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Bleeding in early & late pregnancy

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Bleeding in early & late pregnancy

  1. 1. bleeding in Early & Late pregnancy Dr. Rabi Narayan Satapathy Asst. Professor Dept. of Ob. & Gynae. SCB Medical College, Cuttack Mob. 09861281510
  2. 2. Causes of early bleeding in pregnancy Abortion Ectopic pregnancy Hydatidiform mole
  3. 3. Abortion/Miscarriage  Definition: any fetal loss from conception until the time of fetal viability at 24 weeks gestation. OR: Expulsion of a fetus or an embryo weighing 500 gm or less  Incidence: 15 - 20% of pregnancies total reproductive losses are much higher if one considers losses that occur prior to clinical recognition.  Classification: 1. spontaneous: occurs without medical or mechanical means. 2. induced abortion
  4. 4. Pathology  Haemorrhage into the decidua basalis.  Necrotic changes in the tissue adjacent to the bleeding.  Detachment of the conceptus.  The above will stimulate uterine contractions resulting in expulsion.
  5. 5. Causes of miscarriage  Fetal causes:  Chromosome Abnormality: - 50% of spontaneous losses are associated with fetal chromosome abnormalities. - autosomal trisomy (nondisjunction/balanced translocation): is the single largest category of abnormality and → recurrence. - monosomy (45, X; turner): occurs in 7% of spontaneous abortions and it is caused by loss of the paternal sex chromosome. - triploids: found in 8 to 9% of spontaneous abortions. it is the consequence of either dispermy or failure of extrusion of the second polar body,
  6. 6. Causes of miscarriage  Maternal causes: 1. Immunological: - alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of a normal pregnancy. - autoimmune disease: antiphospholipid antibodies especially lupus anticoagulant (LA) and the anticardiolipin antibodies (ACL) 2. uterine abnormality: - congenital: septate uterus → recurrent abortion. - fibroids (submucus): → (1) disruption of implantation and development of the fetal blood supply, (2) rapid growth and degeneration with release of cytokines, and (3) occupation of space for the fetus to grow. Also polyp > 2 cm diameter. - cervical incompetence: → second trimester abortions.
  7. 7. Causes of miscarriage  Maternal causes: 3. Endocrine : - poorly controlled diabetes (type 1/type 2). - hypothyroidism and hyperthyroidism. - Luteal Phase Defect (LPD): a situation in which the endometrium is poorly or improperly hormonally prepared for implantation and is therefore inhospitable for implantation. (questionable). 4. Infections (maternal/fetal): as TORCH infections, Ureaplasma urealyticum, listeria  Environmental toxins: alcohol, smoking, drug abuse, ionizing radiation……
  8. 8. Types of abortion  Threatened abortion.  Inevitable abortion.  Incomplete abortion.  Complete abortion.  Missed abortion  Septic abortion: Any type of abortion, which is complicated by infection  Recurrent abortion: 3 or more successive spontaneous abortions
  9. 9. Clinical features/management  Threatened abortion: - Short period of amenorrhea. - Corresponding to the duration. - Mild bleeding (spotting). - Mild pain. - P.V.: closed cervical os. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus.  Management - reassurance. - Rest. - Repeated U/S
  10. 10. Inevitable abortion  Clinical feature: - Short period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - P.V.: opened cervical os. - Pregnancy test (hCG): + ve. - US: non-viable fetus and blood inside the uterus.  Management: - fluids…..blood. - ergometrinn & sentocinon. - evacuation of the uterus (medical/surgical).
  11. 11. Incomplete abortion  Clinical feature: - Partial expulsion of products - Bleeding and colicky pain continue. - P.V.: opened cervix… retained products may be felt through it. - US: retained products of conception.  Treatment as inevitable abortion
  12. 12. Complete abortion - expulsion of all products of conception. - Cessation of bleeding and abdominal pain. - P.V.: closed cervix. - US: empty uterus.
  13. 13. Missed abortion  Feature: - gradual disappearance of pregnancy Symptoms Signs. - Brownish vaginal discharge. - Milk secretion. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - US: absent fetal heart pulsations.  Complications - Infection (Septic abortion) - DIC  Treatment - Wait 4 weeks for spontaneous expulsion - evacuate if:  Spontaneous expulsion does not occur after 4 weeks.  Infection.  DIC. - Manage according to size of uterus - Uterus < 12 weeks : dilatation and evacuation. - Uterus > 12 weeks : try Oxytocin or PGs.
  14. 14. Vaginal Bleeding in Late Pregnancy
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Risk Factors for Placenta Previa  Previous cesarean delivery  Previous uterine instrumentation  High parity  Advanced maternal age  Smoking  Multiple gestation
  19. 19. Morbidity with Placenta Previa  Maternal hemorrhage  Operative delivery complications  Transfusion  Placenta accreta, increta, or percreta  Prematurity
  20. 20. Patient History – Placenta Previa  Painless bleeding  2nd or 3rd trimester, or at term  Often following intercourse  May have preterm contractions  “Sentinel bleed”
  21. 21. 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
  22. 22. Laboratory – Placenta Previa  Hematocrit or complete blood count  Blood type and Rh  Coagulation tests  While waiting – serum clot tube taped to wall
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. Bleeding from Abruption  Externalized hemorrhage  Bloody amniotic fluid  Retroplacental clot  20% occult  “uteroplacental apoplexy” or “Couvelaire” uterus  Look for consumptive coagulopathy
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. Sher’s Classification - Abruption  Grade I  Grade II  Grade III with fetal demise  III A - without coagulopathy (2/3)  III B - with coagulopathy (1/3) mild, often retroplacental clot identified at delivery tense, tender abdomen and live fetus
  35. 35. 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
  36. 36. Treatment – Grade III Abruption  Assess mother for hemodynamic and coagulation status  Vigorous replacement of fluid and blood products  Vaginal delivery preferred, unless severe hemorrhage
  37. 37. 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
  38. 38. 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
  39. 39. Risk Factors – Uterine Rupture Previous uterine surgery Adenomyosis Congenital uterine anomaly Fetal anomaly Uterine overdistension Vigorous uterine pressure Gestational trophoblastic neoplasia Difficult placental removal Placenta increta or percreta
  40. 40. Morbidity with Uterine Rupture  Maternal  Hemorrhage with anemia  Bladder rupture  Hysterectomy  Maternal death  Fetal  Respiratory distress  Hypoxia  Acidemia  Neonatal death
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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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