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Vaginal Bleeding in Late Pregnancy. Objectives Identify major causes of vaginal bleeding in the second half of pregnancy Identify major causes of vaginal.

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Presentation on theme: "Vaginal Bleeding in Late Pregnancy. Objectives Identify major causes of vaginal bleeding in the second half of pregnancy Identify major causes of vaginal."— Presentation transcript:

1 Vaginal Bleeding in Late Pregnancy

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

3 Causes of Late Pregnancy Bleeding Placenta Previa Placenta Previa Abruption Abruption Ruptured vasa previa Ruptured vasa previa Uterine scar disruption Uterine scar disruption Cervical polyp Cervical polyp Bloody show Bloody show Cervicitis or cervical ectropion Cervicitis or cervical ectropion Vaginal trauma Vaginal trauma Cervical cancer Cervical cancer Life-Threatening

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

5 Risk Factors for Placenta Previa Previous cesarean delivery Previous cesarean delivery Previous uterine instrumentation Previous uterine instrumentation High parity High parity Advanced maternal age Advanced maternal age Smoking Smoking Multiple gestation Multiple gestation

6 Morbidity with Placenta Previa Maternal hemorrhage Maternal hemorrhage Operative delivery complications Operative delivery complications Transfusion Transfusion Placenta accreta, increta, or percreta Placenta accreta, increta, or percreta Prematurity Prematurity

7 Patient History – Placenta Previa Painless bleeding Painless bleeding  2 nd or 3 rd trimester, or at term  Often following intercourse  May have preterm contractions “Sentinel bleed” “Sentinel bleed”

8 Physical Exam – Placenta Previa Vital signs Vital signs Assess fundal height Assess fundal height Fetal lie Fetal lie Estimated fetal weight (Leopold) Estimated fetal weight (Leopold) Presence of fetal heart tones Presence of fetal heart tones Gentle speculum exam Gentle speculum exam NO digital vaginal exam unless placental location known NO digital vaginal exam unless placental location known

9 Laboratory – Placenta Previa Hematocrit or complete blood count Hematocrit or complete blood count Blood type and Rh Blood type and Rh Coagulation tests Coagulation tests While waiting – serum clot tube taped to wall While waiting – serum clot tube taped to wall

10 Ultrasound – Placenta Previa Can confirm diagnosis Can confirm diagnosis Full bladder can create false appearance of anterior previa Full bladder can create false appearance of anterior previa Presenting part may overshadow posterior previa Presenting part may overshadow posterior previa Transvaginal scan can locate placental edge and internal os Transvaginal scan can locate placental edge and internal os

11 Treatment – Placenta Previa With no active bleeding With no active bleeding  Expectant management  No intercourse, digital exams With late pregnancy bleeding With late pregnancy bleeding  Assess overall status, circulatory stability  Full dose Rhogam if Rh-  Consider maternal transfer if premature  May need corticosteroids, tocolysis, amniocentesis

12 Double Set-Up Exam Appropriate only in marginal previa with vertex presentation Appropriate only in marginal previa with vertex presentation Palpation of placental edge and fetal head with set up for immediate surgery Palpation of placental edge and fetal head with set up for immediate surgery Cesarean delivery under regional anesthesia if: Cesarean delivery under regional anesthesia if:  Complete previa  Fetal head not engaged  Non-reassuring tracing  Brisk or persistent bleeding  Mature fetus

13 Placental Abruption Premature separation of placenta from uterine wall Premature separation of placenta from uterine wall  Partial or complete “Marginal sinus separation” or “marginal sinus rupture” “Marginal sinus separation” or “marginal sinus rupture”  Bleeding, but abnormal implantation or abruption never established

14 Epidemiology of Abruption Occurs in 1-2% of pregnancies Occurs in 1-2% of pregnancies Risk factors Risk factors  Hypertensive diseases of pregnancy  Smoking or substance abuse (e.g. cocaine)  Trauma  Overdistention of the uterus  History of previous abruption  Unexplained elevation of MSAFP  Placental insufficiency  Maternal thrombophilia/metabolic abnormalities

15 Abruption and Trauma Can occur with blunt abdominal trauma and rapid deceleration without direct trauma Can occur with blunt abdominal trauma and rapid deceleration without direct trauma Complications include prematurity, growth restriction, stillbirth Complications include prematurity, growth restriction, stillbirth Fetal evaluation after trauma Fetal evaluation after trauma  Increased use of FHR monitoring may decrease mortality

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

17 Patient History - Abruption Pain = hallmark symptom Pain = hallmark symptom  Varies from mild cramping to severe pain  Back pain – think posterior abruption Bleeding Bleeding  May not reflect amount of blood loss  Differentiate from exuberant bloody show Trauma Trauma Other risk factors (e.g. hypertension) Other risk factors (e.g. hypertension) Membrane rupture Membrane rupture

18 Physical Exam - Abruption Signs of circulatory instability Signs of circulatory instability  Mild tachycardia normal  Signs and symptoms of shock represent >30% blood loss Maternal abdomen Maternal abdomen  Fundal height  Leopold’s: estimated fetal weight, fetal lie  Location of tenderness  Tetanic contractions

19 Ultrasound - Abruption Abruption is a clinical diagnosis! Abruption is a clinical diagnosis! Placental location and appearance Placental location and appearance  Retroplacental echolucency  Abnormal thickening of placenta  “Torn” edge of placenta Fetal lie Fetal lie Estimated fetal weight Estimated fetal weight

20 Laboratory - Abruption Complete blood count Complete blood count Type and Rh Type and Rh Coagulation tests + “Clot test” Coagulation tests + “Clot test” Kleihauer-Betke not diagnostic, but useful to determine Rhogam dose Kleihauer-Betke not diagnostic, but useful to determine Rhogam dose Preeclampsia labs, if indicated Preeclampsia labs, if indicated Consider urine drug screen Consider urine drug screen

21 Sher’s Classification - Abruption Grade I Grade I Grade II Grade II Grade IIIwith fetal demise Grade IIIwith fetal demise  III A - without coagulopathy (2/3)  III B - with coagulopathy (1/3) mild, often retroplacental clot identified at delivery tense, tender abdomen and live fetus

22 Treatment – Grade II Abruption Assess fetal and maternal stability Assess fetal and maternal stability Amniotomy Amniotomy IUPC to detect elevated uterine tone IUPC to detect elevated uterine tone Expeditious operative or vaginal delivery Expeditious operative or vaginal delivery Maintain urine output > 30 cc/hr and hematocrit > 30% Maintain urine output > 30 cc/hr and hematocrit > 30% Prepare for neonatal resuscitation Prepare for neonatal resuscitation

23 Treatment – Grade III Abruption Assess mother for hemodynamic and coagulation status Assess mother for hemodynamic and coagulation status Vigorous replacement of fluid and blood products Vigorous replacement of fluid and blood products Vaginal delivery preferred, unless severe hemorrhage Vaginal delivery preferred, unless severe hemorrhage

24 Coagulopathy with Abruption Occurs in 1/3 of Grade III abruption Occurs in 1/3 of Grade III abruption Usually not seen if live fetus Usually not seen if live fetus Etiologies: consumption, DIC Etiologies: consumption, DIC Administer platelets, FFP Administer platelets, FFP Give Factor VIII if severe Give Factor VIII if severe

25 Epidemiology of Uterine Rupture Occult dehiscence vs. symptomatic rupture Occult dehiscence vs. symptomatic rupture 0.03 – 0.08% of all women 0.03 – 0.08% of all women 0.3 – 1.7% of women with uterine scar 0.3 – 1.7% of women with uterine scar Previous cesarean incision most common reason for scar disruption Previous cesarean incision most common reason for scar disruption Other causes: previous uterine curettage or perforation, inappropriate oxytocin usage, trauma Other causes: previous uterine curettage or perforation, inappropriate oxytocin usage, trauma

26 Risk Factors – Uterine Rupture Previous uterine surgery Previous uterine surgery Adenomyosis Adenomyosis Congenital uterine anomaly Congenital uterine anomaly Fetal anomaly Fetal anomaly Uterine overdistension Uterine overdistension Vigorous uterine pressure Vigorous uterine pressure Gestational trophoblastic neoplasia Gestational trophoblastic neoplasia Difficult placental removal Difficult placental removal Placenta increta or percreta Placenta increta or percreta

27 Morbidity with Uterine Rupture Maternal Maternal  Hemorrhage with anemia  Bladder rupture  Hysterectomy  Maternal death Fetal Fetal  Respiratory distress  Hypoxia  Acidemia  Neonatal death

28 Patient History – Uterine Rupture Vaginal bleeding Vaginal bleeding Pain Pain Cessation of contractions Cessation of contractions Absence of FHR Absence of FHR Loss of station Loss of station Palpable fetal parts through maternal abdomen Palpable fetal parts through maternal abdomen Profound maternal tachycardia and hypotension Profound maternal tachycardia and hypotension

29 Uterine Rupture Sudden deterioration of FHR pattern is most frequent finding Sudden deterioration of FHR pattern is most frequent finding Placenta may play a role in uterine rupture Placenta may play a role in uterine rupture  Transvaginal ultrasound to evaluate uterine wall  MRI to confirm possible placenta accreta Treatment Treatment  Asymptomatic scar disruption – expectant management  Symptomatic rupture – emergent cesarean delivery

30 Vasa Previa Rarest cause of hemorrhage Rarest cause of hemorrhage Onset with membrane rupture Onset with membrane rupture Blood loss is fetal, with 50% mortality Blood loss is fetal, with 50% mortality Seen with low-lying placenta, velamentous insertion of the cord or succenturiate lobe Seen with low-lying placenta, velamentous insertion of the cord or succenturiate lobe Antepartum diagnosis Antepartum diagnosis  Amnioscopy  Color doppler ultrasound  Palpate vessels during vaginal examination

31 Diagnostic Tests – Vasa Previa Apt test – based on colorimetric response of fetal hemoglobin Apt test – based on colorimetric response of fetal hemoglobin Wright stain of vaginal blood – for nucleated RBCs Wright stain of vaginal blood – for nucleated RBCs Kleihauer-Betke test – 2 hours delay prohibits its use Kleihauer-Betke test – 2 hours delay prohibits its use

32 Management – Vasa Previa Immediate cesarean delivery if fetal heart rate is non-reassuring Immediate cesarean delivery if fetal heart rate is non-reassuring Administer normal saline 10 – 20 cc/kg bolus to newborn, if found to be in shock after delivery Administer normal saline 10 – 20 cc/kg bolus to newborn, if found to be in shock after delivery

33 Summary Late pregnancy bleeding may herald diagnoses with significant morbidity/mortality Late pregnancy bleeding may herald diagnoses with significant morbidity/mortality Determining diagnosis important, as treatment dependent on cause Determining diagnosis important, as treatment dependent on cause Avoid vaginal exam when placental location not known Avoid vaginal exam when placental location not known


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