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Vaginal Bleeding in Late Pregnancy. 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. Causes of Late Pregnancy Bleeding.

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objectives
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
causes of late pregnancy bleeding
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

prevalence of placenta previa
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 at >30 weeks
    • No proven benefit to routine screening ultrasound for this diagnosis
risk factors for placenta previa
Risk Factors for Placenta Previa
  • Previous cesarean delivery
  • Previous uterine instrumentation
  • High parity
  • Advanced maternal age
  • Smoking
  • Multiple gestation
morbidity with placenta previa
Morbidity with Placenta Previa
  • Maternal hemorrhage
  • Operative delivery complications
  • Transfusion
  • Placenta accreta, increta, or percreta
  • Prematurity
patient history placenta previa
Patient History – Placenta Previa
  • Painless bleeding
    • 2nd or 3rd trimester, or at term
    • Often following intercourse
    • May have preterm contractions
  • “Sentinel bleed”
physical exam placenta previa
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
laboratory placenta previa
Laboratory – Placenta Previa
  • Hematocrit or complete blood count
  • Blood type and Rh
  • Coagulation tests
  • While waiting – serum clot tube taped to wall
ultrasound placenta previa
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
treatment placenta previa
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
double set up exam
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
placental abruption
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
epidemiology of abruption
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
abruption and trauma
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
bleeding from abruption
Bleeding from Abruption
  • Externalized hemorrhage
  • Bloody amniotic fluid
  • Retroplacental clot
    • 20% occult
    • “uteroplacental apoplexy” or “Couvelaire” uterus
  • Look for consumptive coagulopathy
patient history abruption
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
physical exam abruption
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
ultrasound abruption
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
laboratory abruption
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
Sher’s Classification - Abruption

mild, often retroplacental clot identified at delivery

  • Grade I
  • Grade II
  • Grade III with fetal demise
    • III A - without coagulopathy (2/3)
    • III B - with coagulopathy (1/3)

tense, tender abdomen and live fetus

treatment grade ii abruption
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
treatment grade iii abruption
Treatment – Grade III Abruption
  • Assess mother for hemodynamic and coagulation status
  • Vigorous replacement of fluid and blood products
  • Vaginal delivery preferred, unless severe hemorrhage
coagulopathy with abruption
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
epidemiology of uterine rupture
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
morbidity with uterine rupture
Morbidity with Uterine Rupture
  • Maternal
    • Hemorrhage with anemia
    • Bladder rupture
    • Hysterectomy
    • Maternal death
  • Fetal
    • Respiratory distress
    • Hypoxia
    • Acidemia
    • Neonatal death
patient history uterine rupture
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
uterine rupture
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
vasa previa
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
diagnostic tests vasa previa
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
management vasa previa
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
summary
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