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

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

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*

Placenta Previas

Placenta Previas

Prevalence of Placenta Previa Occurs in 1/200 pregnancies that reach 3rd trimester Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks 90% will have normal implantation when scan repeated @ >30 weeks No proven benefit to routine screening ultrasound for this diagnosis.

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

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

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

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 1950-1996 Anath ObGyn 1996

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 @ 26-28 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.

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.

Speculum exam revealing an anterior placenta previa

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

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

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

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

Complete Previa - Ultrasound

Posterior Previa Transvaginal Scan Posterior Placenta Previa

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

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

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

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

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

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

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!

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.

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

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

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

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

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.

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

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

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.

“Uteroplacental apoplexy or Couvelaire” uterus

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

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

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

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

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.

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

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

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

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

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

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

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)

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.

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

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.

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

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

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

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

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

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

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

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 93.874 cases - 18 cases of vasa previa were diagnosed. 8 developed in setting where a previous placenta previa receded. 6 had vaginal bleeding @ 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

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

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

Management Vasa Previa Immediate Cesarean Delivery if fetal heart non-reassuring Administer normal saline 10-20 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.

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!

Transvaginal Predictive Value TVS Overlap of 10 mm or more @ 15-20 weeks predictive 100% previa at term Lauria US ObGyn Nov 1996 TVS Overlap of 15 mm @ 12-16 weeks predictive at birth 5.1 % Taipale ObGyn 1997

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