Antepartum hemorrhage by Dr. Akebom .pptx

ANTEPARTUM HEMORRHAGE
Dr. AKEBOM
(MD, Asssistant professor of Gynecology and Obestetrics, Mekelle
UniversityCollege of Health Sciences)

OUTLINE
• INTRODUCTION
• DEFINITION
• PREVALENCE
• CAUSES
• RISK FACTORS
• DIAGNOSIS
• MORBIDITY AND MORTALITY
• MANAGEMENT
2
Dr. AKEBOM
(MD, Asssistant professor of Gynecology and Obestetrics,
Mekelle UniversityCollege of Health Sciences

INTRODUCTION
Plasma volume expansion- increase 40% to 50% above baseline by 30 weeks
 Red blood cell (RBC) mass - increase 20% to 30% by the end of pregnancy
 Maternal cardiac output- rises by 30% to 50% above nonpregnant levels.
 Systemic vascular resistance- declines.
 Procoagulant blood factors - increase
 Pregnancy related hemodynamic changes;
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Dr. AKEBOM

INTRODUCTION
 Maternal adaptation to hemorrhage;
• As a woman loses 10% of her circulatory blood volume →vasoconstriction
• As blood loss exceeds 20% of the total blood volume,
↓ Blood pressure , ↑heart rate, ↓cardiac output, ↓preload →shock
＃ if the intravascular volume is not appropriately replaced.
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Dr. AKEBOM

Classification of Hemorrhage and Physiologic Response
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Dr. AKEBOM

DEFINITION
• Bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy
and prior to the birth of the baby
• Bleeding in the second half of pregnancy
• Bleding after 28 weeeks = in our set up????
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Dr. AKEBOM

PREVALENCE
• 2 to 7 percent of pregnancies
• Varies widely depending on ;
 the definition of bleeding and
 method of case ascertainment
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Dr. AKEBOM

EVALUATION
 Make a definitive diagnosis
 Exclude the presence of serious pathology
 Site of evaluation - labor and delivery unit vs office setting
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Dr. AKEBOM

History
• Documentation of intrauterine pregnancy?
• Characteristics of the bleeding?
 Substantial bleeding with uterine contractions and abdominal pain
- placenta previa or placenta abruption
 Light bleeding with abdominal pain, hypotension, tachycardia
- uterine rupture or extensive placental abruption.
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Dr. AKEBOM

Cont...
Light bleeding with no or minimal abdominal pain or contractions
- Cervical insufficiency,
- Small placental abruption,
- Placenta previa,
- Cervical or vaginal lesion (eg, polyp, infection, cancer),
- Impending labor ("bloody show").
• Is there a recent history of trauma?
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Dr. AKEBOM

Physical examination
• Vital signs
• Abdominal examination-Uterine size, tenderness, tone
• Fetal cardiac activity
• A speculum examination-bleeding and suspected leakage of amniotic fluid
• NB; Digital examination of the cervix should be avoided in patients
presenting with bleeding in the second half of pregnancy until placenta previa
has been excluded by transvaginal ultrasound examination.
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Dr. AKEBOM

WORK UP
• A hemoglobin/hematocrit
• Coagulation studies, and type and screen or crossmatch
• RhD typing
• Ultrasonography -is the cornerstone of the evaluation of bleeding in pregnancy
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Dr. AKEBOM

CAUSES
• Placental abruption
• Placenta previa
• Uterine rupture
• Cervical or vaginal lesion
• Cervical insufficiency
• Bloody show
• Labor
• Ruptured vasa previa
• Sytemic causes ( medical illnesses, medications)
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Dr. AKEBOM

PLACENTAL ABRUPTION
• DEFINITION
• INCIDENCE
• PATHOGENESIS
• CLINICAL MANIFESTATIONS
• RISK FACTORS
• DIAGNOSIS
• CONSEQUENCES
• MANAGEMENT
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Dr. AKEBOM

DEFINITION
• Premature separation of a normally implanted placenta prior to
delivery of the fetus and after 20 weeks gestation.
• 28 weeks of gestation????
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Dr. AKEBOM

INCIDENCE
• 3 to 10 per 1000 births
• Varies internationally, with higher rates in the United States
• About one-third of all antepartum bleeding
• Antepartum (56%) vs Intrapartum (44%)
• Most cases occur in the third trimester prior to 37 weeks of gestation
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Dr. AKEBOM

PATHOGENESIS
• The immediate cause is rupture of maternal vessels in the decidua basalis
• Abnormal early development of the spiral arteries
 Decidual necrosis, inflammation, infarction, and bleeding due to
vascular disruption
• Sudden mechanical event or rapid uterine decompression
 Shearing force between the placenta( inelastic) and the uterine
wall(pliable)
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Dr. AKEBOM

Cont...
• Thrombin - released in response to decidual hemorrhage or hypoxia
Uterine hypertonus and contractions,
Enhanced expression of matrix metalloproteinases
Bleeding diathesis.
Functional progesterone withdrawal
Thrombin-mediated events propagate a cyclic pathway of vascular disruption,
hemorrhage, inflammation, contractions, and rupture of membranes.
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Dr. AKEBOM

Cont...
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Dr. AKEBOM

CLINICAL MANIFESTATIONS
• Determined by;
 Clinical presentation (overt vs. concealed)
10% to 20% are concealed.
 The severity of the abruption
 Mild vs Severe(2/3)
Maternal – DIC, hypovolemic shock, blood transfusion,
hysterectomy, renal failure, in-hospital death
Fetal – NRFHS, fetal growth restriction, death
Newborn – Preterm birth, SGA, death
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Dr. AKEBOM

Cont...
 Temporal nature of the abruption ;
 Acute abruption;
 High-pressure arterial hemorrhage in the central area of the placenta
 Rapid development of the potentially life-threatening clinical manifestations(
DIC, NRFHRP)
 C/F; bleeding, abdominal and/or back pain, and uterine contractions
 e.g. blunt trauma, sudden uterine decompression, or motor vehicle accident
 Chronic abruption
 Early abnormal spiral artery development
 Low-pressure venous hemorrhage
 Typically at the periphery of the placenta (ie, marginal abruption)
 Clinical manifestations occur over time
 Light intermittent bleeding, oligohydramnios, and fetal growth
restriction
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Dr. AKEBOM

RISK FACTORS
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Dr. AKEBOM

Diagnosis
• Primarily a clinical diagnosis
• Radiographic
• Laboratory
• Pathologic studies
Supportive
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Dr. AKEBOM

Cont...
• Clinical diagnosis;
 Risk factors
 Vaginal bleeding (80 %)
 Uterine tenderness ( 70%)
 Uterine contractions (35 %, high in frequency and low in amplitude)
 Abdominal and/or back pain -Posterior placenta
± NRFHRP
 Severity of abdominal pain is a useful marker of the severity of the
abruption
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Dr. AKEBOM

Cont...
• Radiology;
 Ultrasound ( Sens-24%; Spec- 96%)-
Major purpose is to exclude placenta previa
 Retroplacental hematoma is the classic ultrasound finding (PPV- 88 %)
 Locations (subchorionic,retroplacental,preplacental)
 Echogenicity (isoechoic, hyper or hypo echoic)
 Suggestive of abruption ( subchorionic collection of fluid,echogenic debris in
the amniotic fluid,or a thickened placenta)
Magnetic resonance imaging (MRI)- when sonography is equivocal
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Dr. AKEBOM

Cont...
- US of intrauterine bleeding
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Dr. AKEBOM

Cont...
• Laboratory;
 Few laboratory studies assist in the diagnosis
 Fibrinogen
 Maternal serum aneuploidy markers (↑ hCG, α-fetoprotein ;
↓unconjugated estriol, PAPPA -increased risk of PA)
 Kleihauer-Betke test or flow cytometry is not useful
• Pathologic Studies;
 Adherent clot and depression of the placental surface(Macroscopic)
 Preservation of the villous stroma, Eosinophilic degeneration of the
syncytiotrophoblast, and scattered neutrophils with villous
agglutination.(Acute)
Chronic deciduitis, maternal floor decidual necrosis, villitis, decidual
vasculopathy, infarction, intervillous thrombosis, villous maldevelopment, and
hemosiderin deposition( Chronic)
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Dr. AKEBOM

CONSEQUENCES
• Maternal ;
Excessive blood loss and
 DIC
 Hypovolemic shock, acute
kidney injury,
ARDS
Multiorgan failure,
Peripartum hysterectomy
Emergency cesarean birth
long-term risk of premature
cardiovascular disease
• Fetal ;
Increased perinatal morbidity and
mortality
Growth restriction/small for
gestational age (SGA) birthweight
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Dr. AKEBOM

MANAGEMENT
• Depends on its severity , Gestational age and Maternal-fetal status
• Baseline laboratory assessment
 CBC, fibrinogen, coagulation studies, complete metabolic profile, and
urine toxicology screen
• Intravenous (IV) access (one or two large-bore catheters)
• Maternal hemodynamic monitoring,
• IV fluid resuscitation
• Blood-loss quantification
• Adequate blood product preparation
• Continuous FHR and contraction monitoring, and
• Anesthesia, operating room (OR), and neonatal personnel.( Multidisciplinary)
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Dr. AKEBOM

Algorithm for Management of Abruption
CD= Cesarean
Delivery
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Dr. AKEBOM

Placenta previa
• Placental tissue that extends over the internal cervical os
• Suspected in any pregnant person beyond 20 weeks of gestation who presents with
vaginal bleeding.
• Prevalence - 4 to 5 per 1000 births
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Dr. AKEBOM

Risk factors
• Major risk factors,
 Previous placenta previa = recurs
in 4 to 8 percent
 Previous cesarean birth
 Multiple gestation
• Other risk factors,
• Previous uterine surgical procedure
• Increasing parity
• Increasing maternal age
• Infertility treatment
• Maternal smoking
• Maternal cocaine use
• Male fetus
• Prior uterine artery embolization
• Endometriosis
• Abortion, either spontaneous or induced
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Dr. AKEBOM

Cont...
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Dr. AKEBOM

Evaluation
• Volume of vaginal bleeding; Light to heavy
• Abdominal/uterine pain; Usually absent
• Uterine tone; Usually absent, but there may be mild intermittent contractions.
• Fetal heart rate; Usually normal
• Ultrasound findings; Placenta covers the cervical os, partially or completely.
= Lowlying or Placenta previa
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Dr. AKEBOM

Diagnosis
• Sonographic identification of placental
tissue extending over the internal
cervical os.
•TVUS diagnostic accuracy ~100%
•TAUS diagnostic accuracy~ 89%
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Dr. AKEBOM

MORBIDITY AND MORTALITY
 Maternal morbidity
 Primarily related to antepartum and/or postpartum hemorrhage
= postpartum hysterectomy,
= uterine/iliac artery ligation, or embolization of pelvic vessels.
 Neonatal morbidity
 Primarilyrelated to preterm birth
= Neonatal ICU admission
= Neonatal death
= Perinatal death
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Dr. AKEBOM

Managment
• Gestational age upon diagnosis
• Bleeding or Asymptomatic
• Inpatient versus outpatient management( ≤ 2 episodes vs > 3 episodes)
• Expectant vs immidate termination
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Dr. AKEBOM

Criteria for discharge /Candidates
• Bleeding has stopped for a minimum of 24 hours and no other pregnancy
complications,
Be able to return to the hospital within 20 minutes
Be reliable (ie, will comply with instructions about sexual activity, etc).
Be able to maintain modified bed rest at home.
Understand the risks entailed by outpatient management.
Have an adult companion available 24 hours/day
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Dr. AKEBOM

Cont...
• Expectant management is terminated, and emergency cesarean birth is indicated if
;
 Labor
 Category III fetal heart rate tracing unresponsive to resuscitative measures
 Maternal hemodynamic stability cannot be achieved or maintained
 Significant vaginal bleeding at ≥34+0 weeks of gestation
 Stable (no or minimal bleeding) = at 36+0 to 37+6 weeks. (CD)
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Dr. AKEBOM

Uterine rupture
• Volume of vaginal bleeding - Light to heavy
• Sudden onset of abdominal pain is common.
• Abdominal/uterine pain - Pain ranges from minimal to severe.
• Uterine tone - Normal
• Uterine contractions - Present if patient is in labor, which is a common
predisposing factor.
• Fetal heart rate - Usually abnormal
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Dr. AKEBOM

Cont...
• Ultrasound findings
 Disruption of the myometrium,
 Hematoma adjacent to a previous hysterotomy scar,
Extrauterine fluid-distended fetal membranes,
Free peritoneal fluid,
Anhydramnios,
Empty uterus with fetal parts outside of the uterus, and/or fetal demise
• Diagnosis
 Identification of complete disruption of all uterine layers on imaging or at
laparotomy.
 In patients with vaginal bleeding and a previous cesarean birth or
transmyometrial surgery, the possibility of uterine rupture should always
be considered
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Dr. AKEBOM

Cervical or vaginal lesion
• Volume of vaginal bleeding - Usually light
• Abdominal/uterine pain - Absent
• Uterine contractions - Absent
• Fetal heart rate - Normal
• Ultrasound findings- Usually normal
• The diagnosis is based on visual identification of the lesion on speculum
examination.
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Dr. AKEBOM

Cervical insufficiency
• Volume of vaginal bleeding- Light;
• Abdominal/uterine pain - Absent
• Uterine tone- Normal
• Uterine contractions- Absent or mild and irregula
• Fetal heart rate- Normal
 Cervical length ≤25 mm before 24 weeks of gestation suggests
cervical insufficiency.
 Cervical dilation and prolapsed fetal membranes
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Dr. AKEBOM

Cont...
• Diagnosis;
Second trimester cervical dilation and effacement in the absence of
contractions or in the presence of weak irregular contractions that
appear inadequate to explain the cervical dilation and effacement. Fetal
membranes may extend beyond the internal or external cervical os.
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Dr. AKEBOM

Bloody show
• Volume of vaginal bleeding- Light
• Abdominal/uterine pain- Absent
• Uterine tone- Normal
• Uterine contractions- Absent or mild and irregular
• Fetal heart rate- Normal
• Ultrasound findings- N/A
• The diagnosis is based on passage of bloody mucus discharge that may precede
the onset of preterm or term labor.
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Dr. AKEBOM

Labor
• Volume of vaginal bleeding - Light
• Abdominal/uterine pain - Intermittent with each contraction
• Uterine contractions - Painful contractions of increasing frequency, intensity, and
duration
• Fetal heart rate - Normal
• Ultrasound findings - N/A
• Diagnosis
 The diagnosis is based on the presence of painful contractions of increasing
frequency, intensity, and duration associated with cervical change
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Dr. AKEBOM

Ruptured vasa previa
• Risk factors for vasa previa include multiple gestation and in vitro fertilization.
• Volume of vaginal bleeding - Light to heavy
• Abdominal/uterine pain - Absent unless the patient is in labor
• Uterine contractions - Present if the patient is in labor
• Fetal heart rate - Abnormal
•
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Dr. AKEBOM

Cont...
Membranous fetal vessels passing
across or in close proximity (within 2
cm) of the internal cervical os by
transvaginal ultrasound with color
Doppler.
The membranous vessels may be
associated with a velamentous
umbilical cord or they may connect the
lobes of a bilobed placenta or the
placenta and a succenturiate lobe.
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Dr. AKEBOM

“Simplicity is the ultimate sophistication”
- Leonardo da Vinci
49
Dr. AKEBOM
Mekelle UniversityCollege of Health Sciences)

THANK YOU
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Dr. AKEBOM
Mekelle UniversityCollege of Health Sciences)

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