Vaginal Bleeding in Late Pregnancy - PowerPoint PPT Presentation

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Vaginal Bleeding in Late Pregnancy

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Vaginal Bleeding in Late Pregnancy – PowerPoint PPT presentation

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Title: Vaginal Bleeding in Late Pregnancy


1
Vaginal Bleeding in Late Pregnancy
2
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

3
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
4
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

5
Risk Factors for Placenta Praevia
  • Previous caesarean delivery
  • Previous uterine instrumentation
  • High parity
  • Advance maternal age
  • Smoking
  • Multiple gestation

6
Morbidity and Placenta Praevia
  • Maternal haemorrhage
  • Operative delivery complications
  • Transfusion
  • Placenta accreta, increta or percreta
  • Prematurity

7
Patient History Placenta Praevia
  • Painless bleeding
  • 2nd or 3rd trimester, or at term
  • Often following intercourse
  • May have preterm contractions
  • Sentinel bleed

8
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

9
Laboratory Placenta Praevia
  • Haematocrit or complete blood count
  • Blood type and Rh
  • Coagulation tests

10
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

11
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

12
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

13
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

14
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

15
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

16
Bleeding from Abruption
  • Externalized hemorrhage
  • Bloody amniotic fluid
  • Retroplacental clot
  • 20 occult
  • Couverlaire uterus
  • Look for consumptive coagulopathy

17
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

18
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

19
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

20
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

21
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)
22
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

23
Treatment Grade III Abruption
  • Assess mother for hemodynamic and coagulation
    status
  • Vigorous replacement of fluid and blood products
  • Vaginal delivery preferred, unless severe
    haemorrhage

24
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

25
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

26
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

27
Morbidity with Uterine Rupture
  • Maternal
  • haemorrhage with anaemia
  • bladder rupture
  • hysterectomy
  • maternal death
  • Fetal
  • respiratory distress
  • hypoxia
  • acidaemia
  • neonatal death

28
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

29
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

30
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

31
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

32
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

33
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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