Bleeding Late Pregnancy

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Bleeding Late Pregnancy

  1. 1. Bleeding in late pregnancy DR.KHALED AL GHAIDANY
  2. 2.  Vaginal bleeding in the third trimester  Complicates 4 % of all pregnancies Antepartum hemorrhage
  3. 3. 1. Placenta previa(PP) 2. Abruptio placenta(AP) 3. Uterine rupture 4. Fetal vessel rupture 5. Cervical lesions lacerations 6. Vaginal lesions lacerations 7. Congenital bleeding disorders 8. Unknown Causes of APH
  4. 4.  Painless vaginal bleeding in a previously normal pregnancy  Usually at age of 30 weeks (13 occurs before 30  Mechanism of bleeding: development and thinning of the lower uterine segment in the 3rd trimester  disruption of the placental attachment Placenta previa
  5. 5.  Incidence : 0.5 % (20 % of all APH)  Presentation: 1. Painless vaginal bleeding (70 %) 2. Bleeding with contractions (20 %) 3. incidental diagnosis “by US or at term” (10 %) Placenta previa
  6. 6.  Multiparty  Increasing maternal age  Prior placenta previa  Multiple gestation  Previous history of PP (4-8 % risk) PP: Predisposing factors
  7. 7.  According to the relationship of the placenta to the internal cervical os: 1. Total “ complete” = centralis 2. Partial 3. Marginal “ marginalis” 4. Low implantation “ lateralis” PP: Classification
  8. 8.  The most accurate tool is US  Transabdominal US (95 % sensitivity)  Transvaginal US: ( 100 % sensitivity, it should be done in hospital !!!)  Double set-up examination (???) PP: Diagnosis
  9. 9.  4 -6 % of patients have some degree of previa on US before 20 weeks gestation  With the development of the lower uterine segment, there is a relative upward placental migration, with 90 % of these resolving by 3rd trimester  However, only 10 % of complete PP resolve PP: prognosis
  10. 10.  Initially stabilize the patient  The goal is to obtain fetal maturation without compromising the mother’s health  Expectant management  Elective CS after 36 wks gestation (Blood loss might reach >1500 ml) PP: Management
  11. 11.  Premature separation of the normally implemented placenta  Complicates 0.5 to 1.5 % of all pregnancies  Result in fetal death in 1 per 500 deliveries Abruptio placenta (AP)
  12. 12.  Hypertension (the most common)  Trauma  Polyhydramnios with rapid decompression on membrane rupture  Cocaine use  Tobacco use  Preterm premature rupture of membrane  A short umbilical cord AP: Predisposing factors
  13. 13.  Hemorrhage into the decidua basalis  formation of a decidual hematoma  placental separation further separation and destruction of placental tissue  2 types: 1. Concealed hemorrhage (20%): when blood dissect upward toward the fundus 2. Revealed(external) hemorrhage: if extend downward toward the cervix AP: pathophysiology
  14. 14.  Primarily a clinical one  Vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone  Increased fundal height  Abdominal pain (66% of cases)  Fetal distress (60%)  US will detect only 2% of abruptions  Do US only to detect the coexisting PP AP: diagnosis
  15. 15.  Perinatal mortality rate: 35 %  Accounts for 15% of 3rd stillbirths  15% of live born infants have significant neurological impairment  AP is the most common cause of DIC in pregnancy (20% of cases)  Recurrence risk: 10 % after one AP, and 25 % after 2 AP AP: Maternal-fetal risks
  16. 16.  Careful maternal hemodynamic monitoring, fetal monitoring, serial evaluation of the hematocrit and coagulation profile, and delivery  CS should be reserved for obstetric indications only  Active delivery is the treatment of most cases AP: Management
  17. 17.  Follow the guidelines in referring high risk pregnancies  Have a high index of suspicion  Stabilize the patient before referral as much as you can  Remember “ information has no side effects”  Build up your safety netting As a GP

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