Late Pregnancy Bleeding --> Gynecology

1. Late Pregnancy Bleeding
Lara Masri
4th year medical student

2. - Late pregnancy bleeding is vaginal bleeding that occurs after 20 weeks’ gestation.
- It complicates 2–5% of pregnancies and most cases involve relatively small
amounts of blood loss. However, significant blood loss poses a risk of mortality and
morbidity to both mother and baby.
- The causes can be classified into placental, fetal and maternal:
• Placental causes:
 placental abruption.
 placenta Previa.
• Fetal cause:
 vasa Previa.
• Maternal causes:
 Cervical causes include erosion, polyps, and, rarely, carcinoma.
 Vaginal causes include varicosities and lacerations.

4. Initial Evaluation
• What are patient’s vital signs?
• Are fetal heart tones present?
• What is fetal status?
• What is the nature and duration of the bleeding?
• Is there pain or contractions?
• What is the location of placental implantation?
Initial Investigation
• Complete blood count
• disseminated intravascular coagulation (DIC) workup (platelets, prothrombin time, partial
thromboplastin time, fibrinogen, D-dimer)
• type and cross-match
• sonogram for placental location.
Never perform a digital or speculum examination until ultrasound study rules out
placenta previa.
Initial Management
Start an IV line with a large-bore needle; if maternal vital signs are unstable, run isotonic
fluids without dextrose wide open and place a urinary catheter to monitor
urine output. If fetal jeopardy is present or gestational age is ±36 weeks, the goal is delivery.

5. Placental abruption
o Placental abruption is defined as the premature
separation of the placenta from the uterus.
o Separation can be partial or complete.
o overt and external bleeding  m/c, In this
situation blood dissects between placental
membranes exiting out the vagina.
o concealed or internal bleeding  less common ,
the retroplacental hematoma remains within the
uterus, resulting in an increase in fundal height
over time.
o The recurrence rate in subsequent pregnancies is
3–15%

8. Classification :
• mild abruption: 48%
• vaginal bleeding is minimal with no fetal monitor abnormality.
• Localized uterine pain and tenderness is noted, with incomplete
• relaxation between contractions.
• moderate abruption: 27%
• symptoms of uterine pain and moderate vaginal bleeding
• can be gradual or abrupt in onset.
• From 25–50% of placental surface is separated.
• Fetal monitoring may show tachycardia, decreased variability, or mild late
decelerations.
• severe abruption: 24%
• symptoms are usually abrupt with a continuous knife-like uterine pain.
• More than 50% of placental separation occurs.
• Fetal monitor shows severe late decelerations, bradycardia, or even fetal death.
• Severe disseminated intravascular coagulation (DIC) may occur.
• Ultrasound visualization of a retroplacental hematoma may be seen.

9. Risk factors: hypertension (m/c), smoking, trauma to the maternal abdomen,
cocaine, polyhydramnios, multiple pregnancy, fetal growth restriction (FGR),
Previous placental abruption, Sudden decrease in intrauterine pressure
o The hypertension and increased levels of catecholamines caused by cocaine
abuse are thought to be responsible for a vasospasm in the uterine blood
vessels that causes placental separation and abruption. However, this
hypothesis has not been definitively proven.
o An increased risk of placental abruption has been demonstrated in patients
younger than 20 years and those older than 35 years.
o Diagnosis is based on the presence of painful late-trimester vaginal bleeding with a
normal fundal or lateral uterine wall placental implantation not over the lower uterine
segment.
o Clinical Presentation:
o Abruptio placentae is the most common cause of late-trimester bleeding (1% of
pregnancies at term).
o It is the most common cause of painful late-trimester bleeding.

10. Abruption is a clinical diagnosis!
Possible US findings
1. Retroplacental echolucency
2. Abnormal thickening of placenta
3. “Torn” edge of placenta

11. Management
• Hemodynamic control: monitor vital signs, maintain airways, volume resuscitation,
type and crossmatch blood
• RhD prophylaxis in RhD negative mothers
• In acute symptoms and a live fetus emergency cesarean delivery independent of
gestational age
• < 36 week of pregnancy Normal fetal findings and a hemodynamically stable mother
 Fetal lung maturity induction with corticosteroids (e.g., betamethasone)
 Aim for a normal delivery
• Vaginal delivery is performed if Normal fetal findings and a hemodynamically stable
mother >36 weeks.
 Perform amniotomy and induce labor.
 Place external monitors to assess fetal heart rate pattern and contractions.
 Avoid cesarean delivery if the fetus is dead.
In patients presenting with abruption, a decision-to-delivery interval of 20 minutes or less
results in improved neonatal outcomes.

12. Complications
• Intrauterine fetal death
• Acute tubular necrosis
• DIC
• Couvelaire uterus refers to blood extravasating between the
myometrial fibers, appearing like bruises on the serosal surface.

13. Placental Previa
o A placenta covering or encroaching on the cervical os may be associated with
bleeding, either provoked or spontaneous
o The bleeding is from the maternal not fetal circulation and is more likely to
compromise the mother than the fetus
o Usually the lower implanted placenta atrophies and the upper placenta
hypertrophies, resulting in migration of the placenta.
o At term, placenta previa is found in only 0.5% of pregnancies.
o Symptomatic placenta previa occurs when painless vaginal bleeding develops
through avulsion of the anchoring villi of an abnormally implanted placenta as
lower uterine segment stretching occurs in the latter part of pregnancy
o Placenta previa is a common incidental finding on second trimester
ultrasonography and should be confirmed in the third trimester.

14. Diagnosis is based on the presence of painless late-trimester vaginal
bleeding with an obstetric ultrasound showing placental implantation over
the lower uterine segment.
Classification:
• Total, complete, or central previa is found when the placenta
completely covers the internal cervical os. This is the most dangerous
location because of its potential for hemorrhage.
• Partial previa exists when the placenta partially covers the internal os.
 <2 cm from the cervical os.
• Marginal or low-lying previa exists when the placental edge is near but
not over the internal os.
 >2 cm from the cervical os.

16. Risk Factors Previous placenta previa, multiple gestation, multiparity, advanced
maternal age, previous caesarean section, uterine structural anomaly, assisted
conception, increased number of prior curettages, tobacco use
Clinical presentation: the classic picture is painless late-pregnancy bleeding,
which can occur during rest or activity, suddenly and without warning.
 It may be preceded by trauma, coitus, or pelvic examination.
 The uterus is nontender and nonirritable.
Thrombin release from the bleeding sites promotes uterine contractions and leads to
a vicious cycle of bleeding–contractions–placental separation–bleeding.
The definitive diagnosis usually relies on ultrasound imaging
A sterile speculum examination can be performed safely in women with second or
third trimester vaginal bleeding before ultrasonographic evaluation of placental
localization, but a digital examination should be avoided until placenta previa is
excluded by ultrasonography.

17. Management
• Emergency cesarean delivery is performed if maternal or fetal jeopardy is present
after stabilization of the mother.
• Conservative in-hospital observation (bed rest) is performed in preterm gestations if
mother and fetus are stable and remote from term.
- The initial bleed is rarely severe.
- Confirm abnormal placental implantation with sonogram and replace blood loss with
crystalloid and blood products as needed.
• Scheduled cesarean delivery is performed if the mother has been stable after fetal
lung maturity has been confirmed by amniocentesis, usually at 36 weeks’ gestation.
• vaginal delivery may be performed in the operating room if the mother is:
1. hemodynamically stable
2. fetal cardiac status is reassuring
3. the placenta lies > 2 cm away from the internal os on ultrasonography

18. Complications
• If placenta previa occurs over a previous uterine scar, the villi may invade into the
deeper layers of the decidua basalis and myometrium, resulting in intractable bleeding
requiring cesarean hysterectomy.
• Profound hypotension can cause anterior pituitary necrosis (Sheehan’s syndrome) or
acute tubular necrosis.

21. Morbidly adherent placenta
• Normally, placental villi invade only the superficial layers of the endometrial decidua
basalis. When the villi invade too deeply into the wall of the uterus, the condition is known
as placenta accreta, placenta increta, or placenta percreta, depending on the depth of the
invasion.
• Placenta accreta (most common, 80% of cases) occurs when the villi invade the deeper
layers of the endometrial decidua basalis but do not penetrate the myometrium.
• Placenta increta (15% of cases) occurs when the villi invade the myometrium but do not
reach the uterine serosal surface or the bladder.
• Placenta percreta (5% of cases) occurs when the villi invade all the way to the uterine
serosa or into the bladder.

22. Pathophysiology
•The exact pathogenesis is unknown
•Two main theories include
• Defective decidua: complete or partial lack of decidua in an area of previous scarring
within the endometrial-myometrial interface
• Excessive trophoblastic invasion: abnormal growth → uncontrolled invasion of villi
through the myometrium, including its vascular system
Risk factors
1. History of uterine surgery (e.g., endometrial ablation, hysteroscopic removal
of intrauterine adhesions, dilatation, curettage)
2. Prior births by cesarean delivery
3. Placenta previa
4. Multiparity
5. Advanced maternal age
6. Assisted reproduction procedures
7. Asherman syndrome

24. Clinical features
Most common manifestations
1. Abnormal uterine bleeding
2. Postpartum hemorrhage at the time of attempted
manual separation of the placenta
Other manifestations
1. Fever
2. Rarely, hematuria in placenta percreta
In women with placenta previa and previous cesarean
delivery, imaging with color flow Doppler ultrasonography
should be performed to evaluate for placenta accreta.

25. Treatment
Active management of the third stage of labor
Surgical procedures
• Dilation and curettage (D&C) or vacuum removal of RPOC under
anesthesia
• Cesarean hysterectomy
• Generally, the mode of delivery and treatment for placenta accreta
spectrum
• The placenta is left in place after delivery and
complete hysterectomy is performed

26. Vasa previa
Vasa previa is present when fetal vessels traverse the fetal membranes over the internal
cervical os.
These vessels may be from either
 velamentous insertion of the umbilical cord
 may be joining an accessory (succenturiate) placental lobe to the main disk of
the placenta.
If these fetal vessels rupture, the bleeding is from the fetoplacental circulation, and fetal
exsanguination will rapidly occur, leading to fetal death.
Epidemiology 1/2500 births
Diagnosis: This is rarely confirmed before delivery but may be suspected when antenatal
sonogram with color-flow Doppler reveals a vessel crossing the membranes over the
internal cervical os. The diagnosis is usually confirmed after delivery on examination of the
placenta and fetal membranes

28. Clinical presentation: the classic triad is
1. Rupture of membranes
2. Painless vaginal bleeding
3. Fetal bradycardia.
Vasa previa is seen more commonly with velamentous insertion of the umbilical cord,
accessory placental lobes, and multiple gestation.
Management: Immediate cesarean delivery of the fetus is essential or the fetus will die
from hypovolemia.

29. Uterine rupture
Uterine rupture is complete separation of the wall of the
pregnant uterus with or without expulsion of the fetus that
endangers the life of the mother or the fetus, or both.
The rupture may be incomplete (not including the
peritoneum) or complete (including the visceral
peritoneum).
Clinical Presentation. The most common findings are vaginal
bleeding, loss of electronic fetal heart rate signal, abdominal
pain, and loss of station of fetal head.
Rupture may occur both before labor as well as during labor.
Diagnosis: Confirmation of the diagnosis is made by
surgical exploration of the uterus and identifying the tear.

31. The most common risk factors are previous classic uterine incision,
myomectomy, and excessive oxytocin stimulation, multiparity and marked
uterine distention.
A vertical fundal uterine scar is 10 times more likely to rupture than a low
segment incision.
Maternal and perinatal mortality is also much higher with the vertical incision
rupture.
Treatment is surgical. Immediate delivery of the fetus is imperative.
 Uterine repair is indicated in a stable young woman to conserve fertility.
 Hysterectomy is performed in the unstable patient or one who does not
desire further childbearing.