If you are a doctor

In the midnight, the pregnant women awakens to find that they have to sleep in a pool of blood

• How to diagnosis？

• How to management？

You

Antepartum Hemorrhage

Obstetrics & Gynecology Hospital of Fudan University

Xu Huan

Rationale (why we care…)

• 4-5% of pregnancies complicated by 3rd trimester bleeding

• Immediate evaluation needed• Significant threat to mother & fetus

(consider physiologic increase in uterine blood flow)• Consider causes of maternal & fetal death• Priorities in management (triage!)

Objectives• We will be able to:

• Describe the approach to the patient with third-trimester bleeding

• Compare symptoms, physical findings, and diagnostic methods that differentiate bleeding etiologies

• Describe management and delivery options for 3rd trimester bleeding etiologies

• Describe potential maternal and fetal morbidity & mortality

• Describe management of postpartum hemorrhage• Apply knowledge in the discussion of clinical case

scenarios

Vaginal Bleeding: Differential diagnosis

• Common:• Abruption, previa, preterm labor, labor

• Less common: • Uterine rupture, fetal vessel rupture,

lacerations/lesions, cervical ectropion, polyps, vasa previa, bleeding disorders

• Unknown• NOT vaginal bleeding!!!

(happens more than you think!)

Other Etiologies

• Cervicitis• infection • Cervical erosion • Trauma • Cervical cancer • Foreign body • Bloody show/labor

Perinatal mortality and morbidity

• Previa• Decreased mortality from 30% to 1% over last 60 years• Now emergent cesarean delivery often possible• Risk of preterm delivery

• Abruption• Perinatal mortality rate 35%• Accounts for 15% of 3rd trimester stillbirths• Risk of preterm delivery• Most common cause of DIC in pregnancy

• Massive hemorrhage --> risk of acute renal failure, Sheehan’s, etc.

Placenta previa

Definition

• After 28 pregnant weeks placental implantation over the cervical os or in the lower uterine segment

• It constitutes an obstruction of descent of the presenting part

• Main cause of obstetrical hemorrhage(20%)• Incidence

0.24%-1.57% (our country).

Risk factors

• Prior cesarean delivery/myomectomy• Prior previa (4-8% recurrence risk) • Previous abortion • Increased parity • Multiple pregnancy• Advanced maternal age • Abnormal presentation • Smoking

Etiology

• Causes1. Endometrial abnormality1) Scared or poorly vascularized endometrium in the

corpus.2) Curettage, Delivery, CS and infection of

endometrium2. Placental abnormality Large placenta (multiple pregnancy), succenturiate

lobe3. Delayed development of trophoblast

Classification

Complete

placenta previa

Partrial

placenta previa

Marginal placenta previa

Classification

Symptoms(1)

• Painless vaginal bleeding (70%)• Spontaneous,After coitus• The most characteristic symptom• late pregnancy (after the 28th week) and delivery• Characteristics: sudden, painless and profuse

• Contractions• No symptoms

• Routine ultrasound finding

The mean gestational age of first bleed: 30 wks 1/3 before 30 weeks

Symptoms(2)

• Anemia or shock

repeated bleeding→ anemia

heavy bleeding→ shock• Abnormal fetal position

a high presenting part

breech presentation (often)

Physical Findings

• Bleeding on speculum exam• Cervical dilation• Abnormal position/lie• Non-reassuring fetal status • If significant bleeding:

• Tachycardia • Postural hypertension• Shock

Diagnosis(1)

• History

1. Painless hemorrhage

2. At late pregnancy or delivery

3. History of curettage or CS

Diagnosis(2)

• Signs

1. Abdominal findings

1) Uterus is soft, relaxed and nontender.

2) Contraction may be palpated.

3) A high presenting part can’t be pressed into the pelvic inlet. (Breech presentation)

4) Fetal heart tones maybe disappear (shock or abruption)

Diagnosis(3)

• Speculum examination

Rule out local causes of bleeding, such as cervical erosion or polyp or cancer.

• Limited vaginal examination (seldom used)

Palpation of the vaginal fornices to learn if there is an intervening bogginess between the fornix and presenting part.

• Rectal examination is useless and dangerous

Limited vaginal examination

Diagnosis(4)

• Ultrasound• abdominal 95% accurate to detect• transvaginal (TVUS) will detect almost all

• consider what placental location a TVUS may find that was missed on abdominal

• MRI• Check the placenta and membrane after delivery remember: no digital exams unless previa RULED

OUT!

Diagnosis(5)

• Before 20 weeks’ gestation,4-6% have some degree of placenta previa on ultrasonic examination

• 90% of these resolving by the third trimester

• Only 10% of complete placenta

Differential Diagnosis

• Placental abruption

vagina bleeding with pain, tenderness of uterus. • vasa previa

In cases of velamentous cord insertion fetal vessels cover cervical os

• Abnormality of cervix

cervical erosion or polyp or cancer

vasa previa

Velamentous placenta

vasa previa

Effects

• obstetrical hemorrhage• Placenta accreta, increta, and percreta • Anemia and infection• Premature labor or fetal death or fetal distress

Abnormally adherent placentation. A. Placenta accreta. B. Placenta increta. C. Placenta percreta

A

B

C

Management(1)

• Less than 36 wks gestation - expectant management if stable, reassuring• Rest: keep the bed • No vaginal exams (not negotiable) • Steroids for lung maturation (<32 wks) • Controlling the contraction: MgSO4

• Treatment of anemia • Preventing infection

70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean

Management(2)

• Initial evaluation/diagnosis• Observe/admit to Labor & Delivery• Intravenous access, routine (maybe serial) labs • Continuous electronic fetal monitoring

• Continuous at least initally• May re-evaluate later if stable, no further bleeding

• Delivery???

Management

• Termination of pregnancy1. CS1) total placenta previa (36th week), Partial placenta

previa (37th week) and heavy bleeding with shock2) Preventing postpartum hemorrhage: pitocin and PG3) Hysterectomy: Placenta accreta or uncontroled

bleeding

Cesarean hysterectomy specimens with placenta percreta.

Cesarean hysterectomy specimens with placenta percreta. (Lateral fundal percreta caused hemoperitoneum in late pregnancy )

Management

• 36+ weeks gestation• Cesarean delivery if positive fetal lung maturity by

amniocentesis• Delivery vs expectant management if fetal lung immaturity• Schedule cesarean delivery at 37 weeks• Discussion/counseling regarding cesarean hysterectomy

Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why Obstetrics is so much fun!)

Other Considerations

• Placenta accreta, increta, percreta• Cesarean delivery may be necessary• History of uterine surgery increases risk• Must consider these diagnoses if previa present• Could require further evaluation, imaging (MRI

considered now)

NOT the delivery you want to do at 2 am

Management

2. Vaginal delivery

Marginal placenta previa ( ＞ 2cm)

Vaginal bleeding is limited

Placental abruption

Definition

• abruptio placentae or placental abruption: placental separation from its implantation site before delivery (the normally implanted placenta )

• Incidence • complicates 0.5-1.5% of all pregnancies • recurrence risk

• 10% after 1st episode • 25% after 2nd episode

Risk factors & Associations

• Cocaine

• maternal hypertension

• abdominal trauma

• smoking

• prior abruption

• preeclampsia

• multiple gestation

• prolonged PROM

• uterine decompression

• short umbilical cord

• chorioamnionitis

• multiparity

Pathology

• Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma– Concealed hemorrhage

– Revealed hemorrhage

revealed hemorrhage concealed hemorrhage mixed hemorrhage

Total placental abruption with concealed hemorrhage and fetal death

Maternal-fetal risk

• perinatal mortality: 35%

• DIC

• hypovolemic shock

• acute renal failure

• Sheehan’s syndrome

Symptoms

• Vaginal bleeding • Abdominal or back pain• Uterine contractions • Uterine tenderness

Physical Findings

• Vaginal bleeding• Uterine contractions • Hypertonus • Tetanic contractions • Non-reassuring fetal status or demise• Can be concealed hemorrhage

Laboratory Findings

• Anemia• may be out of proportion to observed blood loss

• DIC• Can occur in up to 10% (30% if “severe”)• First, increase in fibrin split products • Followed by decrease in fibrinogen

Diagnosis

• Clinical scenario• Physical exam

• Not digital pelvic exams until rule out previa• Careful speculum exam

• Ultrasound• Can evaluate previa• Not accurate to diagnose abruption

Management

• Physical exam• Continuous electronic fetal monitoring • Ultrasound

• Assess viability, gestational age, previa, fetal position/lie

• Expectant management• vaginal vs cesarean delivery

• Available anesthesia, OR team for cesarean delivery

Partial placental abruption with adhered clot

Couvelaire Uterus

腹壁子宫按摩法 腹部 -阴道双手压迫子宫法

A bimanual compression

Packing the uterine cavityPacking the uterine cavity

正面观

背面观

正面观Flash

B-lynch/Bind suture

Cho/patch suture

Ligation of the utering arteries

Management

• Careful maternal hemodynamic monitoring• Fetal monitoring • Serial evaluation of the hematocrit,

coagulation profile,delivery• Blood products for replacement• A large-bore intravenous line