Vaginal Bleeding in Late Pregnancy

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Vaginal Bleeding in Late Pregnancy
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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

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Causes of Late Pregnancy Bleeding

• Placenta Praevia
• Abruption
• Ruptured vasa praevia
• Uterine scar disruption
• Cervical polyp
• Bloody show
• Cervicitis or cervical ectropion
• Vaginal trauma
• Cervical cancer

Life-threatening
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Prevalence of Placenta Praevia

• 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 gt 30 weeks
• No proven benefit to routine screening ultrasound
  for this diagnosis

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Risk Factors for Placenta Praevia

• Previous caesarean delivery
• Previous uterine instrumentation
• High parity
• Advance maternal age
• Smoking
• Multiple gestation

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Morbidity and Placenta Praevia

• Maternal haemorrhage
• Operative delivery complications
• Transfusion
• Placenta accreta, increta or percreta
• Prematurity

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Patient History Placenta Praevia

• Painless bleeding
• 2nd or 3rd trimester, or at term
• Often following intercourse
• May have preterm contractions
• Sentinel bleed

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Physical Exam Placenta Praevia

• 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

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Laboratory Placenta Praevia

• Haematocrit or complete blood count
• Blood type and Rh
• Coagulation tests

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Ultrasound Placenta Praevia

• Can confirm diagnosis
• Full bladder can create false appearance of
  anterior praevia
• Presenting part may overshadow posterior praevia
• Transvaginal scan can locate placental edge and
  internal os

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Treatment Placenta Praevia

• 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

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Double Set-Up Exam

• Appropriate only in marginal praevia with vertex
  presentation
• Palpation of placental edge and fetal head with
  set up for immediate surgery
• Caesarean delivery under regional anaesthesia if
• complete praevia
• fetal head no engaged
• non-reassuring tracing
• brisk or persistent bleeding
• mature foetus

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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

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Epidemiology of Abruption

• Occurs in 1-2 of pregnancies
• Risk factors
• hypertensive diseases of pregnancy
• smoking or substance abuse (e.g. cocaine)
• trauma
• overdistension of the uterus
• history of previous abruption
• unexplained elevation of MSAFP
• placental insufficiency
• maternal thrombophilia/metabolic abnormalities

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Abruption and Trauma

• Can occur with blunt abdominal trauma and rapid
  deceleration without direct trauma
• Complications inculde prematurity, growth
  restriction, stillbirth
• Fetal evaluation after trauma
• Increased use of FHR monitoring may decrease
  mortality

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Bleeding from Abruption

• Externalized hemorrhage
• Bloody amniotic fluid
• Retroplacental clot
• 20 occult
• Couverlaire uterus
• Look for consumptive coagulopathy

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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 blood show
• Trauma
• Other risk factors (e.g. hypertension)
• Membrane rupture

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Physical Exam - Abruption

• Signs of circulatory instability
• Mild tachycardia normal
• Signs and symptoms of shock represent gt 30
  blood test
• Maternal abdomen
• Fundal height
• Leopolds estimated fetal weight, fetal lie
• Location of tenderness
• Tetanic contractions

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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

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Laboratory - Abruption

• Complete blood count
• Type and Rh
• Coagulation tests
• Kleihauer-Betke not diagnostic, but useful to
  determine Rhogam dose
• Preeclampsia labs, if indicated
• Consider using drug screen

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Shers Classification - Abruption
Grade I mild, often retroplacental clot identified at delivery
Grade II tense, tender abdomen and live fetus
Grade III III A III B with fetal demise without coagulopathy (2/3) with coagulopathy (1/3)
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Treatment Grade II Abruption

• Assess fetal and maternal stability
• Amniotomy
• IUPC to detect elevated uterine tone
• Expeditious operative or vaginal delivery
• Maintain urine output gt 30cc/hr and haematocrit gt
  30
• Prepare for neonatal resuscitation

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Treatment Grade III Abruption

• Assess mother for hemodynamic and coagulation
  status
• Vigorous replacement of fluid and blood products
• Vaginal delivery preferred, unless severe
  haemorrhage

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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

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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 caesarean incision most common reason
  for scar disruption
• Other causes previous uterine curettage or
  perforation, inappropriate oxytocin usage, trauma

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Risk Factors Uterine Rupture

• adenomyosis
• fetal anomaly
• vigorous uterine pressure
• difficult placental removal
• placenta increta or percreta

• pervious uterine surgery
• congenital uterine anomaly
• uterine overdistension
• gestational trophoblastic neoplasia

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Morbidity with Uterine Rupture

• Maternal
• haemorrhage with anaemia
• bladder rupture
• hysterectomy
• maternal death
• Fetal
• respiratory distress
• hypoxia
• acidaemia
• neonatal death

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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

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Uterine Rupture

• Sudden deterioration of FHR pattern is most
  frequent finding
• Placenta may play a role in uterine rupture
• Transvaginal ultrasound to elevate uterine wall
• MRI to confirm possible placenta accreta
• Treatment
• Asymptomatic scar disruption expectant
  management
• Symptomatic rupture emergent caesarean delivery

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Vasa Praevia

• Rarest cause of haemorrhage
• 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
• colour doppler ultrasound
• palpate vessels during vaginal examination

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Diagnostic Tests Vasa Praevia

• Apt test based on colorimetric response of
  fetal haemoglobin
• Wright stain of vaginal bleed for nucleated
  RBCs
• Kleihauer-Betke test 2 hour delay prohibits its
  use

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Management Vasa Praevia

• Immediate caesarean delivery if fetal hear rate
  non-assuring
• Administer normal saline 10-20 cc/kg bolus to
  newborn, if found to be in shock after delivery

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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