1. Bleeding Late in Pregnancy
When the placenta misbehaves
Grace Cavallaro MD, FACOG

2. Objectives
Identify major causes of vaginal bleeding second half of pregnancy
Describe a systematic approach to identify the cause of bleeding
Describe specific treatment options based on diagnosis

3. Causes of Late Pregnancy Bleeding
Placenta Previa
Abruption
Ruptured Vasa Previa
Uterine Scar Disruption
Cervical Polyp
Bloody Show
Cervicitis
Vaginal Trauma
Cervical Cancer
Life
Threatening*

4. Placenta Previas

5. Placenta Previas

6. Prevalence of Placenta Previa
Occurs in 1/200 pregnancies that reach 3rd trimester
Low-lying placenta seen in 50% of ultrasound scans at weeks
90% will have normal implantation when scan >30 weeks
No proven benefit to routine screening ultrasound for this diagnosis.

7. Risk factors for previa
Previous Cesarean Sections
Previous Uterine Instrumentation
High Parity
Advancing Maternal Age
Women over 40 have a RR of 9.0
Smoking
Multiple Gestation
Bleeding More Likely than those with an unscarred uterus
Incidence increases with increasing number of cesareans
Febrile Post-op Period
3.9% in women with previous C-sections
Increased in
Endometritis
Short Inter-pregnancy interval

8. Morbidity with Placenta Previa
Maternal Hemorrhage
Operative Delivery Complications
Transfusion
Placenta accreta, increta or percreta
Prematurity
Digital exam can cause exanguinating hemorrhage
Transfusion may be necessary
Placenta accreta et al more common in women with a previous c-section as depicted in the previous slide
Complications of premarturity, and management should be influenced by the gestational age and balanced against the maternal condition

9. Placenta Migration
Migration means the dynamic relationship between the placenta and the internal os
Trophotropism vs elongating lower uterine segment!

10. Previous C-sections and Previas
10% risk of an accreta with a previous cesarean and a previa.
In any patient with a previous cesarean and a previa, a transvaginal sono of the LUS should be done to determine in vaginal or cesarean delivery is done
Previous Cesarean Sections - preference to ant. Wall- 66%,
Bleeding more likely than in those with an intact uterus 44%-28.5%
Incidence increases with increasing number of cesareans (Anath). Metanalysis of studies published between
Anath ObGyn 1996

11. Patient History - Placenta Previa
Painless Bleeding*
2nd or 3rd trimester, or at term
Often following intercourse
May have preterm contractions*
Sentinel Bleed
From large central previa
@ weeks gestation
Bleeding after intercourse is often reported yet is nonspecific
Pain that persists btwn contractions is suggestive of abruption
Sentinal Bleed is that which is not so excessive as to require delivery, but is a warning. With slowing of bleeding, clinician must decide wjether to care for locally od transfer.

12. 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 exam unless placental location known
Previa should be considered in patients with an abnormal lie. May influence the type of uterine incision - transverse lie with spine up - consider low trans, spine down - vertical incision
Gentle speculum exam permissible and useful. The endocervical canal and the vagina are at right angles.

13. Speculum exam revealing an anterior placenta previa

14. Laboratory - Placenta Previa
Hematocrit or complete blood count
Blood Type and Rh
Coagulation tests
(While waiting - serum clot tube taped to the wall)

15. 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

16. The Placenta’s Ultrasound Appearance
Echodense placental tissue
Echolucent myometrial
Area rich in blood supply

17. Vagina and Cervix meet at 90 degrees
)Transvaginal Ultrasound Scanning is safe in the bleeding patient
Vagina and the cervix meet at a 90 degree angle, careful insertion of the vaginal probe midway into the vagina will image the
Careful insertion of the vaginal probe midway into the vagina will image the LUS and the cervical os

18. Complete Previa - Ultrasound

19. Posterior Previa
Transvaginal Scan
Posterior Placenta
Previa

20. False Previa Full bladder No Previa c Lower placental border
Normal cervical canal. Longitudinal scans demonstrate a normal canal(arrows)
Which is in a nearly vertical orientation because of an empty urinary bladder(test?)
With a full urinary bladder the cervical canal(arrow) is in a more horizontal orientation.
Also note that the cervical canal and lower uterine segment are artificially lengthened from compression by a distended bladder
Lower placental border
Full bladder
No Previa

21. False Previa - Overdistended Bladder
Cervical canal
A false positive diagnosis of placenta previa in this case owing to an overly distended placenta previa in this case owing to an overly distended urinary bladder which resulted in the elongation of the cervix to 7 cm
Arrows point to the the artificially elongated endocervical canal c

22. Placental Edge by U/S and Route of Delivery
>2 cm os - placenta edge = safe for vaginal delivery
<1cm os - placenta edge - Cesarean delivery
1-2 cm = may be able to deliver vaginal
Dawson et al Jultrasound Medicine 1996

23. Ultrasound’s Role
Previa = usually definitive except in very low lying posterior placentas in the obese patient
Abruption - definitive diagnosis is not possible
Transvaginal Scanning is safe in the bleeding patient

24. Clinical Signs and Symptoms
Painless Bleeding = Previa
Painful Bleeding = Abruption
Painless Fetal Bleeding = Vasa Previa

25. Initial management 1) ABC’s 2) Fetal Well Being 3) No Vaginal Exams
Amount of bleeding noted is unreliable
2) Fetal Well Being
3) No Vaginal Exams
Until you know where the placenta is!
4) Ultrasound

26. Fetal/Neonatal Considerations
Gestational Age of Fetus dictates local of care
SGA/Prematurity are major problems
Communication with consultants is key!
Fetal/Neonatal Considerations
GA of fetus may dictate where patients are observed/delivered as well as considerations for obstetrical co-morbidity
SGA, Prematurity and asphyxia were major problems associated with placental abruptions in a Scandinavian study of 9592 cases of placental abruption in 1.4 million births over a 24 year period.
Communication between primary physician and consultant is key!

27. Cesarean Sections and Previas
Category C
Pre-op Scan
Patients with Previas undergoing C-Section
Bleed More
Require More Blood Transfusion
Require More C-Hysterectomies
Placenta accreta may accompany 10%
Bladder invasion may be associated with
DIC and massive hemorrhage
Considerations for those performing C-sections on patients. Since risk of a previa increases with each cesarean, this entity is something every patient should be screened for in the prenatal period to alert clinician of this condition (Deutchman). Ultrasonography can be also utilized to screen and detect placenta perorate wit bladder invasion. (Chung)
In one study, the patients who had previas undergoing sections were compared with control patients undergoing cesarean section. Patients with previas bled more (1154 vs 632cc’s), required more blood transfusions (15% vs. 4.5%) and underwent Cesarean Hysterectomy 4.5% vs 0%. In one study the incidence of placenta accreta among women with placenta previa was nearly 10%(Craig). If bladder invasion occurs, other potential complications can result, including massive hemorrhage and the development of DIC(Silver) at the time of surgery. This underscores the importance of having the intra-operative involvement of a surgeon capable of performing a cesarean hysterectomy at the time of surgery.

28. Treatment Placenta Previa
With no active bleeding
Expectant management
No intercourse, digital exam
Rescan after 30 weeks
With late pregnancy bleeding
Assess overall status, circulatory stability
Full dose Rhogam if Rh -
Consider maternal transfer if premature
May need corticosteroids, tocolysis, amniocentesis
Category B
Inpatient vs Output management depends on the gestational age, number and severity of bleeding episodes, pt reliability and distance from home
Hospital care may provide no benefit (Cat C)
Cerclage placement may reduce the risk of delivery prior to 34 weeks.(Cat C)
No contraindications to tocolytic in a 3ry care center. No rtc data- Cat B

29. Expectant Management
May discharge home if stable after 72 hours of inpatient observation.
Reduces stay in hospital by average of 14 days.
No increase in
Hemorrhage
Need for transfusion
Poor maternal or neonatal outcomes

30. Tocolytics in Placenta Previa
Greatest morbidity and mortlity related to prematurity.
Tocolytics can add an additional 11 days to pregnancy.
Allows for administration of corticosteroids
No increase in maternal or fetal complications
Increase birth weights average of 320 grams

31. Double Set-up Exam: digital exam in OR with ability to do immediate CD
Appropriate only in marginal (anterior) 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 Persistant bleeding
Mature fetus
A posterior low lying or a posterior a posterior marginal previa may obstruct the descent of the fetal head.
Marginal Ant previa test ? If vaginal delivery is felt to be permissible, then labor is allowed to proceed, with close monitoring and ready availability of operative personnel.
General anesthesia is associated with increased blood loss and need for a blood transfusion. Regional anesthesia is a safe alternative
Category D

32. 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
IN marginal sinus rupture - fetal compromise not present. Vaginal bleeding resolves without explanation, uterine tenderness are absent and prognosis is good.

33. Epidemiology of Abruption*
Occurs in 1-2% of all pregnancies
Risk Factors
Hypertensive diseases of pregnancy
Smoking or substance abuse*
Trauma*
Overdistension of the Uterus*
History of Previous Abruption*
Unexplained elevation of MSAFP
Placental insufficiency
Maternal Thrombophilia/Metabolic abnormalities
Substance abuse-particularly alcohol and cocaine

34. Abruptions and Trauma Category C
Can occur with blunt abdominal trauma and rapid deceleration without direct trauma
Complications include prematurity, growth restriction and stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease mortality
Separation of the placenta and retroplacental hemorrhage can occur with trauma
Shearing forces or shock in deceleration without trauma
In pregnant women at Level 1/II trauma centers - 84% experienced blunt trauma, 16% had penetrating injuries
Placental abruptions was the most common, 3.5% of injured pregnant women, >50% demise. Only 61% received cardiotoco monitoring.
Category C

35. Bleeding from Abruption
Externalized hemorrhage
Bloody amniotic fluid
Retroplacental clot
20% occult
“uteroplacental apoplexy or Couvelaire uterus
Look for consumptive coagulopathy
20% of abruptions are occult.
Bleeding into the myometrium results in “uteroplacental apoplexy or a Couvelaire uterus which may or not contract effectively and result in postpartum hemorrhage
Coagulaopathy results from a consumption of clotting factors in extravacular coagulopathies. Separation of the placenta is also associated with a release of thrombi plastic substances that may set off clotting cascade.

36. “Uteroplacental apoplexy or Couvelaire” uterus

37. Cigarette Smoking as Risk factor
Nova Scotia Registry of 87, 184 pregnancies
33% smoked
2.05 Relative Risk of Abruption
1.75 Relative Risk of Previa
No dose effect noted
Anath AmJ of Epidemiology 1996

38. Cocaine/Metamphetamine
Associated with
chorionic villous hemorrhage
Villous edema
Even in the absence of clinical abruption placenta

39. 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/drugs)
Membrane rupture
Active laboring women should not complain of abd pain or tenderness(test?) between contractions
If bleeding occurs at time of SROM-vasaprevia should be suspected
Questions re: trauma, presence of pain, contractions, srom and risk factors

40. 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
Examine patient quickly for:
Are there orthostatic changes
If patient has previous hypertensive disease - consider her BP in comparison
Neuro exam or complete physical may be needed
Tetanic contractions - high resting tone with superimposed small frequent contractions. The presence of the finding is significant as it is often accompanied with a non reassuring fhr tracing

41. Fetal/Uterine Monitor in an Abruption
If no reassuring- emergent cesarean delivery should occur, since a significant number will end in fetal demise even in patient’s who present to the hospital with a live fetus.

42. 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

43. Placental Abruption Hemorrhage isoechoic with placenta
Placental abruption with isoechoic hematoma. This hematoma has no distinct margin with the placenta. The straight arrows delineate the anterior margin of the placenta, curved arrows mark the posterior aspect of the hematoma at the myometrium
The right image reveals a large retroplacental hematoma. A large heterogeneous echotexture (asterisk) is seen behind a posterior placenta. This hematoma could be easily mistaken for a myofibroma or contraction
Hemorrhage isoechoic with placenta
Hematoma retroplacental

44. Abruption - Retroplacental Hematoma
Retroplacental hematoma initial sonogram at 25 weeks gestation is large hyperechoic arrowhead in the placenta
Repeat sonogram 1 week later shows that the hemotoma has become hypoechoic relative to the placenta. There was subsequent fetal death.
Retro placental hematoma day1
7 days later

45. False Abruption? Contraction Mimicking Abruption
These subsegmental contractions can last a few to many minutes
No Contraction
30 minutes later

46. Placenta Lakes Subchorionic Placental Lake
Placenta lake are subchoironic, yet can be marginal
Doppler can help differentiate it from a clot
Doppler revealing flow through the lake

47. Laboratory-Abruption
Complete blood count
Type and Rh
Coagulation tests + “Clot test”
Kleihauer-Betke test not diagnostic, but useful to determine Rhogam dose
Pre-eclampsia labs, if indicated
Consider urine drug screen
Tape additional sample to wall in red top tube - check in 7-10 minutes
Pre-eclampsia labs - Fibrinogen levels <250mg/dl are abnormal and those <150 are diagnostic for coagulopathy
PT/PTT may be abnormal
FDP may be abnormal yet presence of D-dimer is poorly correlated with the diagnosis of abruption.
Fibrin D Dimer is poorly correlated with the diagnosis of abruption
A new marker - thrombomodulin, has been utilized in confirming placental abruption in some studies yet not widely available

48. Sher’s Classification
Grade I
Mild, often retroplacental clot identified at delivery
Grade II
Tense, tender abdomen and live fetus
Grade III
-IIIA
-IIIB
With fetal demise
-without coagulopathy (2/3)
-with coagulopathy (1/3)
Expeditious vaginal delivery is indicated for patients presenting with both a live fetus (grade II) and a dead fetus (grade III)

49. 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 hemotocrit > 30%
Prepare for neonatal resuscitation
Category C
If the patient has a reassuring fetal heart rate tracing and is in active labor, vaginal delivery can be permitted
The threshold for operative delivery should include any demonstration of fetal intolerance of labor in a patient where vaginal delivery is not imminent.
If labor is continuing, an amniotomy should be done to accelerate the process
And may reduce the incidence of amniotic fluid embolus.
If labor not progressing rapidly to a vaginal delivery then a cesarean delivery should be performed because of the high risk to the fetus.

50. Treatment - Grade III Abruption
Assess mother for hemodynamic and coagulation status
Vigorous replacement of fluid and blood products
Vaginal delivery preferred, unless severe hemorrhage
Oxytocin administration is not contraindicated if labor hypotonic but should be used judicious with the aid of an IUPC
Indications for cesarean delivery include failure of labor progression, brisk hemorrhage that cannot be compensated by a transfusion.
Category C

51. Coagulopathy with Abruption
Occurs in 1/3 of Grade III abruptions
Usually not seen if live fetus
Etiologies: consumption, DIC
Administer platelets, FFP
Give Factor VIII if severe
Etiologies
Consumption and DIC
Admin platelets and FFP prior to operative delivery, cryoprecipitate or Factor VIII may be of specific benefit in severe coagulopathy.

52. Epidemiology of Uterine Rupture*
Occult dehiscence vs.. symptomatic rupture
.03%-.08% of all women
.03%-1.7% of all women with uterine scar
Previous cesarean incision most common reason for scar disruption
Other causes: previous uterine curettage or perforation, inappropriate oxytocin usage, trauma, drugs*
Rupture of 2.6% for inducted VBAC’s

53. Risk Factors - Uterine Rupture*
Previous Uterine Surgery*
Congenital Uterine Anomalies
Uterine Overdistension*
Gestational Trophoblastic Disease
Adenomyosis
Fetal Anomaly
Vigorous Uterine Pressure
Difficult Placental Removal
Placenta Increta or Percreta (US/MRI)
During labor or delivery
Conditions present during index pregnancy
Conditions during labor and delivery

54. Uterine Scar Disruption
Can be an occult separation, thinning or dehiscence that is discovered at repeat cesarean section. Complete rupture as in these examples requires emergency laparotomy and may include fetal extrusion and/or demise
Extension of
Transverse
Scar
Midline
Classical
Rupture
Catastrophic
Rupture

55. Morbidity with Uterine Rupture
Maternal
Hemorrhage with anemia
Bladder rupture
Hysterectomy
Maternal Death
Fetal
Respiratory distress
Hypoxia
Acidemia
Neonatal death
Bladder rupture .05%
Hysterectomy .1 %
Maternal death rare
Fetal morbidity is more common

56. Patient History -Uterine Rupture*
Vaginal Bleeding
Pain
Cessation of contractions*
Absences FHR
Loss of Station
Palpable fetal parts through maternal abdomen
Profound maternal tachycardia and hypotension
13% of uterine ruptures occur outside of the hospital. Patient’s with a previous uterine scar should be advised to come to the hospital for evaluation upon the onset of contractions, abd pain or vaginal bleeding asap

57. Uterine Rupture Category C
Sudden deterioration of FHR pattern is a 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
Category C
Institute intrauterine resuscitation while waiting for cesarean
maternal position changes, iv fluids, d/c pit, o2 administration, sq terb
A small false negative rate of cesarean deliveries may be acceptable in the clinical setting of an abrupt change in fetal hr in a previous scarred uterus.
Uterine rupture is not always associated with the prior uterine incision. Of those patients who experienced a uterine rupture, the placenta was found at the uterine rupture site and was partially or completely abrupted.
Transvaginal ultrasonography may be useful for measurement of the uterine wall after previous cesarean delivery.
MRI may be helpful for confirmation of a possible placenta accreta

58. Vasa Previa
Fetal blood vessels transversing presenting membranes and is associated with abnormal insertion of fetal membranes into the membranes rather than the placenta.(velamentous insertion)
Bridging vessels

59. Vasa Previa Category C Rarest cause of hemorrhage
Onset with membrane rupture
Blood Loss is fetal, with 56% mortality (3%)
Associated with placenta previa, velamentous insertion of the cord, bilobed/succenturiate lobe, or IVF
Antepartum diagnosis
Amnioscopy
Color doppler ultrasound
Palpate vessels during vaginal examination
Rarest cause of obstetrical hemorrhage
occurs in placentas that are low-lying and with a velamentous insertion or a placenta with a succenturiate lobe. This is the only cause of major blood loss in pregnancy where blood loss in mainly fetal. Fetal mortality is high as much as 50%.
In a review of cases - 18 cases of vasa previa were diagnosed. 8 developed in setting where a previous placenta previa receded. 6 had vaginal 31 weeks mean, 3 had normal 3rd trimester u/s and subsequent vaginal deliveries. The remaining had cesareans
Color flow doppler may be a useful modality in the evaluation of patients suspected to have a vasa previa. Digital palpation of the membranes prior to artificial rupture is wize
Category C

60. 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 hour delay prohibits its use
Apt test -Modified Apt Test
Several cc’s of blood from vagina
Mix with Tap water
Centrifuge
Mix supernatant with NaOH
Read Color in Two minutes
Fetal = pink
Adult = brown

61. Modified Apt Test Several cc’s of blood from vagina Mix with Tap water
Centrifuge
Mix supernatant with NaOH
Read Color in Two minutes
Fetal = pink
Adult = brown
-Several cc’s of blood from vagina, mix with small amount of tap water, hemolysis occurs. Centrifuge for several minutes. Mix the pink supernatant with 1cc 1% NaOH (.25 normal) for every 5 cc supernatant, read the color in two minutes. Fetal: PINK!!! Adult stays brown
Or simply do a Wright’s Stain on the vaginal blood smear, look for nucleated rbc’s – if present = fetal blood = vasa previa

62. Management Vasa Previa
Immediate Cesarean Delivery if fetal heart non-reassuring
Administer normal saline cc/kg bolus to newborn, if found to be in shock after delivery
Fetal exsanguinations is the cause of mortality in this disorder, preparation for resuscitation at the delivery includes availability of normal saline at 102/ cc/kg bolus to administer if the newborn is in shock.

63. 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!

64. Transvaginal Predictive Value
TVS Overlap of 10 mm or weeks predictive 100% previa at term
Lauria US ObGyn Nov 1996
TVS Overlap of weeks predictive at birth 5.1 %
Taipale ObGyn 1997

65. Risk factors for Abruptions
Younger Women RR 1.4
Parity > 3 RR 10
May reflect effects of close pregnancy spacing
Previous Abruption RR 10
Chronic Hypertension
Preeclampsia RR 1.7
PROM RR 3.0