history examination sign and symptoms management

1. Vaginal bleeding in 2nd Half of
pregnancy
(Ante-partum hemorrhage)
Yahyia Al-Abri
90440

2. Objectives
• Antepartum hemorrhage
– Definition
– Causes
• Case scenario
• Placenta previa
• Placental abruption
• Vasa previa
• Uterine rupture

3. Definition
• Bleeding from or in to the genital tract,
occurring from 24 + weeks of pregnancy and
prior to the birth of the baby. (Royal College of Obstetricians
and Gynecologists )
• Uterine bleeding after 20 weeks of gestation
that is unrelated to labor and delivery. (UPTODATE)

4. Causes
Common
– Abruptio placentae
– Placenta previa
– Preterm labor
Uncommon
– Uterine rupture
– Vasa previa
– Cervical lesion (cervicitis,
polyp, ectropion, cervical
cancer)
– Other:coagulopathy.
Hacker and moore

5. Case scenario
• H is 30 years old lady pramigarvida at 30 week of gestation she
presented to the A/E with P/V bleeding.
– LMP: 11/5/2016
– EDD: 15/2/2017
– Admission : 09/12/2016
– The bleeding started 1 hour ago low in amount. She noted the
bleeding while she was passing urine. She had two episodes in less
than 24 hours.
– no abdominal pain
– no dysuria
– No fever
– No other complain
– good fetal movements

6. Case scenario
• Past medical:
– GDM on Insulin (N15/8 units, R5/5 units) and Metformin 500 mg BID.
– No HTN
– No bleeding disorder
• Family history not remarkable
• Gyne
– Regular period every 28 days bleeding for 4 -5 days
– Never used of contraceptive
– No pap smear done
• Obstetric
– Planed pregnancy .Anomaly scan on 13/10/2016 no gross anomaly
seen
• Family history:
- mother diabetic

7. Case scenario
• On examination:
– Looks well.
– Vitally stable.
• T: 36.5
• P: 88
• BP: 130/80
• saturation 98%
– Patient abdomen: soft, relaxed uterus, no tenderness.
– Patient cervix : no bleeding, os closed.

8. PLACENTA PREVIA

9. Definition
• Abnormal location of placenta near , partially ,
or completely over the internal cervical os.
• Epidemiology:
– 0.5% of all pregnancies.

10. Risk factors
– Multiparty.
– Increasing maternal age.
– History of prior placenta previa.
– Multiple gestation

11. Placenta previa in referral hospital in
oman

12. Classifications
• Placenta Previa is classified according to the
relationship of the placenta to the internal cervical
os.

13. Clinical features
• PAINLESS bright red vaginal bleeding
(recurrent)
• Shock/anemia correspond to degree of
apparent blood loss.
• Uterus soft and non-tender
• Malpresentation, failure of the fetal head to
engage.
• FHR usually normal
Do NOT perform a vaginal exam until
placenta previa has been ruled out
by U/S

14. Investigations
(laboratory)
• CBC ( hemoglobin, platelet).
• Coagulation profile(INR/aPTT).
• Blood group type and Cross match.
• CTG ( fetal monitoring )

15. Radiological
• Ultrasound
– Transvaginal U/S is more accurate than
transabdominal U/S at diagnosing placenta previa
at any gestational age.

16. Placenta previa
• Treatment:
– Asymptomatic placenta previa:
1. monitor placental position with ultrasound
examination as an outpatient
2. avoid vaginal intercourse, digital examination,
avoid exercise
3. Advise to seek immediate medical attention if
contractions or vaginal bleeding occur
4. Delivery by C-section at 37 weeks

17. Management
• Symptomatic
• Stabilize and monitor
– Maternal stabilization: large bore IV lines with
hydration, O2 for hypotensive patients.
– Maternal monitoring: vitals, urine output, blood
loss.
– CTG.
– U/S assessment:
• Determine fetal viability.
• Placental status/position.

18. Management
GA <37 weeks and minimal bleeding:
• Expectant management
• Admit to hospital
• Limited physical activity, no douches,
enemas,
• Consider corticosteroids for fetal lung
maturity
• Delivery when fetus is mature or
hemorrhage is excessive
GA ≥37 weeks, and/or bleeding is
excessive:
• Delivery must be accomplished by
• C-section regardless of gestational
age!

19. Complications
• *postpartum hypopituitarism caused by ischemic necrosis due to blood
loss and hypovolemic shock during and after childbirth.
Fetal Maternal
• Perinatal mortality
• Prematurity
• Maternal mortality <1%
• Sheehan syndrome*
• Placenta accreta
• Hysterectomy
• Acute renal failure

20. PLACENTAL ABRUPTION

21. Definition
• Premature separation of normal implanted
placenta from the uterine wall before the
delivery of the fetus.
• Epidemiology :
– 0.5% to 1.5% of all pregnancies.

22. Abruptio placenta
• Pathophysiology:
hemorrhage into the decidua basalis
Decidua splits
Decidual hematoma formation
Separation and compression of the placenta
adjacent to it
destruction of placental tissue.

23. Perinatal mortality in Oman

24. Risk factors
• Maternal hypertension (most common factor).
• History of placental abruption in a prior
pregnancy.
• Trauma.
• Premature rupture of membranes.
• Short umbilical cord.
• Smoking.

25. Partial Vs Complete

26. Visible Vs Concealed

27. Clinical features
• PAINFUL (80%) vaginal bleeding
– bleeding not always present if abruption is
concealed.
• Pain
– sudden onset, constant, localized to lower back
and uterus.

28. Clinical features
• O/E
– General condition depends on the amount of
bleeding (shock/anemia out of proportion to
apparent blood loss)
– Uterus is Hard and Tender
– nonreassuring FH, reduced or absent fetal
movements, fetal distress

29. Investigations
• U/S not sensitive for diagnosing abruption
(sensitivity = 15%)
• Classical US finding is retroplacental clot.

30. Management
• Stabilization & monitoring :
– Maternal stabilization: large bore IV with
hydration, O2 for hypotensive patients.
– Maternal monitoring: vitals, urine output, blood
loss.
– CTG.
– Blood products on hand, because of DIC risk.

31. Management
• Mild abruption
– GA <37 weeks: use serial Hct to assess concealed
bleeding, deliver when fetus is mature or when
hemorrhage is excessive.
– GA ≥37 weeks: stabilize and deliver.
• Moderate to severe abruption
– Immediate delivery.
– Vaginal delivery if no contraindication and no
evidence of fetal or maternal distress OR fetal demise.
– C/S if there is fetal or maternal distress.

32. Complications
Fetal Maternal
• Perinatal mortality
• Prematurity
• Intrauterine hypoxia
• Maternal mortality
• DIC (in 20% of abruptions)
• Acute renal failure
• Anemia
• Sheehan syndrome
Abruptio placentae is the most common
cause of DIC in pregnancy

33. VASA PREVIA

34. Definition
• Unprotected fetal vessels pass over the cervical os;
• Associated with velamentous insertion of cord into
membranes of placenta.

35. Clinical Features
• PAINLESS vaginal bleeding .
• Fetal distress.

36. Vasa previa
• Investigations
– Apt test (alkai denaturation test) to determine
if the source of bleeding is fetal.
– TVS examination with color Doppler
• Treatment:
– emergency C/S (since bleeding is from fetus, a
small amount of blood loss can have
catastrophic consequences)

37. UTERINE RUPTURE

38. Definition
• Complete separation of the uterine musculature
through all of its layers, with all or a part of the fetus
being extruded from the uterine cavity.
• Epidemiology:
– 0.5% of all pregnancies.
– A prior uterine scar is associated with 40% of cases.

39. Risk factors
• Previous CS (types and number).
• Previous uterine myomectomy.
• Congenital uterine anomalies.
• Multiparty.
• Fetal macrosomia.
• Labor induction.
• Uterine instrumentation trauma.

40. Clinical features
• highly variable.
– Sudden onset of intense abdominal pain.
– Vaginal bleeding.
– Shock (Profound maternal tachycardia and
hypotension)
– Fetal parts may be more easily palpated
abdominally.

41. Management
• Immediate laparotomy
• In most cases, total abdominal hysterectomy is the
treatment of choice.
• Debridement of the rupture site and primary closure
may be considered in women of low parity who
desire more children.
• fluid and blood transfusion

42. Case scenario
• last scan 10/12/16
– active, cephalic, liquor normal, placenta posterior
up, no signs of placental separation or
retroplacental clots.
• Hb-9.7
• Coagulation : normal

43. Case scenario
• Glycosylated Haemoglobin = 5.9
• Urine MCS = Normal
• Group: O Rh Positive
• Antibody Screen: No atypical antibodies
detected.

44. Case scenario
• Started on dexa prophylaxis and blood sugar
monitoring.
• CTG and fetal heart monitoring at least once
daily /or as indicated
• Rest
no more p/v spotting upon
admission

45. References
• Hacker and Moore’s obstetrics and
gynecology.
• Toronto Notes 2015.
• www.uptodate.com
• www.ncbi.nlm.nih.gov
• Medscape.com