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

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Presentation on theme: "Bleeding Late in Pregnancy When the placenta misbehaves Grace Cavallaro MD, FACOG."— Presentation transcript:

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

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

8 Morbidity with Placenta Previa Maternal Hemorrhage Operative Delivery Complications Transfusion Placenta accreta, increta or percreta Prematurity

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 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

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

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 Careful insertion of the vaginal probe midway into the vagina will image the LUS and the cervical os

18 Complete Previa - Ultrasound c c

19 Posterior Previa Transvaginal Scan Posterior Placenta Previa

20 False Previa Lower placental border c Full bladder No Previa

21 False Previa - Overdistended Bladder Bladder c Cervical canal

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’s1) ABC’s –Amount of bleeding noted is unreliable 2) Fetal Well Being2) Fetal Well Being 3) No Vaginal Exams3) No Vaginal Exams –Until you know where the placenta is! 4) Ultrasound4) Ultrasound

26 Fetal/Neonatal Considerations Gestational Age of Fetus dictates local of care SGA/Prematurity are major problems Communication with consultants is key!

27 Cesarean Sections and Previas 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

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

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

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

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

34 Abruptions and Trauma 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

35 Bleeding from Abruption Externalized hemorrhage Bloody amniotic fluid Retroplacental clot –20% occult –“uteroplacental apoplexy or Couvelaire uterus Look for consumptive coagulopathy

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

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

41 Fetal/Uterine Monitor in an Abruption

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 Hematoma retroplacental

44 Abruption - Retroplacental Hematoma Retro placental hematoma day1 7 days later

45 False Abruption? Contraction Mimicking Abruption Contraction No Contraction 30 minutes later

46 Placenta Lakes Subchorionic Placental Lake 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

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)

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

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

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

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*

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

54 Extension of Transverse Scar Midline Classical Rupture Catastrophic Rupture Uterine Scar Disruption

55 Morbidity with Uterine Rupture Maternal –Hemorrhage with anemia –Bladder rupture –Hysterectomy –Maternal Death Fetal –Respiratory distress –Hypoxia –Acidemia –Neonatal death

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

57 Uterine Rupture 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

58 Vasa Previa Bridging vessels

59 Vasa Previa 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

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

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

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

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


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