THIRD TRIMESTER BLEEDING

THIRD TRIMESTER BLEEDING PowerPoint PPT Presentation


  • 287 Views
  • Updated On :
  • Presentation posted in: General

OBJECTIVES. Identify the major causes of third trimester bleedingIdentify the steps needed to evaluate a patient with an antepartum hemorrhageDiscuss the management of a patient with a third-trimester bleed . BACKGROUND. Non-pregnant state: uterus receives 1% of cardiac outputPlasma volume increases by 50%CO increases by 30-50%Third trimester: uterus receives 20% of an increased outputReal potential for massive hemorrhage.

Download Presentation

THIRD TRIMESTER BLEEDING

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


1. THIRD TRIMESTER BLEEDING MARY E. DELMONTE, M.D., FAAFP DEWITT ARMY COMMUNITY HOSPITAL DEPARTMENT OF FAMILY PRACTICE

2. OBJECTIVES Identify the major causes of third trimester bleeding Identify the steps needed to evaluate a patient with an antepartum hemorrhage Discuss the management of a patient with a third-trimester bleed

3. BACKGROUND Non-pregnant state: uterus receives 1% of cardiac output Plasma volume increases by 50% CO increases by 30-50% Third trimester: uterus receives 20% of an increased output Real potential for massive hemorrhage There are many causes of vaginal bleeding in prgnancy. So when a pt. Presents, you must rapidly ascertain the cause. Because of the physiologic changes of pregnancy, there is a real potential for a massive hemorrhage. There are many causes of vaginal bleeding in prgnancy. So when a pt. Presents, you must rapidly ascertain the cause. Because of the physiologic changes of pregnancy, there is a real potential for a massive hemorrhage.

4. BACKGROUND Third trimester bleeding occurs in approximately 4% of patients. Approximately 50% will have an inconsequential cause and 50% will have a life-threatening event Third trimester bleeding occurs in approximately 4% of patients. Approximately 50% will have an inconsequential cause while the remainder will have either a placenta previa or an abruption Third trimester bleeding occurs in approximately 4% of patients. Approximately 50% will have an inconsequential cause while the remainder will have either a placenta previa or an abruption

5. DIFFERENTIAL DIAGNOSIS LIFE THREATENING Placental abruption Placenta previa Uterine Rupture Vasa previa

6. DIFFERENTIAL DIAGNOSIS NON-LIFE THREATENING Contact bleeding (trauma) Cervical inflammation Cervical effacement and dilatation Rectal bleeding Urinary bleeding Coagulation disorders Cervical cancer

7. ABRUPTIO PLACENTA Premature separation of the normally implanted placenta Occurs in approximately 1 in 120 births Accounts for 15% of perinatal mortality

8. TRIAD Uterine bleeding Uterine hypertonicity and/or hyperactivity Fetal distress and/or death

9. RISK FACTORS Smoking Maternal hypertension (>140/90) Blunt abdominal trauma Chorioamnionitis Previous abruption Placental insufficiency Rapid decompression of the overdistended uterus (twins, polyhydramnios) Poor nutrition Cocaine use

10. PATIENT HISTORY Pain Varies from mild cramping to severe pain Back pain—think posterior abruption Bleeding May not reflect true amount of blood loss Trauma Other risk factors

11. PHYSICAL EXAM Signs of circulatory instability Mild tachycardia normal Maternal hypotension never normal Cap refill, urine output, mentation Shock represents >30% blood loss Maternal abdomen Fundal height EFW, fetal lie Location of tenderness Tetanic contractions

13. LABORATORY CBC Type and Rh Coagulation tests Preeclampsia labs if indicated Consider drug screen

14. ULTRASOUND Diagnostic in less than 25% of cases--helpful in ruling-out other causes If pt. is stable, can attempt an US. Retroplacental hematomas carry a worse prognosis for fetal survival than subchorionic hemorrhages. The size of the hemorrhage is also predictive of fetal survival. Large retroplacental hemorrhages (>60 ml) are associated with a 50 percent or greater fetal mortality, whereas similar sized subchorionic hemorrhages are associated with a 10 percent mortality. If US exam fails to show a previa, and if other local causes of vag bleeding have been ruled out, then abruption becomes most likely dx. If pt. is stable, can attempt an US. Retroplacental hematomas carry a worse prognosis for fetal survival than subchorionic hemorrhages. The size of the hemorrhage is also predictive of fetal survival. Large retroplacental hemorrhages (>60 ml) are associated with a 50 percent or greater fetal mortality, whereas similar sized subchorionic hemorrhages are associated with a 10 percent mortality. If US exam fails to show a previa, and if other local causes of vag bleeding have been ruled out, then abruption becomes most likely dx.

15. ABRUPTION LOCATION Location: prognostic indicator of fetal outcome Retroplacental abruptions carry worst prognosis Size/location of abruption also significant: --retroplacental blood loss > 60 cc associated with 50% fetal mortality --subchorionic blood loss of 60 cc only associated with 10% fetal mortality

16. ULTRASOUND SIGNS Retroplacental echolucency Thickening of the placenta Abnormally round “torn edge”

18. GRADE I: slight vaginal bleeding uterine irritability normal maternal blood pressure normal maternal fibrinogen normal fetal heart rate pattern

19. TREATMENT--GRADE I Often diagnosed at delivery with placental clot

20. GRADE II: mild to moderate bleeding irritable uterus with tetanic contractions normal BP elevated pulse rate reduced fibrinogen level (150-250) fetal distress

22. TREATMENT--GRADE II Stabilize mother Maintain urine output > 30 cc/hr and HCT > 30% Amniotomy to prevent embolism Tocolytics IUPC to document intrauterine pressure Expeditious operative or vaginal delivery Prepare for neonatal resuscitation

23. GRADE III: moderate to severe bleeding (may be concealed) tetanic and painful uterus maternal hypotension FETAL DEATH

24. GRADE III Grade III a: without coagulopathy Grade III b: with coagulopathy fibrinogen reduced to less than 150 mg% with other overt signs of coagulopathy

25. TREATMENT—GRADE III Assess mother for hemodynamic and coagulation status Vigorous replacement of fluid and blood products Vaginal delivery preferred, unless severe hemorrhage

27. PREVIA

28. PLACENTA PREVIA Implantation of the placenta over the cervical os Painless bleeding 1 in 200 live births Rarely cause of exsanguinating maternal hemorrhage unless instrumentation or exam performed Maternal morbidity: operative delivery Rarely a cause of exsanguinating maternal hemorrhage unless instrumentation or digital exam is performed. Most common maternal morbity is necessity for operative delivery and its associated risks of bleeding ,anesthetic and postop complications.Rarely a cause of exsanguinating maternal hemorrhage unless instrumentation or digital exam is performed. Most common maternal morbity is necessity for operative delivery and its associated risks of bleeding ,anesthetic and postop complications.

29. PLACENTAL MIGRATION At 17 weeks gestation, placental tissue will cover the os in 5-15% of all patients Differential growth of the lower uterine segment 90% will resolve by term

30. RISK FACTORS Maternal age > 35 years Smoking Increased parity Previous previa Previous cesarean delivery—linear increase. 4 or more, risk is 10% Instrumentation or surgical procedure: inability of placenta to migrate Linear increase with increasing number of c-sections. 4 or more, risk is 10% Uterine curettage increases the risk from 40-400%. Damage to endometrium or myometrium causes scar tissue formation, low implantation, and inability of placenta to migrate away from the os.Linear increase with increasing number of c-sections. 4 or more, risk is 10% Uterine curettage increases the risk from 40-400%. Damage to endometrium or myometrium causes scar tissue formation, low implantation, and inability of placenta to migrate away from the os.

31. COMPLETE PREVIA Os completely covered Most serious/greatest blood loss

32. PARTIAL PREVIA Partial occlusion of the os

33. MARGINAL PREVIA Encroachment to the margin of the os

34. BLEEDING Associated with the development of the lower uterine segment in the third trimester Placental attachment is disrupted as the lower uterine segment thins Uterus in unable to contract adequately to stop the flow from the open vessels

35. EVALUATION Maternal stabilization Labs Fetal monitoring Ultrasound evaluation Gentle speculum exam Blood work: CBC, blood type and Rh, coag studies to r/o DIC Gentle speculum exam is permissible, and useful, whether or not placental location is known. The endocervical canal is oriented at nearly a 90-degree angle with respect to the vagina, so a speculum should not result in disruption of a previa.Blood work: CBC, blood type and Rh, coag studies to r/o DIC Gentle speculum exam is permissible, and useful, whether or not placental location is known. The endocervical canal is oriented at nearly a 90-degree angle with respect to the vagina, so a speculum should not result in disruption of a previa.

37. MANAGEMENT Dependent on: Gestational age of fetus Amount of bleeding Fetal condition Gestational age of fetus: preterm vs term Amount of bleeding: does the bleeding subside Fetal condition PresentationGestational age of fetus: preterm vs term Amount of bleeding: does the bleeding subside Fetal condition Presentation

38. CESAREAN DELIVERY Indications: Complete previa at term Persistent bleeding in pre-term patient General anesthesia has been associated with increased intraoperative blood loss and need for blood transfusionGeneral anesthesia has been associated with increased intraoperative blood loss and need for blood transfusion

39. VAGINAL DELIVERY Pre-viable gestations Intrauterine fetal demise Double set-up: patients with marginal or partial placenta previa in labor with minimal bleeding and ability to tamponade with fetal head Double set-up exam if you believe that tamponade of the bleeding is possible with the fetal head. Should be performed in the delivery or operating room. Insert finger through the os and palpate the location of the placental edge. Palpate the fetal head. If placenta is covering all or part of the cervix or the head is not engaged secondary to displacement, than c-section.Double set-up exam if you believe that tamponade of the bleeding is possible with the fetal head. Should be performed in the delivery or operating room. Insert finger through the os and palpate the location of the placental edge. Palpate the fetal head. If placenta is covering all or part of the cervix or the head is not engaged secondary to displacement, than c-section.

40. EXPECTANT MANAGEMENT Preterm with resolution of bleeding Bedrest Hospitalization Home care Rh-immune globulin Tocolytics Magnesium sulfate Corticosteroids Expectant management for preterm pregnancies with resolution of bleeding Inpt vs outpt should be individualized according to gest age, number and severity of bleeding episodes, patient reliability and distance from hospital. Any antepartum bleeding should be treated with a full dose of Rh immunoglobulin in Rh negative women. Tocolytic of choice is Mag sulfate: reduced risk of cardiovascular complications Expectant management for preterm pregnancies with resolution of bleeding Inpt vs outpt should be individualized according to gest age, number and severity of bleeding episodes, patient reliability and distance from hospital. Any antepartum bleeding should be treated with a full dose of Rh immunoglobulin in Rh negative women. Tocolytic of choice is Mag sulfate: reduced risk of cardiovascular complications

41. Approximately 25-30% of patients can be expected to complete 36 weeks gestation without labor or recurrence of bleeding

42. CO-EXISTING PLACENTAL CONDITIONS Placenta accreta No prior uterine surgery + previa = 4% Previous c-section + previa = 10-35% Multiple c-sections + previa = 60-65% 2/3 with previa/accreta will require cesarean hysterectomy Placenta increta Placenta percreta

43. UTERINE RUPTURE

44. UTERINE RUPTURE Spontaneous rupture: 0.03 to 0.08% of all delivering women Patients with a history of uterine scar: 0.3-1.7% Uterine incisional dehiscence is commonly used to describe the occult or asymptomatic scar separation or thinning that is occasionally observed at surgery in patients with a prior low transverse incision. A useful operational definition of dehiscence is a uterine scar separation that does not penetrate the uterine serosa, does not produce hemorrhage, and does not cause major clinical problems.[5] Dehiscence is most often detected among women who have experienced a failed TOL. Some patients may develop Uterine incisional dehiscence is commonly used to describe the occult or asymptomatic scar separation or thinning that is occasionally observed at surgery in patients with a prior low transverse incision. A useful operational definition of dehiscence is a uterine scar separation that does not penetrate the uterine serosa, does not produce hemorrhage, and does not cause major clinical problems.[5] Dehiscence is most often detected among women who have experienced a failed TOL. Some patients may develop

45. RISK FACTORS Hx of uterine curettage or perforation Inappropriate (excessive) oxytocin use Trauma Previous uterine surgery Overdistention Intra-amniotic installation Adenomyosis

46. ASSOCIATED MATERNAL MORBIDITY Hemorrhage/Transfusion Bladder rupture Hysterectomy

47. FETAL MORBIDITY Respiratory distress Hypoxia Acidemia Death

48. CLASSIC PRESENTATION Vaginal bleeding Pain Cessation of contractions Absence of fetal heart rate Loss of station Palpable fetal parts through abdomen Maternal shock

49. MANAGEMENT Maternal position change IV fluids Discontinuation of pitocin O2 Terbutaline C-section

50. CANDIDATES FOR VBAC No contraindication to labor Clinically adequate pelvis One prior LTCS Obstetrician immediately available for CD Availability of Anesthesia and nursing personnel for emergency CD

51. CONTRAINDICATIONS TO VBAC Prior classical or T-shaped incision or extensive fundal surgery (myomectomy) Previous uterine rupture Inability to perform emergency CD (nursing or anesthesia personnel) Two prior uterine scars and no vaginal deliveries

52. SUCCESS RATE 60-80% of patients given a trial of labor after CD result in successful vaginal birth Women whose primary CD was for breech presentation had highest success rate (85%) Women with previous dystocia had lowest success rate (60%)

53. DECREASED SUCCESS RATE Need for oxytocin induction or augmentation Gestational age greater than 40 weeks Fetal weight greater than 4000 grams Interdelivery interval less than 19-24 months Maternal obesity (> 300 pounds)

54. VASA PREVIA

55. VASA PREVIA Rupture of a fetal vessel Result of a velamentous insertion of the umbilical cord into the membranes Veins travel across the amniotic membranes before coming together in umbilical cord Onset of bleeding coincides with rupture of membranes Velamentous Insertion of the umbilical cord - Normally, blood vessels run from the placenta via the umbilical cord to the baby. Velamentous insertion means that these veins travel across the amniotic membranes before they come together into the umbilical cord. Velamentous insertion happens in 1-2% of all pregnancies. The figures beneath show Velamentous insertion of Nathan's cord.  Notice how the vessels run across the membranes.  This is a delicate arrangement, but doesn't necessarily pose any threat (or symptoms, for that matter) during pregnancy.Velamentous Insertion of the umbilical cord - Normally, blood vessels run from the placenta via the umbilical cord to the baby. Velamentous insertion means that these veins travel across the amniotic membranes before they come together into the umbilical cord. Velamentous insertion happens in 1-2% of all pregnancies. The figures beneath show Velamentous insertion of Nathan's cord.  Notice how the vessels run across the membranes.  This is a delicate arrangement, but doesn't necessarily pose any threat (or symptoms, for that matter) during pregnancy.

56. ALTERATIONS IN THE FETAL HEART RATE Initial fetal tachycardia—fetus attempts to compensate for acute blood loss Bradycardia Intermittent accelerations

57. rapid development of fetal bradycardia after AROM and subsequent vaginal bleeding rapid development of fetal bradycardia after AROM and subsequent vaginal bleeding

58. In the delivery room, the fetal heart rate tracing shows the characteristic bradycardia-tachycardia heart rate response as the fetus attempts to compensate for acute blood loss. An emergency cesarean delivery was performed, and the infant was anemic. After rapid volume infusion and resuscitation, the infant survived and is developing normally. In the delivery room, the fetal heart rate tracing shows the characteristic bradycardia-tachycardia heart rate response as the fetus attempts to compensate for acute blood loss. An emergency cesarean delivery was performed, and the infant was anemic. After rapid volume infusion and resuscitation, the infant survived and is developing normally.

59. Examination of the placenta showed a velamentous insertion of the umbilical cord and a lacerated fetal vessel as a result of spontaneous rupture of the membranes. In this case, the unprotected fetal vessels passed over the cervical os, a vasa previa. Examination of the placenta showed a velamentous insertion of the umbilical cord and a lacerated fetal vessel as a result of spontaneous rupture of the membranes. In this case, the unprotected fetal vessels passed over the cervical os, a vasa previa.

60. VASA PREVIA High index of suspicion Must make diagnosis rapidly and institute definitive therapy and delivery Fetal mortality reported to be greater than 50%

61. APT TEST Can be done on labor and delivery Used to detect fetal blood

62. DOWN THE HOME STRETCH...

63. CONTACT BLEEDING Increased vascularity of cervix Intercourse can rupture a vessel Impressive bleeding Diagnosis made when suggested by history and physical and other causes excluded

64. CERVICAL INFLAMMATION Vaginal infection may cause spontaneous bleeding Quantity of blood usually small Other causes should be excluded

65. EFFACEMENT AND DILATATION Bleeding may be presenting complaint of labor Usually accompanied by passage of cervical mucous, although not always

66. OTHERS (uncommon) Cervical cancer Check prenatal pap Visualize the cervix Coagulation disorders Initial labs Family history

67. CASE 32 y.o. G2P1 at 36 weeks EGA by LMP presents to L & D with bright red vaginal bleeding. She is in town for a family reunion, and has no medical records available.

68. HISTORY Past OB History Prior episodes of bleeding (sentinel bleed) Abdominal pain Uterine Contractions Recent intercourse Tobacco/Substance Abuse Past Medical History Need to take a complete hx on all patients, but particularly: Prior episodes of bleeding: Sentinel bleed of previa Abdominal pain: abruption, uterine rupture Uterine Contractions: Recent intercourse: common in cervical inflammation, previa Need to take a complete hx on all patients, but particularly: Prior episodes of bleeding: Sentinel bleed of previa Abdominal pain: abruption, uterine rupture Uterine Contractions: Recent intercourse: common in cervical inflammation, previa

69. EXAMINATION Assessment of uterine contractions and tenderness Electronic fetal monitoring Gentle speculum exam Digital cervical exam after determination of placental location Exam maternal abdomen to assess fundal height, fetal position, EFW, heart tones. Knowledge of fetal lie is important prior to operative delivery since it may affect the choice of uterine incision. Assessment of uterine contractions and tenderness Electronic fetal monitoring, looking for fetal distress Gentle speculum exam Digital cervical exam after determination of placental location Exam maternal abdomen to assess fundal height, fetal position, EFW, heart tones. Knowledge of fetal lie is important prior to operative delivery since it may affect the choice of uterine incision. Assessment of uterine contractions and tenderness Electronic fetal monitoring, looking for fetal distress Gentle speculum exam Digital cervical exam after determination of placental location

70. LABS AND ULTRASOUND Ultrasound for placental position CBC PT/PTT, FDPs, platelet count, fibrinogen Type and Cross-match Double-check the prenatal labs Ultrasound for placental position CBC PT/PTT, FDPs, platelet count, fibrinogen Type and Cross-match Double-check the prenatal labs, especially the cultures and Pap smearUltrasound for placental position CBC PT/PTT, FDPs, platelet count, fibrinogen Type and Cross-match Double-check the prenatal labs, especially the cultures and Pap smear

71. TREATMENT Maternal Stabilization ABC’s O2 IV fluids Blood products Delivery Vaginal vs. C-section

  • Login