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Vaginal Bleeding in
Late Pregnancy
Presented ByNirsuba Gurung Master in nursing
Women health and development
Obstetric Haemorrhage
Ranks as the First cause of maternal mortality accounting for 25 – 50 % of maternal deaths
APH: Epidemiology & Causes Magnitude: 4% of women may
develop APH. Causes:
placenta previa (1/200) placental abruption (1/100) uterine rupture (<1% in scarred uterus) vasa previa (1/2000-3000) Local causes
Cervical polyp Bloody show Cervicitis or cervical ectropion Cervical cancer
Vasa Previa
Velamentous Insertion of the umbilical cord
ABRUPTIO PLACENTA Definition:
Early separation of the normally implanted placenta after 28/40 and before the end of second stage of labour
Recurrence: The risk of recurrent abruption in a
subsequent pregnancy is high.
Epidemiology of Abruption Occurs in 1-2% of pregnancies
20% of all third-trimester bleeders
Recurrence risk 10% in first pregnancy 25% in second pregnancy
Epidemiology of Abruption It is a significant cause of
perinatal mortality – 15-20%
Maternal mortality- 2-5%
Risk factors
Prevalence is high in Smoking or substance abuse (e.g.
cocaine) History of previous abruption High birth order Advancing maternal age Poor-socioeconomic condition Malnutrition Placental insufficiency
Risk factors
Etiology Hypertension in pregnancy
•Spasm of utero-placental blood vessels
•Anoxic endothelial damage
•Rupture of vessels or•Extravasations' of blood in decidual basalis
Trauma External cephalic version RTA Needle puncture during
amoiocentesis
Sudden uterine decompression
Delivery of first twins Sudden escape of liquor amnii in
hydraminous Premature rupture of membrane
Short cord Supine hypotension syndrome Placental anomaly Sick placenta Folic acid deficiency Uterine anomaly Thrombophilias
Pathogenesis
Umbilical artery (UA)Umbilical vein (UV)
Uterine arteries
Uterine veins
Abruption
Archer TL 2006 unpublished
Placental abruption: fetal asphyxiation (O2 supply is cut off).
Placental abruption with trauma
Elastic myometrium
Liquid placenta
Placenta shears off
Miller’s Anesthesia chap. 58
Occult hemorrhage in abruption
Features of retroplacental clots Depression found in maternal
surface of placenta
Area of infraction with varying degree of organization
Abruptio placenta: Classifications
Are based on1.Extent of separation: Partial vs
complete 2.Location of separation: Marginal Vs
central 3.Clinical presentation: Revealed,
concealed and mixed4.Clinical Severity: Mild, Moderate and
Severe
Grade 1 Mildest form: approx 40 of all cases.
• No vaginal bleeding to mild vaginal bleeding
• Slightly tender uterus
• Normal maternal BP and heart rate
• No coagulopathy (clotting problems)
• No fetal distress
Clinical Severity
Grade 2: moderate -approx
45% of all cases. • No vaginal bleeding to
moderate vaginal bleeding• Moderate-to-severe uterine
tenderness with possible tetanic contractions
• Maternal tachycardia with orthostatic changes in BP and heart rate
• Fetal distress or even death • Low fibrinogen levels present
(causing clotting problems)
Grade 0: no clinical features• Diagnosis made after placental exmaninatio
Grade 3: Severe form: Approx 15% of all cases.
• No vaginal bleeding to heavy vaginal bleeding• Very painful tetanic uterus• Maternal shock• Coagulopathy• Fetal death
Clinical Severity
Abruptio Placenta: Features
Pain and tenderness Initially localized then becomes
generalized due to endometrial injury – extravasations of blood
Vaginal bleeding Maternal distress Often I.U.F.D
Clinical manifestation of hemorrhage Concealed type: blood
accumulates behind placenta Revealed type: blood dissect
downwards between membranes and uterine wall and ultimately escape out through the cervix or may be kep concealed by the pressure of fetal head on the lower uterine segment
Clinical manifestation of hemorrhage Blood may gain access to the
amniotic cavity after rupturing the membrane
Couvelaire uterus : blood may percolate through the layer of myometrium
Couvelaire uterus Naked eye features
Dark port wine color:patchy and diffused
Sub peritoneal petechial hemorrhage
Free blood may be present in peritoneal cavity
Couvelaire uterus Microscopic appearance:
Necrosed uterine muscles in the affected part
Blood infiltration between the muscle bundle
Blood vessels may show acute degenerative changes
Muscular dissociation occurs in middle and outer muscle layer
Clinical features
Revealed Mixed(Concealed features predominate)
Symptoms Abdominal bleeding and discomfort followed by bleeding
Acute, intense abdominal pain followed by slight bleeding
Character of bleeding Continuous dark color Continuous dark color or blood stained serous discharge
General condition Proportionate to the visible blood loss, shock is usually absent
Shock may be pronounced which is proportionate to the visible blood loss
Pallor Related with visible blood loss
Pallor is usually severe and out of proportion to the visible blood loss
Features of pre-eclampsia
May be absent Frequent association
Revealed Mixed(Concealed features predominate)
Uterine height Proportionate to the POG
May be disproportionately enlarged and globular
Uterine feel Normal feel with localized tenderness, contractions frequent and local amplitude
Uterus is tense ,tender and rigid
Fetal parts Can be identified easily
Difficult to make out
FHS Usually present Usually absent
Laboratory test Revealed Mixed(Concealed
features predominate) Hemoglobin Low value proportionate to
the blood loss Markedly lower than vi
Coagulation profile Usually unchanged Variable changes •Clotting time increased(>6min)•Fibrinogen level low(<150mg/dl)•Low platelet count•^ Partial thromboplastin time•^ FDP and D-dimer
Urine for protein Confusion in diagnosis
May be absent Usually present
Confusion in diagnosis Placenta previa Acute obstretrical-gynaecological –surgical complication
Ultrasound - Abruption Abruption is a clinical diagnosis! Placental location and appearance
Retroplacental echolucencyAbnormal thickening of placenta“Torn” edge of placenta
Fetal lie Estimated fetal weight
Large, extensive sonographic preplacental collection beneath the chorionic plate
Large, retroplacental sonographic abruption between the placenta and uterus.
Sonographic blood collection at the placental margin
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
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
Placental Abruption: Complications Shock Acute renal failure
Cause: ?seriously impaired renal perfusion 2° to ↓CO and intrarenal vasospasm as in preeclampsia
DIC Consumptive coagulopathy 2° to
hypofibrinogenemia along with elevated levels of fibrinogen–fibrin degradation products
Placental Abruption: Complications Fetal distress/demise PPH Couvelaire Uterus:
Widespread extravasation of blood into the uterine musculature and beneath the uterine serosa.
Sheehan syndrome Puerperal sepsis
Placental Abruption: Management Prevention : Aim
Elimination of the known factorsCorrection of anemia Prompt detection and institution
of the therapy to minimize complication
Prevention of known factors Early detection and effective
therapy Needle puncture: USG guided Avoidance of trauma Avoid sudden decompression of
the uterus To avoid supine hypotension Routine administration of folic acid
Placental Abruption: Management Management depends on:
fetal maturity, degree of severity, viability of the fetus/fetal distress
Assessment of case Blood loss Maturity of fetus Whether patient is in labor or not Presence of complication Types and grade of abruption
Emergency measures Sent blood for Hb and hematocrit,
coagulation profile, ABO and Rh grouping
Urine for detection of protein IV RL drip with wide bore cannula
and arrangement for BT Close monitoring of maternal and
fetal well being
Treatment modalities
Expectant management of pregnancy
Definitive management Induction/augmentation of labor
Caesarean section
If patient in labor Low Rupture of membrane Augmentation
Bed site clotting timeDone regularly
Vaginal delivery Limited placental abruption Reassuring FHS Facilities of continous FHS
monitoring Prospect of vaginal delivery is soon Placental abruption with dead
fetus
The patient not in labor Bleeding continues > grade 1 abruption
Delivery either by • Induction of labor• C/S
Placental Abruption: General Management
1. Delivery Resuscitation
FFP, whole blood, IV fluids Monitor BP Catherization - monitor urine
output
Placental Abruption: General Management
2. Caesarean Section Indications for Caesarean Section
salvageable baby, Severe vaginal bleeding,Poor progress,Transverse lie, inadequate pelvis
Post delivery -watch out for PPHMyometrial myofibrin loose contractilityFailure to clot
Expectant management If bleeding stopped Grade 1 Fetus reactive and remote from
term
Goal : prolong pregnancy Meanwhile administer
betamethasone for fetal lung maturity