Objectives

Identify the major causes of antepartum and third trimester bleeding Identify the steps needed to evaluate a patient with an antepartum hemorrhage Discuss the management of a patient with a third-trimester bleeding

Physiology
Non-pregnant state: uterus receives 1% of cardiac output Plasma volume increases by 50% CO increases by 30-50% Third trimester: uterus receives 20% of an increased output Real potential for massive hemorrhage

Definition
Antepartum Hemorrhage -defined as vaginal bleeding from 22 weeks up to delivery MC Causes: >placenta previa >placenta accreta >abruptio placenta >reproductive tract lesions

ABRUPTIO PLACENTA

Premature separation of normally implanted placenta

Types 1. Revealed 2. Concealed > Total/ partial

Pathophysiology
Not fully understood Hemorrhage at the decidual-placental

interface>vasospasm>thrombosis> decidual necrosis & venous hemorrhage

ACUTE
>shearing forces from resulting trauma >sudden uterine decompression (membrane

rupture w/ hydramnios Cocaine use> vasoconstriction> placental separation >deprives fetus of oxygen and nourishment >consumption of coagulation factors>DIC

Recomendations
1.The dx of abruptio placenta is a clinical one and it is suspected in women who present with -vaginal bleeding -abdominal pain or both -hx of trauma w/ unexplained PTL (Grade C)

Criteria for diagnosis

-2 or more of the following

1.Unexplained bleeding after 20 weeks gestation 2.Uterine hypertonus (>5x/10min) 3.Uterine tenderness or back pain 4.Evidence of fetal distress on EFM

There is correlation between the extent of placental separation and the risk of still birth, w/ stillbirth occuring in most cases in which there is greater than 50% placental separation Fetal distress may be manifest on heart rate monitoring as repetetive late deceleration,severe variable deceleration w/ loss of baseline variability or sustaiened bradycardia(Level III)

2.Clinical test most useful are the ultrasonographic examination of the uterus and placenta and EFM (GradeA) FHR-recurrent late or variable deceleration,reducedvariability, bradycardia or a sinusoidal pattern(Level III)

-Ultrasonography will fail to detect atleast of cases of abruptio however when ultrasonogram seems to show an abruptio, the likelihood that there is indeed an abruptio is extremely high -a negative ultrasonogram does not rule out an abruption. -placental location

Level II-2

Yeo and colleagues-prospective cohort study(73 px, vaginal bleeding in the 2nd trim, 7 parameters)
-sensitivity-80%

-specificity -92%
Positive predictive value- 95% Negative predictive value-69%

Ultrasonographic criteria for Diagnosis of Abruptio Placenta

1. Preplacental collection under the chorionic

plate 2.Jello-like movt of the chorionic plate w/ fetal activity 3.Retroplacental collection 4.Marginal hematoma 5.Subchorionic hematoma 6.Inc heterogenous placental thickness(>5cm) 7.Intra-amniotic hematoma (Level II-2)

Differentials
Placenta previa Appendicitis UTI Preterm labor Fibroid degeneration Ovarian Pathology Muscular pain

Management of Abruptio
Stabilizing the patient Detect coagulation derangement Monitor maternal as well as fetal compromise (Grade C)

Recommended by University of Cincinnati Medical Center

Nasal oxygen b. IV hydration w/ large bore catheter c. Type and crossmatch PRBC d. Evaluation of hematologic and clotting parameters e. Monitor urine output f. Continous EFM and uterine activity (Level III)
a.

At near term or term w/ a live fetus, prompt delivery is indicated once there is evidence of fetal compromise, severe uterine hypertonus, life threatening vaginal bleeding

1. Cesarean (Grade B)
Term or near term
Evidence of fetal compromise Severe Uterine Hypertonus

Life threatening vaginal Bleeding or DIC

2. Expectant Management (Grade B)

When both maternal and fetal status are

reassuring When there is fetal demise as long as the mother is stable >Severe abruptio w/ fetal death-expectant mgmt is acceptable as long as the mother is stable (Level II-2)

3. Conservative Management
20-34 weeks with maternal and fetal

reassuring status (Grade B) Steroids should be given to promote fetal lung maturation Prolonged hospitalization and monitoring (Level III)

4. Tocolytics
Sholl, retrospective study and case control

study evaluated the safety of tocolytics (including intravenous magnesium sulfate and intravenous/oral alphasymphatomimetics) in bleeding in second half of pregnancy and w/ suspected stable abruptio placenta (Level II-2)

Risk for Adverse pregnancy Outcomes

Ten fold increase risk for abruptio Increased risk for preterm births and pre-eclampsia Increases risk of impaired uteroplacental perfusion

Term/Near term

Fetus alive

Fetus dead

Reasuring Fetal status

>CI to vag delivery >NRFS >Unstable Mother

Vaginal Delivery

CI to vaginal delivery

>Failure to progress & Unstable Mother

Vaginal Delivery

Cesarean delivery

Cesarean Delivery

Term

Alive < 24 wks

>24 weeks

Dead

Assess

Assess

Deliver

Unstable Mother

Stable

NRFS Unstable Moteher

Reassuring Fetal status Stable mother Manage Conservatively >Steroids >Tocolyitics >Monitor >UTZ

Deliver

Manage Conservatively

Deliver

PLACENTA PREVIA

Definition:
Placenta implanted in the lower uterine

segment of the uterus

Types

1. Complete 2. Partial 3. Marginalis 4. Low lying placenta-within 2-3cm from os

Pathophysiology
-defective decidual vascularization occurs

causing adherence over the cervix (sec to inflammatory or atrophic change) Well formed LUS(3rd Trim)

Disruption of placental attachment

Bleeding

Bleeding Thrombin Contraction

Placental separation

Risk Factors
Advancing age
Multiparity Infertility Treatment

Multiple gestation
Prior Uterine Surgery Recurrent abortions

Short interpregnancy interval

Smoking

Classic Symptom
Painless vaginal bleeding -stops spontaneously and recurs w/ labor

Diagnostics 1. TVS-gold standard (grade A) 2.MRI-more sensitive for placenta accreta Reporting starts at 18 weeks(Grade A)

O mm-placental edge reaching the os Placental edge may extend from 0mm and

20mm away from the os Placental edge may extend from 0mm to 20 mm beyond the os and maybe reported as mm overlap

Mode of delivery

1. >20mm away from os-may go on labor 2. 20 to 0 mm-high cs rate( grade A)

PLACENTA ACCRETA
Definition: -abnormal adherence of the placenta to the uterus with failure to separate after delivery of the fetus -there is abnormal development of the decidua basalis and imperfect development of the fibrinoid layer.

It is hypothesized that the early embryo implants preferentially into areas of uterine scarring and deficient decidua because of relative deficiency of blood flow and oxygen tension in this area with the trophoblasts invading deeply into the myomettrium resulting to placenta accreta. (Level II-2)

Types According to depth A. Placenta accreta vera (75%)-decidua B.Placenta increta (15%)-myometrium C.Placenta percreta(5%)-serosa and other adjacent structures

Types According to # of Cotyledons involved a. Total -all b. Partial- few to several C. Focal-single

Effect on the Mother

-massive obstetrics hemorrhage
-DIC -ARDS

-renal failure
-Infection -death

Effect on the Fetus

-preterm delivery
-restricted fetal growth

*close antenatal fetal surveillance *steroids to enhance pulmonary maturity (Grade B)

Who should be screened? -w/ placenta previa w/ or w/o previous uterine scar -Asherman syndrome -submucous myoma -multiparity (Grade B)

Diagnosis: 1.Gray scale ultrasound w/ clinical risk factors-screening 2.Gray scale ultrasound + Color ad Power doppler-establish dx 3.MRI

Sonographic Characteristics of Placenta Accreta (gray scale + power doppler)

1.Loss of normally visible retroplacental hypoechoic zone 2.Pregressive thinning of the rhz < 2mm on serial exams 3.Presence of multiple placental lakes (swiss cheese apperance) 4.Thinning or focal disruption of the utrine serosa bladder wall complex. 5. Focal mass-like elevation of tissue w/ the same echogenicity as the placenta beyond the uterine serosa.

15-20 wks aog

-presence of lacunae in the placenta is the

most predictive sign of placenta accreta (sensitivity 79% PPV 92%)

Management:
Extirpative surgery but conservative

management approach can be done in selective cases (Grade B)

Mgmt Antenatal (Grade C) 1.Counsel px about delivery risk and complication 2.Consider early delivery after steroid treatment 3.Ensure availability of adequate blood

Conservative management -leaving the placenta -giving methotrexate therapy -uetrine artery embolization + conservative mgmt -wedge resection of the area followed by repair of myometrium

Medical mgmt w/ MTX -weekly at 50mg IM for 4-6 doses (Level III) >ligation of the cord >antibiotic x 72 hrs >daily utz >1mg/kg on alternat days for 4-6 doses >d/c if liver profile is elevated, thrombocytopenia, neutropenia or renal dysfxn >if unstable-hysterectomy

POST PARTUM HEMORRHAGE

Leading cause of maternal mortality 60% of all maternal deaths Occur within 4 hrs of delivery

Definition;
Blood loss of 500cc (vaginal delivery)

1,000cc (cs) 1,400cc (electtive cs hys) 3,000cc (emergency cs hys) Dec in hct level >10% of prenatal values Any blood loss that results in s/sx of hemodynamic instability

Blood loss % 10-15 ml 500-1000

Systolic Blood Pressure

Sigsn and Symptoms

Norml

Palpitation,dizziness, tachycardia Weakness,sweating, tachycardia restlessness.pallor, Oliguria Collapse,air hunger anuria

15-25

1000-1500

Slightly Normal

25-35

1500-2000

70-80

35-45

2000-3000

50-70

WHO Classification of PPH

Hemorrgae Class 0 1 EBL <500 500-1000 Blood Volume loss (%) <10 15 Clinical S/Sx None Minimal

1200-1500

20-25

Oliguria,tachyca rdia,tachypnea, postural hypotension

Hypotension,tac hycardia,cold clammy Profound shock

1800-2100

30-35

>2400

>40

Causes of PPH - FOUR Ts

1.Tone 2.Tissue 3.Thrombin 4.Trauma

TONE-UTERINE ATONY
Leading cause 40-50% of all PPH Defined as failure of the uterus to contract ad retract following child birth Associated w/ the ff

Overdistended uterus Uterine muscle fatigue Uterine distortion Chorioamnionitis Uterine relaxing drugs

Management of Uterine Atony

1. Active mgmt of 3rd stage of labor(AMSTL)

-administration of oxytocin after babys

birth(Grade A) -delayed cord clamping(Grade B) -uterine massage

*Oxytocin is preferred over the misoprostol (Grade A)

B.) Non Surgical Procedure (Level II-3)

If desirous of maintaining reproductive

potential 1.Bimanual uterine compression 2.Internal uterine tamponade procedures

Bi-manual uterine compression

C.) Surgical (Grade C)

-brace compression suture
-vaso-occlusive measures(uterine or internal

iliac artery ligation) Angiographic arterial embolization

B-lynch

TISSUE-RETAINED PLACENTA

Definition:
-retention of the placenta > 30 mins
Management 1.Umbilical vein ijection (grade B) 2.Manual removal-definitive mgmt (grade B)

TRAUMA-UTERINE RUPTURE
Rare and often catastrophic Definition: full thicknes separation of the uterine wall and the overlying serosa -non specific s/sx

Risk Factors A.)Unscarred-grand multiparity -neglected labor -malpresentation -breech extraction -uterine instrumentation -congenital uterine anomalies (Grade B)

B.) Scarred-previous CS scar -inc oxytocin induction -cervical ripening w/ PG -shorter inter delivery interval -one layer closure of uterine incision - fetal macrosomia -increasing maternal age -previous classical -previous myomectomies (Grade B)

Signs and Symptoms 1.Abnormal FHT-prolonged decel 2.Loss of uterine contractility or hyperstimulation 3.abnormal labor or failure to progress 4.Recession of the fetal presenting part 5.Hemorrhage and shock (Grade B)

Effect of Uterine Rupture

MATERNAL

FETAL

Anoxia or hypoxia

Bladder injury

Acidosis

Severe blood loss

Depressed Apgar

Hypovolemic shock

Hysterectomy Death

MANAGEMENT A. Conservative -low transverse uterine rupture -no extension of the tear to the bladder or the cervix -easily controllable uterine hemorrhage -hemodynamically stable -desire for future child bearing -no clinical or laboratory evidence of an evolving coagulopathy

Hysterectomy-tx of choice if uncontrolled bleeding, multiple uterine rupture sites, longitudinal or low lying

Previous CS scar-managed by revision of the edges of the prior incision followed by primary closure

10-37 mins-time available for successful intervention

Keep in mind: (Level III) 1. Maintain a suitably high level of suspicion esp. In high risk patient 2.When in doubt act quickly and definitively

TRAUMA-GENITAL TRACT LACERATION

-occurs during child birth -involve the perineum.vagina and cervix -may occur spontaneously or arise from episiotomy

LOCATION

DEGREE OR DEPTH

Anterior (labia, anterior vagina, urethra or clitoris) Posterior (posterior vaginal wall,perineal muscles or anal sphincter or rectum)

1st (fourchette,perineal skin and vaginal mucosa) 2nd (1st +fascia and muscles of the perineal body)
3rd (2nd + anal sphincter) 3a-<50% ext. Anal sphincter torn 3b->50% ext anal 3c-int and ext anal sphincter torn 4th Extension through rectal mucosa

RECOMMENDATIONS 1.Suspected if bleeding persists despite well contracted uterus.(Grade C) 2.Restricting episiotomy reduce incidence of severe perineal trauma. (Grade A) 3.Minimizing operative vaginal delivery can dec incidence of perineal trauma. Vacuum extraction is more effective in reducing perineal trauma. (Grade B)

4. Any cervical tear which is actively bleeding and or 2 cm in length or longer should be sutured. Done thru interrupted or running suture. (Grade C) 5.For repair of the external anal sphincter either an overlapping or end to end anastomosis can be used w/ equivalent outcome. (Grade A) -use of broad spectrum antibiotic is recommended -reassesed after 6-12 wks for any devt of incontinence

6. Women may rseume sexual intercourse 3-6 months after repair of laceration

TRAUMA-GENITAL TRACT HEMATOMAS

>Uncommon >can be a cause of serious morbidity and even maternal death >occur in 1:300 to 1:1500 deliveries

Types 1. Vulvar hematoma-injury to the branches of the pudendal artery, including the inferior rectal, transverse perineal, or posterior labial branches. 2. Paravaginal hematomas-damage to the descending branch of the uterine artery. 3. Supravaginal or subperitoneal hematomas-damage to the uterine artery branches in the broad ligament.

RECOMMENDATIONS 1. Good surgical technique w/ attention to hemostasis in the repair of lacerations shld limit the occurrence of hematoma. (Grade C) 2. Excessive perineal pain is a hallmark symptom of puerperal hematomas.But a change in vital signs disproportionate to the amount of blood loss shld prompt a gentle pelvic examination.(Grade C)

 3. A high index of suspicion is require to

diagnose and manage these hematomas promptly before signs of cardiovascular colapse develops.

MANAGEMENT 1. Large hematomas (> 3cm)- surgical evacuation, primary closure and compresson for 12-24 hrs 2. Small hematomas-conservatively, ice pack, pressure dressing and analgesia Grade C

3. Internal iliac artery ligation, hysterctomy or even selective aterial embolization.

TRAUMA-UTERINE INVERSION
>complication of childbirth >occurs bet 1 in 2148 and 1 in 6407 births
ONSET Acute-within 24 hrs -mc 83.4 % prevalence Subacute->24 wks but within 4 wks post partum Chronic->4 weeks ANATOMICAL SEVERITY 1st stage-uterine base w/in uterine cavity 2nd stage-uterine base crossed the cervix and passed through the vagina 3rd stage-involves visualization of the uterine base at the vulva 4th stage-vaginal walls participate w/ the inversion

RECOMMENDATIONS 1. Clinical s/sx such as hemorrhage, shock and severe pelvic pain mainly support the dx. Bimanual exam will confirm the dx and also reveal the degree of inversion.(Grade C) 2. Early recognition and prompt replacement of the uterus w/ w/o gen anesthesia and/or tocolytics.

 3. Placenta shld be left in place until after

reduction.(Grade C) 4. Uterotonic drugs should only be given immediately after repositioning of the uterus. 5. Hysterectomy is the last resort of mgmt after repositioning of the uterus and medical mgmt failed.(Grade C)