Obstetric Hemorrhage
Dr mukhamad Nooryanto,SpOG
Placental Abruption
Risk FactorsTrauma (usually shearing, such as a car accident), preeclampsia (and maternal HTN), smoking, cocaine abuse, high parity, previous history of abruption
Clinical PresentationVaginal bleeding (maternal and fetal blood present)Constant and severe back pain or uterine tendernessIrritable, tender, and typically hypertonic uterusEvidence of fetal distressMaternal shock
Figure 9-3. Placental abruption
Diagnosis
Ultrasound will show retroplacental hematoma only part of the time
Clinical and pathological findings
Management Correct shock (packed RBCs, fresh frozen
plasma, cryoprecipitate, platelets)
Expectant management: Close observation of mother and fetus with ability to intervene immediately
If there is fetal distress, perform C-section
Placenta Previa
A condition in which the placenta is implanted in the immediate vicinity of the cervical canal. It can be classified into three types:
1. Complete placenta previa: The placenta covers the entire internal cervical os
2. Partial placenta previa: The placenta partially covers the internal cervical os
3. Marginal placenta previa: One edge of the placenta extends to the edge of the internal cervical os
Figure 9-4.
Incidence0,5 to 1 %
EtiologyUnknown, but associated with: Increased parity Older mothers Previous abortions Previous history of placenta previa Fetal anomalies
Clinical Presentation Painless, profuse bleeding in T3 Postcoital bleeding Spotting during T1 and T2 Cramping (10% of cases)
Diagnosis
Transabdominal ultrasound (95% accurate)
Double set-up exam: Take the patient to the operating room and prep for a C-section. Do speculum exam: If there is local bleeding, do a C-section; if not, palpate fornices to determine if placenta is covering the os. The double set-up exam is performed only on the rare occasion that the ultrasound is inconclusive
Management
Cesarean section is always the delivery method of choice for placenta previa. The specific management is geared toward different situations
For Preterm If there is no pressing need for delivery, monitor in hospital or send home after
bleeding has ceased Transfusions to replace blood loss, and tocolytics to prolong labor to 36 weeks if
necessary
Even after the bleeding has stopped, repeated small hemorrhages may cause IUGRFor Mature Fetus C-section
For a Patient in Labor C-section
If Severe Hemorrhage C-section regardless of fetal maturity
Fetal Vessel Rupture
Two conditions caused third-trimester bleeding resulting from fetal vessel rupture:
1. Vasa previa
2. Velamentous cord insertion
These two conditions often occur together
Vasa Previa
A condition in which the fetal cord vessels unprotectedly pass over the internal os, making them susceptible to rupture and bleeding
Incidence0.03 to 0.05%
PresentationRapid vaginal bleeding and fetal distress (sinusoidal variation of fetal
heart rate)
ManagementCorrection of shock and immediate C-section
Velamentous Cord Insertion
The velamentous insertion of the umbilical cord into the fetal membrane other words, the fetal vessels insert between amnion and chorion. This cause them susceptible to ripping when the amniotic sac ruptures
Epidemiology 1% of single pregnancies 10% of twins 50% of triplets
Clinical PresentationVaginal bleeding with fetal distress
ManagementCorrection of shock and immediate C-section
Uterine Rupture
The ripping of the uterine musculature through all of its layers, usually part of the fetus protruding through the opening
Incidence
0,5%
Risk Factors
Prior uterine scar is associated with 40% of cases:
Vertical scar:5% risk
Transverse scar:0,5% risk
Presentation and Diagnosis Sudden cessation of uterine contractions with a “tearing” Recession of the fetal presenting part Increased suprapubic pain and tenderness with labor Vaginal bleeding (or bloody urine) Sudden, severe fetal heart rate decelerations Sudden disappearance of fetal heart tones Maternal hypovolemia from concealed hemorrhage
Management Total abdominal hysterectomy is treatment of choice If childbearing is important to the patient, rupture repair
is risky
Other obstetric causes of Third-
Trimester bleeding
Circumvillate placenta: The chorionic plate (on fetal side of placenta)is smaller than the basal plate