Antepartum Hemorrhage

1. Antepartum Hemorrhage Lecture Petrenko N., MD, PhD

2. Introduction • Definition: Vaginal bleeding which occurs after fetal viability. • Incidence: 2 – 6 %.

3. ANTEPARTUM HEMORRHAGE Per vagina blood loss after 20 weeks’ gestation. Complicates close to 4% of all pregnancies and is a MEDICAL EMERGENCY! Is one of the leading causes of antepartum hospitalization, maternal morbidity, and operative intervention.

4. Placental: Abruptio placenta. Placenta previa. Non-placental: Vasa previa. Bloody show. Trauma. Uterine rupture. Cervicitis. Carcinoma. Idiopathic. Causes

5. Abruptio Placenta

6. Introduction • Definition: It is the separation of the placenta from its site of implantation before delivery of the fetus. • Incidence: 1 in 200 deliveries.

7. Increased age & parity. Hypertensive disorders. Preterm ruptured membranes. Multiple gestation. Polyhydramnios. Smoking. Thrombophilia. Cocaine use. Prior abruption. Uterine fibroid. Trauma. Risk Factors

8. Types • Total or partial. • Concealed or reveiled.

9. Placental Abruption external hemorrhage concealed hemorrhage Total Partial

10. Presentation • Vaginal bleeding. • Uterine tenderness or back pain. • Fetal distress. • High frequency contractions. • Uterine hypertonus. • Idiopathic PTL. • IUFD.

11. Diagnosis • The diagnosis is primarily clinical, but may be supported by radiologic, laboratory, or pathologic findings. • It is generally obvious in severe cases. • In milder forms the diagnosis is often made by exclusion.

12. Diagnosis The echogenic appearance depends upon the onset of symptoms: • Acute hemorrhage is hyperechoic to isoechoic compared with the placenta. • Resolving hematomas is hypoechoic within one week and sonolucent within two weeks.

13. Diagnosis Laboratory testing is not useful in making the diagnosis: • Kleihauer-Betke test: sensitivity 17%. • CA-125: elevated. • D-dimer: sensitivity 67, specificity 93% • Thrombomodulin: sensitivity 88, specificity 77%. • Hypofibrinogenemia < 200 mg/dL. • Thrombocytopenia < 100,000/microL.

14. Diagnosis • Gross examination of the placenta often reveals a clot and/or depression in the maternal surface. • It may be absent with acute abruption.

15. Initial Management • Stabilization of the maternal cardiopulmonary status. • Blood work: - CBC. - Coagulation profile. - Fibrinogen. - Blood type and Rh.

16. Initial Management • Large-bore intravenous lines and continuous fetal monitoring • Correction of the intravascular fluid deficit via crystalloid +/- PRBC. • If the PT and PTT > 1.5x control  2u FFP. • If the platelet count is < 50,000/microL  6u plt.

17. Initial Management • Heparin or other anticoagulants ? • Tocolysis is generally contraindicated. • Delivery is the optimal treatment. DIC & hemorrhage will resolve over 12 hours when the placenta is removed.

18. Initial Management Medical treatment of coagulopathy for: • Marked thrombocytopenia (< 20,000/microL) • Moderate thrombocytopenia(<50,000/microL) &serious bleeding or planned cesarean delivery. • FFP or cryoprecipitate if fibrinogen is <100 mg/dL

19. Mild Abruption • Expectant management with short term hospitalization. • Corticosteroid. • Tocolysis may be of value in mild cases.

20. Delivery The mode and timing of delivery depend upon: • GA. • The condition of the fetus. • The condition of the mother (eg, hypotension, coagulopathy, hemorrhage). • The status of the cervix.

21. Delivery • The term or near term fetus should be expeditiously delivered. • Amniotomy with placement of a fetal scalp electrode. • Oxytocin may be used to augment uterine activity.

22. Delivery • C/S is performed in the presence of a nonreassuring fetal heart rate pattern & when delay in delivery will endanger the mother or fetus. • It should be done after rapid maternal hemodynamic and clotting factor stabilization.

23. Maternal: Hypovolemia. DIC. Renal failure. Death. Fetal: IUGR. IUFD. Complications

24. Placenta Previa

25. Introduction • Definition: The presence of placental tissue overlying or proximate to the internal cervical os after viability. • Incidence: Complicates approximately 1 in 300 pregnancies.

26. Risk Factors • Increasing parity: incidence 0.2 percent in nulliparas versus up to 5 percent in grand multiparas. • Maternal age: incidence 0.03 percent in nulliparous women aged 20 to 29 versus 0.25 percent in nulliparous women 40 years of age. • Number of prior cesarean deliveries incidence 10 percent after four or more. • Number of curettages for spontaneous or induced abortions.

27. Independent Risk Factors • Maternal smoking • Residence at higher altitudes • Male fetus • Multiple gestation: 3.9 and 2.8 previas per 1000 live twin and singleton births, respectively • Gestational age: the prevalence of placenta previa is much higher early in pregnancy than at term

28. Classification • Complete placenta previa: The placenta completely covers the internal os. • Partial placenta previa: The placental edge does not completely cover the internal cervical os but partially covers it. • Marginal placenta previa: The placenta is proximate to the internal os. • Low-lying placenta: in which placental edge lies within 2 to 3 cm of the internal os. (reference)

29. Maggie Myles: Textbook for Midwives

30. Clinical Manifestations • Painless vaginal bleeding occurs in 70 to 80 percent of patients. • 10 to 20 percent present with uterine contractions associated with bleeding. • Fewer than 10 percent are incidentally detected by ultrasound.

31. Associated Conditions • Malpresentation. • PPROM. • Congenital anomalies. • IUGR.

32. Diagnosis • The diagnosis is based upon results of ultrasound examination. • Clinical findings are used to support the sonographic diagnosis. • Placenta previa should be suspected in any woman beyond 24 weeks of gestation who presents with painless vaginal bleeding.

33. Transabdominal US • It has a diagnostic accuracy as high as 95% in detecting placenta previa, with a false negative rate of 7%. • Sagittal, parasagittal and transverse sonographic views should be obtained.

34. Transabdominal US • It requires the identification of echogenic placental tissue overlying or proximate to the internal cervical os (a distance >2 cm).

35. Transvaginal US • It has become the gold standard for the diagnosis of placenta previa. • It is a safe and effective technique, with diagnostic accuracy greater than 99 percent. • The probe does not need to come into contact with the cervix to provide a clear image.

36. Ultrasound • Both the transabdominal and transvaginal US should be used as complementary studies. • Initial transabdominal examination, with transvaginal sonography if there is any ambiguity in the placental position. • Translabial ultrasound imaging is an alternative technique.

37. Antepartum Management • Avoidance of coitus and digital cervical examination. • Counseling to seek immediate medical attention if there is any vaginal bleeding. • Women are also encouraged to avoid exercise, decrease their activity, and notify the physician of uterine contractions. • Serial ultrasound evaluations every two to four weeks to assess placental location and fetal growth.

38. Acute Care of Symptomatic Placenta Previa • Large bore IV access & administration of crystalloid. • Type and cross-match for four units of PRBC. • Transfuse to maintain a Hct of 30% if the patient is actively bleeding. • Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree of blood loss.

39. Acute Care of Symptomatic Placenta Previa • The fetal heart rate is continuously monitored. • Quantitative monitoring of vaginal blood loss. • The source of the vaginal blood (maternal versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis. • Urine output is evaluated hourly with a Foley catheter & should be at least 30 mL/hour.

40. Acute Care of Symptomatic Placenta Previa • Hb & Hct. • Serum electrolytes and indices of renal function. • Coagulation profile (fibrinogen, Plt, PT & PTT) are checked especially if there is a suspicion of coexistent abruption.

41. Delivery • Tocolysis is not administered to actively bleeding patients. • Delivery is indicated if:          (1) there is a nonreassuring fetal heart rate.          (2) life threatening refractory maternal hemorrhage.

42. Mode of Delivery • Cesarean delivery is the delivery route of choice. • Vaginal delivery may be considered in the presence of: • a fetal demise • previable fetus • some cases of marginal previa, as long as the mother remains hemodynamically stable.

43. Conservative Management of Stable Preterm Patients • The patient is hospitalized at bedrest with bathroom privileges. • Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining. • Periodic assessment of the maternal hematocrit. • Ferrous gluconate supplements (300 mg orally three or four times per day) are given with vitamin C to improve intestinal iron absorption.

44. Conservative Management of Stable Preterm Patients • Cross match to provide two to four units of packed red blood cells. • Prophylactic transfusions to maintain the maternal hematocrit above 30 percent in stable asymptomatic patients in anticipation of future blood loss.

45. Conservative Management of Stable Preterm Patients • A single course of corticosteroid between 24 and 34 w. • Rh(D)-negative women should receive Rh(D)-immune globulin if they bled. • Readministration is not necessary if delivery or rebleeding occurs within three weeks, unless a large fetomaternal hemorrhage is detected by KBT.

46. Conservative Management of Stable Preterm Patients • Fetal growth, amniotic fluid volume, and placental location are evaluated sonographically every two to four weeks. • Tocolysis may be safely utilized if contractions are present and delivery is not otherwise mandated by the maternal or fetal condition.

47. Conservative Management of Stable Preterm Patients • Amniocentesis can be done at 36 weeks to assess pulmonary maturity. • Scheduled abdominal delivery is suggested @ 37w or upon confirmation of pulmonary maturity.

48. Delivery • Abdominal delivery. • Two to four units of PRBC should be available for the delivery. • Appropriate surgical instruments for performance of a cesarean hysterectomy should also be available since there is a 5 to 10 percent risk of placenta accreta.

49. C/S • The surgeon should try to avoid disrupting the placenta when entering the uterus. • If the placenta is encountered upon opening the uterus then it is necessery to cut through the placental tissue to deliver the fetus.

50. Outpatient Managaement • Women who have never bled. • Women with placenta previa if bleeding has stopped for more than one week. • There are no other pregnancy complications, such as fetal growth restriction.