 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 â 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,
6. Causes of miscarriage
īŽ 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 â recurrent abortion.
- fibroids (submucus): â (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: â second trimester abortions.
7. Causes of miscarriage
īŽ 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
īŽ Environmental toxins: alcohol, smoking, drug abuse, ionizing
radiationâĻâĻ
8. Types of abortion
īŽ Threatened abortion.
īŽ Inevitable abortion.
īŽ Incomplete abortion.
īŽ Complete abortion.
īŽ Missed abortion
īļ Septic abortion: Any type of
abortion, which is complicated by
infection
īļ Recurrent abortion: 3 or more
successive spontaneous abortions
9. Clinical features/management
īŽ 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.
ī§ Management
- reassurance.
- Rest.
- Repeated U/S
10. Inevitable abortion
ī§ 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.
īŽ Management:
- fluidsâĻ..blood.
- ergometrinn & sentocinon.
- evacuation of the uterus
(medical/surgical).
11. Incomplete abortion
īļ Clinical feature:
- Partial expulsion of
products
- Bleeding and colicky pain
continue.
- P.V.: opened cervixâĻ
retained products may be
felt through it.
- US: retained products of
conception.
īļ Treatment
as inevitable abortion
12. Complete abortion
- expulsion of all products of conception.
- Cessation of bleeding and abdominal pain.
- P.V.: closed cervix.
- US: empty uterus.
13. Missed abortion
ī§ 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.
ī§ Complications
- Infection (Septic abortion)
- DIC
īŽ Treatment
- Wait 4 weeks for spontaneous
expulsion
- evacuate if:
ī§ Spontaneous expulsion does not
occur after 4 weeks.
ī§ Infection.
ī§ DIC.
- Manage according to size of
uterus
- Uterus < 12 weeks : dilatation
and evacuation.
- Uterus > 12 weeks : try
Oxytocin or PGs.
15. Objectives
īŽ Identify major causes of vaginal bleeding in the
second half of pregnancy
īŽ Describe a systematic approach to identifying
the cause of bleeding
īŽ Describe specific treatment options based on
diagnosis
16. Causes of Late Pregnancy
Bleeding
īŽ Placenta Previa
īŽ Abruption
īŽ Ruptured vasa previa
īŽ Uterine scar disruption
īŽ Cervical polyp
īŽ Bloody show
īŽ Cervicitis or cervical ectropion
īŽ Vaginal trauma
īŽ Cervical cancer
Life-Threatening
17. Prevalence of Placenta Previa
īŽ Occurs in 1/200 pregnancies that reach 3rd
trimester
īŽ Low-lying placenta seen in 50% of ultrasound
scans at 16-20 weeks
īŽ 90% will have normal implantation when scan
repeated at >30 weeks
īŽ No proven benefit to routine screening ultrasound
for this diagnosis
18. Risk Factors for Placenta Previa
īŽ Previous cesarean delivery
īŽ Previous uterine instrumentation
īŽ High parity
īŽ Advanced maternal age
īŽ Smoking
īŽ Multiple gestation
20. Patient History â Placenta Previa
īŽ Painless bleeding
īŽ 2nd or 3rd trimester, or at term
īŽ Often following intercourse
īŽ May have preterm contractions
īŽ âSentinel bleedâ
21. Physical Exam â Placenta Previa
īŽ Vital signs
īŽ Assess fundal height
īŽ Fetal lie
īŽ Estimated fetal weight (Leopold)
īŽ Presence of fetal heart tones
īŽ Gentle speculum exam
īŽ NO digital vaginal exam unless placental location known
22. Laboratory â Placenta Previa
īŽ Hematocrit or complete blood count
īŽ Blood type and Rh
īŽ Coagulation tests
īŽ While waiting â serum clot tube taped to wall
23. Ultrasound â Placenta Previa
īŽ Can confirm diagnosis
īŽ Full bladder can create false appearance of
anterior previa
īŽ Presenting part may overshadow posterior previa
īŽ Transvaginal scan can locate placental edge and
internal os
24. Treatment â Placenta Previa
īŽ With no active bleeding
īŽ Expectant management
īŽ No intercourse, digital exams
īŽ With late pregnancy bleeding
īŽ Assess overall status, circulatory stability
īŽ Full dose Rhogam if Rh-
īŽ Consider maternal transfer if premature
īŽ May need corticosteroids, tocolysis,
amniocentesis
25. Double Set-Up Exam
īŽ Appropriate only in marginal previa with vertex
presentation
īŽ Palpation of placental edge and fetal head with set
up for immediate surgery
īŽ Cesarean delivery under regional anesthesia if:
īŽ Complete previa
īŽ Fetal head not engaged
īŽ Non-reassuring tracing
īŽ Brisk or persistent bleeding
īŽ Mature fetus
26. Placental Abruption
īŽ Premature separation of placenta from uterine
wall
īŽ Partial or complete
īŽ âMarginal sinus separationâ or âmarginal sinus
ruptureâ
īŽ Bleeding, but abnormal implantation or abruption
never established
27. Epidemiology of Abruption
īŽ Occurs in 1-2% of pregnancies
īŽ Risk factors
īŽ Hypertensive diseases of pregnancy
īŽ Smoking or substance abuse (e.g. cocaine)
īŽ Trauma
īŽ Overdistention of the uterus
īŽ History of previous abruption
īŽ Unexplained elevation of MSAFP
īŽ Placental insufficiency
īŽ Maternal thrombophilia/metabolic abnormalities
28. Abruption and Trauma
īŽ Can occur with blunt abdominal trauma and
rapid deceleration without direct trauma
īŽ Complications include prematurity, growth
restriction, stillbirth
īŽ Fetal evaluation after trauma
īŽ Increased use of FHR monitoring may decrease
mortality
29. Bleeding from Abruption
īŽ Externalized hemorrhage
īŽ Bloody amniotic fluid
īŽ Retroplacental clot
īŽ 20% occult
īŽ âuteroplacental apoplexyâ or âCouvelaireâ uterus
īŽ Look for consumptive coagulopathy
30. Patient History - Abruption
īŽ Pain = hallmark symptom
īŽ Varies from mild cramping to severe pain
īŽ Back pain â think posterior abruption
īŽ Bleeding
īŽ May not reflect amount of blood loss
īŽ Differentiate from exuberant bloody show
īŽ Trauma
īŽ Other risk factors (e.g. hypertension)
īŽ Membrane rupture
31. Physical Exam - Abruption
īŽ Signs of circulatory instability
īŽ Mild tachycardia normal
īŽ Signs and symptoms of shock represent >30%
blood loss
īŽ Maternal abdomen
īŽ Fundal height
īŽ Leopoldâs: estimated fetal weight, fetal lie
īŽ Location of tenderness
īŽ Tetanic contractions
32. Ultrasound - Abruption
īŽ Abruption is a clinical diagnosis!
īŽ Placental location and appearance
īŽ Retroplacental echolucency
īŽ Abnormal thickening of placenta
īŽ âTornâ edge of placenta
īŽ Fetal lie
īŽ Estimated fetal weight
33. Laboratory - Abruption
īŽ Complete blood count
īŽ Type and Rh
īŽ Coagulation tests + âClot testâ
īŽ Kleihauer-Betke not diagnostic, but useful to
determine Rhogam dose
īŽ Preeclampsia labs, if indicated
īŽ Consider urine drug screen
34. Sherâs Classification - Abruption
īŽ Grade I
īŽ Grade II
īŽ Grade III with fetal demise
īŽ III A - without coagulopathy (2/3)
īŽ III B - with coagulopathy (1/3)
mild, often retroplacental
clot identified at delivery
tense, tender abdomen and
live fetus
35. Treatment â Grade II Abruption
īŽ Assess fetal and maternal stability
īŽ Amniotomy
īŽ IUPC to detect elevated uterine tone
īŽ Expeditious operative or vaginal delivery
īŽ Maintain urine output > 30 cc/hr and
hematocrit > 30%
īŽ Prepare for neonatal resuscitation
36. Treatment â Grade III Abruption
īŽ Assess mother for hemodynamic and
coagulation status
īŽ Vigorous replacement of fluid and blood
products
īŽ Vaginal delivery preferred, unless severe
hemorrhage
37. Coagulopathy with Abruption
īŽ Occurs in 1/3 of Grade III abruption
īŽ Usually not seen if live fetus
īŽ Etiologies: consumption, DIC
īŽ Administer platelets, FFP
īŽ Give Factor VIII if severe
38. Epidemiology of Uterine Rupture
īŽ Occult dehiscence vs. symptomatic rupture
īŽ 0.03 â 0.08% of all women
īŽ 0.3 â 1.7% of women with uterine scar
īŽ Previous cesarean incision most common
reason for scar disruption
īŽ Other causes: previous uterine curettage or
perforation, inappropriate oxytocin usage,
trauma
40. Morbidity with Uterine Rupture
īŽ Maternal
īŽ Hemorrhage with anemia
īŽ Bladder rupture
īŽ Hysterectomy
īŽ Maternal death
īŽ Fetal
īŽ Respiratory distress
īŽ Hypoxia
īŽ Acidemia
īŽ Neonatal death
41. Patient History â Uterine Rupture
īŽ Vaginal bleeding
īŽ Pain
īŽ Cessation of contractions
īŽ Absence of FHR
īŽ Loss of station
īŽ Palpable fetal parts through maternal
abdomen
īŽ Profound maternal tachycardia and
hypotension
42. Uterine Rupture
īŽ Sudden deterioration of FHR pattern is most
frequent finding
īŽ Placenta may play a role in uterine rupture
īŽ Transvaginal ultrasound to evaluate uterine wall
īŽ MRI to confirm possible placenta accreta
īŽ Treatment
īŽ Asymptomatic scar disruption â expectant
management
īŽ Symptomatic rupture â emergent cesarean
delivery
43. Vasa Previa
īŽ Rarest cause of hemorrhage
īŽ Onset with membrane rupture
īŽ Blood loss is fetal, with 50% mortality
īŽ Seen with low-lying placenta, velamentous insertion
of the cord or succenturiate lobe
īŽ Antepartum diagnosis
īŽ Amnioscopy
īŽ Color doppler ultrasound
īŽ Palpate vessels during vaginal examination
44. Diagnostic Tests â Vasa Previa
īŽ Apt test â based on colorimetric response of
fetal hemoglobin
īŽ Wright stain of vaginal blood â for nucleated
RBCs
īŽ Kleihauer-Betke test â 2 hours delay prohibits its
use
45. Management â Vasa Previa
īŽ Immediate cesarean delivery if fetal heart rate is
non-reassuring
īŽ Administer normal saline 10 â 20 cc/kg bolus to
newborn, if found to be in shock after delivery
46. Summary
īŽ Late pregnancy bleeding may herald diagnoses
with significant morbidity/mortality
īŽ Determining diagnosis important, as treatment
dependent on cause
īŽ Avoid vaginal exam when placental location not
known