1. Vaginal Bleeding in Late Pregnancy

2. Objectives
Identify major causes of vaginal bleeding in the second half of pregnancy
Describe a systematic approach to identifying 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 or cervical ectropion
Vaginal trauma
Cervical cancer
Life-Threatening

4. 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 repeated at >30 weeks
No proven benefit to routine screening ultrasound for this diagnosis

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

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

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

8. 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 vaginal exam unless placental location known

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

10. 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

11. Treatment – Placenta Previa
With no active bleeding
Expectant management
No intercourse, digital exams
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
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 persistent bleeding
Mature fetus

13. 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

14. Epidemiology of Abruption
Occurs in 1-2% of pregnancies
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
Complications include prematurity, growth restriction, stillbirth
Fetal evaluation after trauma
Increased use of FHR monitoring may decrease mortality

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

17. 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)
Membrane rupture

18. 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

19. 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

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

21. Sher’s Classification - Abruption
Grade I
Grade II
Grade III with 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
Amniotomy
IUPC to detect elevated uterine tone
Expeditious operative or vaginal delivery
Maintain urine output > 30 cc/hr and hematocrit > 30%
Prepare for neonatal resuscitation

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

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

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

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

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

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

29. Uterine Rupture
Sudden deterioration of FHR pattern is 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

30. Vasa Previa Rarest cause of hemorrhage Onset with membrane rupture
Blood loss is fetal, with 50% mortality
Seen with low-lying placenta, velamentous insertion of the cord or succenturiate lobe
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
Wright stain of vaginal blood – for nucleated RBCs
Kleihauer-Betke test – 2 hours delay prohibits its use

32. Management – Vasa Previa
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

33. 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