3. Generally !
Late pregnancy bleeding is vaginal bleeding that
occurs after 20 weeks’ gestation. Prevalence is
<5%, but when it does occur, prematurity and
perinatal mortality quadruple.
8. Placental abruption
• A normally implanted placenta (not in the lower uterine segment)
separates from the uterine wall before delivery of the fetusas a result
of rupture of maternal decidual vessels.
• Separation can be partial or complete.
9.
10. Clinical Presentation
• Sudden-onset vaginal bleeding (80%)
• Abdominal or back pain
• High-frequency, low-intensity contractions
• Hypertonic, tender uterus
• DIC
severe abdominal pain and a tender, hypertonic uterus !
12. Classification : mild abruption
• vaginal bleeding is minimal
• with no fetal monitor abnormality.
• Localized uterine pain and
tenderness
13. Classification : Moderate and Sever abruption
With moderate abruption,
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.
With severe abruption, 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.
14. Diagnosis and Management :
• Primarily by clinical presentation
• Ultrasound (not required for diagnosis) to rule out placenta
previa; may show retroplacental hematoma
Complications: ATN & ARF ,DIC
15. Couvelaire uterus: refers to blood extravagating between the
Myometrial fibers, appearing like bruises on the serosal surface.
18. Uterine Rupture
• A 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).
Uterine rupture typically occurs in patients with prior
uterine surgery (eg, prior cesarean delivery regardless of
subsequent vaginal delivery) because inelastic uterine scar
tissue can separate with contractions
19. Risk Factors
• The most common risk factors are :
– previous classic uterine incision,
– myomectomy,
– and excessive oxytocin stimulation.
– grand multiparity and marked uterine distention.
21. • If the placenta is involved, fetal perfusion is disrupted, leading to
fetal hypoxia (ie, late decelerations, prolonged bradycardia).
• If the umbilical cord prolapses into the maternal abdomen, cord
compression may increase (ie, variable decelerations). Because either
or both are likely to occur, an abrupt fetal heart rate tracing
abnormality is the most common finding of uterine rupture.
Clinical Presentation
22. • Disordered contractions occur because ruptured myometrial
fibers cannot contract in unison. This is often evidenced by
progressively decreasing contraction amplitude (ie, staircase
sign on tocodynamometry).
• Partial fetal delivery into the maternal abdomen can cause
fetal head retraction (eg, +1 to - 2 station) and loss of fetal
station.
• Myometrial tearing causes severe abdominal pain and
massive intraabdominal bleeding, which may result in
hemodynamic instability.
Clinical Presentation
23. Management :
• 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
27. Placenta Previa
• Occurs when the placenta is implanted in the lower uterine
segment. This is common early in the pregnancy, but is not
typically associated with bleeding.
• 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.
28. Grading
This is the most
dangerous location
because of its potential for
hemorrhage.
Massive Maternal Hemorrhage.
Heavy and Persistent
30. Digital cervical examination is contraindicated in patients with placenta
previa as digital examination enters the cervical canal,disrupting the previa
and leading to severe hemorrhage.
In contrast, speculum examination can be used in patients with known
or suspected placenta previa to verify and quantify vaginal bleeding as it
does not enter the cervical canal.
32. 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.
34. Vasa Previa
• Vasa previa is present when fetal vessels traverse the fetal
membranes over the internal cervical os.
• Either a velamentous insertion of the umbilical cord
• Or may be joining an accessory (succenturiate) placental lobe
to the main disk of the placenta
36. Vasa Previa
• Normal fetal vessels travel in the umbilical cord surrounded by
thick, gelatinous tissue (ie, Wharton jelly) that protects the
vessels.
• Vasa previa is The fetal vessels overlie the cervix surrounded
only by thin fetal membranes.
• Their location over the cervix and lack of protection by Wharton
jelly make these vessels prone to tear with rupture of
membranes or contractions.
38. Vasa Previa
• If these fetal vessels rupture the bleeding is from the
fetoplacental circulation, and fetal exsanguination will
• rapidly occur, leading to fetal death
39. Clinical Presentation
• The classic triad is rupture of membranes and painless
vaginal bleeding, followed by fetal bradycardia
• Painless vaginal bleeding with ROM or contractions
• FHR abnormalities (eg, bradycardia, sinusoidal pattern)
• Fetal exsanguination & demise Vaginal bleeding is minimal
because total fetal blood
volume is low (250 ml, or 1
cup)
Minimal and Transient
44. Abnormal Attachment
• • Normal placenta attaches to decidua
• • Abnormal decidua → abnormal attachment
• • Placenta attaches directly to myometrium
• • Leads to bleeding after delivery
• • Three forms
– • Placenta accreta (most common)
– • Placenta increta
– • Placenta percreta
Approximately 1 in 2,500 pregnancies
experience placenta accreta, increta,
or percreta
45. Abnormal Attachment
• Caused by defective uterine decidualization
• • Most important risk factor: prior C-section
• • Especially with placenta previa
• • Other risk factors:
– • Prior uterine surgery or D&C
46. Abnormal Attachment
• Placenta accreta
– • Placenta attached to myometrium
– • No penetration into myometrium
• • Placenta increta
– • Placenta penetrates myometrium
• • Placenta percreta
– • Placenta penetrates through myometrium
– • Invades uterine serosa (outer layer)
– • Can attach to bladder/rectum
47. Abnormal Attachment
• Clinical Presentation
– • Usually diagnosed by prenatal ultrasound
• • Undetected: placenta fails to detach after birth
– • Part/all of placenta remains attached to uterus
– • Breaks into pieces
• • Massive bleeding
• • Maternal hemorrhage
• • Shock, DIC, ARDS
• • Delivery usually by C-section
• • Often requires hysterectomy
