Transcript Vaginal Bleeding in Late Pregnancy

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
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Causes of Late Pregnancy Bleeding
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Placenta Previa
Abruption
Life-Threatening
Ruptured vasa previa
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer
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
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Risk Factors for Placenta Previa
Previous cesarean delivery
 Previous uterine instrumentation
 High parity
 Advanced maternal age
 Smoking
 Multiple gestation
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Morbidity with Placenta Previa
Maternal hemorrhage
 Operative delivery complications
 Transfusion
 Placenta accreta, increta, or percreta
 Prematurity
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Patient History – Placenta Previa
Painless bleeding
nd or 3rd trimester, or at term
2
 Often following intercourse
 May have preterm contractions
 “Sentinel bleed”
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Physical Exam – Placenta Previa
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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
Hematocrit or complete blood count
 Blood type and Rh
 Coagulation tests
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While waiting – serum clot tube taped to
wall
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
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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
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Double Set-Up Exam
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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
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
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Epidemiology of Abruption
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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
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
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Bleeding from Abruption
Externalized hemorrhage
 Bloody amniotic fluid
 Retroplacental clot
 20% occult
 “uteroplacental apoplexy” or
“Couvelaire” uterus
 Look for consumptive coagulopathy
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Patient History - Abruption
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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
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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
Abruption is a clinical diagnosis!
 Placental location and appearance
 Retroplacental echolucency
 Abnormal thickening of placenta
 “Torn” edge of placenta
 Fetal lie
 Estimated fetal weight
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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
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Sher’s Classification - Abruption
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Grade I
mild, often retroplacental
clot identified at delivery
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Grade II
tense, tender abdomen and
live fetus
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Grade III
 III A
(2/3)
 III B
with fetal demise
- without coagulopathy
- with coagulopathy (1/3)
Treatment – Grade II Abruption
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Assess fetal and maternal stability
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Amniotomy
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IUPC to detect elevated uterine tone
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Expeditious operative or vaginal delivery
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Maintain urine output > 30 cc/hr and
hematocrit > 30%
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Prepare for neonatal resuscitation
Treatment – Grade III Abruption
Assess mother for hemodynamic and
coagulation status
 Vigorous replacement of fluid and blood
products
 Vaginal delivery preferred, unless severe
hemorrhage
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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
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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
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Risk Factors – Uterine Rupture
Previous
uterine surgery
Congenital uterine
anomaly
Adenomyosis
Uterine
Vigorous
overdistension
Fetal
anomaly
uterine
pressure
Gestational trophoblastic Difficult placental
neoplasia
removal
Placenta
percreta
increta or
Morbidity with Uterine Rupture
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Maternal
 Hemorrhage with anemia
 Bladder rupture
 Hysterectomy
 Maternal death
Fetal
 Respiratory distress
 Hypoxia
 Acidemia
 Neonatal death
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
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Uterine Rupture
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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
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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
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
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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
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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
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