2Introduction Definition: Vaginal bleeding which occurs after fetal viability.Incidence:2 – 6 %.
3ANTEPARTUM HEMORRHAGE Per vagina blood loss after 20 weeks’ gestation.Complicates close to 4% of all pregnancies and is a MEDICAL EMERGENCY!Is one of the leading causes of antepartum hospitalization, maternal morbidity, and operative intervention.3
9Placental Abruption external hemorrhage concealed hemorrhage Total Partial9
10Presentation Vaginal bleeding. Uterine tenderness or back pain. Fetal distress.High frequency contractions.Uterine hypertonus.Idiopathic PTL.IUFD.
11DiagnosisThe diagnosis is primarily clinical, but may be supported by radiologic, laboratory, or pathologic findings.It is generally obvious in severe cases.In milder forms the diagnosis is often made by exclusion.
12Diagnosis The echogenic appearance depends upon the onset of symptoms: Acute hemorrhage is hyperechoic to isoechoic compared with the placenta.Resolving hematomas is hypoechoic within one week and sonolucent within two weeks.
13Diagnosis Laboratory testing is not useful in making the diagnosis: Kleihauer-Betke test: sensitivity 17%.CA-125: elevated.D-dimer: sensitivity 67, specificity 93%Thrombomodulin: sensitivity 88, specificity 77%.Hypofibrinogenemia < 200 mg/dL.Thrombocytopenia < 100,000/microL.
14DiagnosisGross examination of the placenta often reveals a clot and/or depression in the maternal surface.It may be absent with acute abruption.
15Initial ManagementStabilization of the maternal cardiopulmonary status.Blood work:- CBC.- Coagulation profile.- Fibrinogen.- Blood type and Rh.
16Initial ManagementLarge-bore intravenous lines and continuous fetal monitoringCorrection of the intravascular fluid deficit via crystalloid +/- PRBC.If the PT and PTT > 1.5x control 2u FFP.If the platelet count is < 50,000/microL 6u plt.
17Initial Management Heparin or other anticoagulants ? Tocolysis is generally contraindicated.Delivery is the optimal treatment. DIC & hemorrhage will resolve over 12 hours when the placenta is removed.
18Initial Management Medical treatment of coagulopathy for: Marked thrombocytopenia (< 20,000/microL)Moderate thrombocytopenia(<50,000/microL) &serious bleeding or planned cesarean delivery.FFP or cryoprecipitate if fibrinogen is <100 mg/dL
19Mild Abruption Expectant management with short term hospitalization. Corticosteroid.Tocolysis may be of value in mild cases.
20Delivery The mode and timing of delivery depend upon: GA. The condition of the fetus.The condition of the mother (eg, hypotension, coagulopathy, hemorrhage).The status of the cervix.
21DeliveryThe term or near term fetus should be expeditiously delivered.Amniotomy with placement of a fetal scalp electrode.Oxytocin may be used to augment uterine activity.
22DeliveryC/S is performed in the presence of a nonreassuring fetal heart rate pattern & when delay in delivery will endanger the mother or fetus.It should be done after rapid maternal hemodynamic and clotting factor stabilization.
25Introduction Definition: The presence of placental tissue overlying or proximate to the internal cervical os after viability.Incidence:Complicates approximately 1 in 300 pregnancies.
26Risk FactorsIncreasing parity: incidence 0.2 percent in nulliparas versus up to 5 percent in grand multiparas.Maternal age: incidence 0.03 percent in nulliparous women aged 20 to 29 versus 0.25 percent in nulliparous women 40 years of age.Number of prior cesarean deliveries incidence 10 percent after four or more.Number of curettages for spontaneous or induced abortions.
27Independent Risk Factors Maternal smokingResidence at higher altitudesMale fetusMultiple gestation: 3.9 and 2.8 previas per 1000 live twin and singleton births, respectivelyGestational age: the prevalence of placenta previa is much higher early in pregnancy than at term
28ClassificationComplete placenta previa: The placenta completely covers the internal os.Partial placenta previa: The placental edge does not completely cover the internal cervical os but partially covers it.Marginal placenta previa: The placenta is proximate to the internal os.Low-lying placenta: in which placental edge lies within 2 to 3 cm of the internal os. (reference)
30Clinical Manifestations Painless vaginal bleeding occurs in 70 to 80 percent of patients.10 to 20 percent present with uterine contractions associated with bleeding.Fewer than 10 percent are incidentally detected by ultrasound.
32DiagnosisThe diagnosis is based upon results of ultrasound examination.Clinical findings are used to support the sonographic diagnosis.Placenta previa should be suspected in any woman beyond 24 weeks of gestation who presents with painless vaginal bleeding.
33Transabdominal USIt has a diagnostic accuracy as high as 95% in detecting placenta previa, with a false negative rate of 7%.Sagittal, parasagittal and transverse sonographic views should be obtained.
34Transabdominal USIt requires the identification of echogenic placental tissue overlying or proximate to the internal cervical os (a distance >2 cm).
35Transvaginal USIt has become the gold standard for the diagnosis of placenta previa.It is a safe and effective technique, with diagnostic accuracy greater than 99 percent.The probe does not need to come into contact with the cervix to provide a clear image.
36UltrasoundBoth the transabdominal and transvaginal US should be used as complementary studies.Initial transabdominal examination, with transvaginal sonography if there is any ambiguity in the placental position.Translabial ultrasound imaging is an alternative technique.
37Antepartum Management Avoidance of coitus and digital cervical examination.Counseling to seek immediate medical attention if there is any vaginal bleeding.Women are also encouraged to avoid exercise, decrease their activity, and notify the physician of uterine contractions.Serial ultrasound evaluations every two to four weeks to assess placental location and fetal growth.
38Acute Care of Symptomatic Placenta Previa Large bore IV access & administration of crystalloid.Type and cross-match for four units of PRBC.Transfuse to maintain a Hct of 30% if the patient is actively bleeding.Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree of blood loss.
39Acute Care of Symptomatic Placenta Previa The fetal heart rate is continuously monitored.Quantitative monitoring of vaginal blood loss.The source of the vaginal blood (maternal versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis.Urine output is evaluated hourly with a Foley catheter & should be at least 30 mL/hour.
40Acute Care of Symptomatic Placenta Previa Hb & Hct.Serum electrolytes and indices of renal function.Coagulation profile (fibrinogen, Plt, PT & PTT) are checked especially if there is a suspicion of coexistent abruption.
41Delivery Tocolysis is not administered to actively bleeding patients. Delivery is indicated if: (1) there is a nonreassuring fetal heart rate. (2) life threatening refractory maternal hemorrhage.
42Mode of Delivery Cesarean delivery is the delivery route of choice. Vaginal delivery may be considered in the presence of:a fetal demisepreviable fetussome cases of marginal previa, as long as the mother remains hemodynamically stable.
43Conservative Management of Stable Preterm Patients The patient is hospitalized at bedrest with bathroom privileges.Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining.Periodic assessment of the maternal hematocrit.Ferrous gluconate supplements (300 mg orally three or four times per day) are given with vitamin C to improve intestinal iron absorption.
44Conservative Management of Stable Preterm Patients Cross match to provide two to four units of packed red blood cells.Prophylactic transfusions to maintain the maternal hematocrit above 30 percent in stable asymptomatic patients in anticipation of future blood loss.
45Conservative Management of Stable Preterm Patients A single course of corticosteroid between 24 and 34 w.Rh(D)-negative women should receive Rh(D)-immune globulin if they bled.Readministration is not necessary if delivery or rebleeding occurs within three weeks, unless a large fetomaternal hemorrhage is detected by KBT.
46Conservative Management of Stable Preterm Patients Fetal growth, amniotic fluid volume, and placental location are evaluated sonographically every two to four weeks.Tocolysis may be safely utilized if contractions are present and delivery is not otherwise mandated by the maternal or fetal condition.
47Conservative Management of Stable Preterm Patients Amniocentesis can be done at 36 weeks to assess pulmonary maturity.Scheduled abdominal delivery is 37w or upon confirmation of pulmonary maturity.
48Delivery Abdominal delivery. Two to four units of PRBC should be available for the delivery.Appropriate surgical instruments for performance of a cesarean hysterectomy should also be available since there is a 5 to 10 percent risk of placenta accreta.
49C/SThe surgeon should try to avoid disrupting the placenta when entering the uterus.If the placenta is encountered upon opening the uterus then it is necessery to cut through the placental tissue to deliver the fetus.
50Outpatient Managaement Women who have never bled.Women with placenta previa if bleeding has stopped for more than one week.There are no other pregnancy complications, such as fetal growth restriction.
51Outpatient Management Live within 15 minutes of the hospital.Have an adult companion available 24 hours a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding.Be reliable and able to maintain bed rest at home.Understand the risks entailed by outpatient management.
52OutcomeThe maternal and perinatal mortality rates in pregnancies complicated by placenta previa have been reduced over the past few decades because of:The introduction of conservative obstetrical management.The liberal use of cesarean rather than vaginal delivery.Improved neonatal care.
54IntroductionVasa previa refers to vessels that traverse the membranes in the lower uterine segment in advance of the fetal head.Rupture of these vessels can occur with or without rupture of the membranes and result in fetal exsanguination.The incidence is 1 in 2000 – 3000 deliveries.
56DiagnosisThe diagnosis of vasa previa is considered if vaginal bleeding occurs upon rupture of the membranes.Concomitant fetal heart rate abnormalities, particularly a sinusoidal pattern.Ideally, vasa previa is diagnosed antenatally by US with color flow Doppler.
57Antenatal ManagementConsider hospitalization in the third trimester to provide proximity to facilities for emergency cesarean delivery.Fetal surveillance to detect compression of vessels.Antenatal corticosteroids to promote lung maturity.Elective cesarean delivery at 35 to 36 weeks of gestation.
58Antepartum Management Immediate C/S.Avoid amniotomy as the risk of fetal mortality is 60-70% with rupture of the membranes.
60Risk FactorsThe most common risk factor is a previous uterine incision.The rate is higher with classical & T-shape uterine incision in comparison to low vertical & transverse incisions.The rate increases with the number of previous uterine incisions.
62Presentation Sudden severe fetal heart decelerations. Abdominal pain & PV bleeding ( <10%).Diaphragmatic irritation.Loss of fetal station.Cessation of uterine contractions.
63Prognosis Fetal death 50-75%. Maternal mortality is high if not diagnosed & managed promptly.Maternal morbidity: hemorrhage & infection.
64Management stabilization of maternal hemodynamics. Prompt C/S with either repair of the uterine defect or hysterectomy.Antibiotics.
65A 23-y-o 29w comes to A&E for evaluation following a RTA in which a restrained passenger in the back seat. She denies any symptoms & examination is normal with fetal heart rate of 150bpm. Before discharging the patient your recommendation regarding electronic fetal monitoring:Do none.Monitor for 2-6h.Monitor for 6-12h.Monitor for 12-18h.Monitor for 18-24h.
66In counseling a woman with a prior C/S regarding IOL, you tell her that the highest risk of uterine rupture is associated with:Osmotic cervical dilator.Transcervical Foley balloon placement.Prostaglandins.Oxytocin.
67A 34-y-o woman G3P2, present @38w in early labor A 34-y-o woman G3P2, in early labor. V/E: 3cm with a firm ridge in the membranes by palpation. U/S: placenta located both anteriorly & posteriorly in the lower uterine segment. There is no placenta previa. A tocolytic is administered. What should be the next step in management?Allow continued labor.Speculum examination.Amniocentesis.Color flow Doppler U/S.Amniotomy.
68A 19y-o PG 34w with heavy vaginal bleeding & regular contractions. She reports no leakage of fluid. BP:156/98. F Ht 35cm. CTG is reactive. U/S: anterior placenta & no retroplacental sonolucency. V/E: 4cm. The most likely Dx is:Vasa previa.Placental abruption.Chorioangioma.Placenta accreta.Placental succenturiate lob.