Vaginal Bleeding in Late Pregnancy

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

Causes of Late Pregnancy Bleeding

Placenta Previa Abruption Life-Threatening Ruptured vasa previa Uterine scar disruption Cervical polyp Bloody show Cervicitis or cervical ectropion Vaginal trauma Cervical cancer

Prevalence of Placenta Previa

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

Risk Factors for Placenta Previa

Previous cesarean delivery Previous uterine instrumentation High parity Advanced maternal age Smoking Multiple gestation

Morbidity with Placenta Previa

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

Patient History Placenta Previa

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

Physical Exam Placenta Previa

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

Laboratory Placenta Previa

Hematocrit or complete blood count Blood type and Rh Coagulation tests

While waiting serum clot tube taped to wall

Ultrasound Placenta Previa

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

Treatment Placenta Previa

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

Double Set-Up Exam

Appropriate only in marginal previa with vertex presentation Palpation of placental edge and fetal head with set up for immediate surgery Cesarean delivery under regional anesthesia if: Complete previa Fetal head not engaged Non-reassuring tracing Brisk or persistent bleeding Mature fetus

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

Epidemiology of Abruption

Occurs in 1-2% of pregnancies Risk factors Hypertensive diseases of pregnancy Smoking or substance abuse (e.g. cocaine) Trauma Overdistention of the uterus History of previous abruption Unexplained elevation of MSAFP Placental insufficiency Maternal thrombophilia/metabolic abnormalities

Abruption and Trauma

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

Bleeding from Abruption

Externalized hemorrhage Bloody amniotic fluid Retroplacental clot 20% occult uteroplacental apoplexy or Couvelaire uterus Look for consumptive coagulopathy

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

Physical Exam - Abruption

Signs of circulatory instability Mild tachycardia normal Signs and symptoms of shock represent >30% blood loss Maternal abdomen Fundal height Leopolds: estimated fetal weight, fetal lie Location of tenderness Tetanic contractions

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

Laboratory - Abruption
Complete blood count Type and Rh Coagulation tests + Clot test Kleihauer-Betke not diagnostic, but useful to determine Rhogam dose Preeclampsia labs, if indicated Consider urine drug screen

Shers Classification - Abruption

Grade I Grade II Grade III III A (2/3) III B

mild, often retroplacental clot identified at delivery

tense, tender abdomen and live fetus

with fetal demise - without coagulopathy - with coagulopathy (1/3)

Treatment Grade II Abruption

Assess fetal and maternal stability Amniotomy IUPC to detect elevated uterine tone

Expeditious operative or vaginal delivery

Maintain urine output > 30 cc/hr and hematocrit > 30% Prepare for neonatal resuscitation

Treatment Grade III Abruption

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

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

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

Risk Factors Uterine Rupture

Previous

uterine surgery Congenital uterine anomaly

Uterine

Adenomyosis Fetal

anomaly

overdistension

Vigorous

uterine

pressure Gestational trophoblastic Difficult placental neoplasia removal

Placenta

increta or

percreta

Morbidity with Uterine Rupture

Maternal Hemorrhage with anemia Bladder rupture Hysterectomy Maternal death Fetal Respiratory distress Hypoxia Acidemia Neonatal death

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

Uterine Rupture

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

Vasa Previa

Rarest cause of hemorrhage 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 Color doppler ultrasound Palpate vessels during vaginal examination

Diagnostic Tests Vasa Previa

Apt test based on colorimetric response of fetal hemoglobin Wright stain of vaginal blood for nucleated RBCs Kleihauer-Betke test 2 hours delay prohibits its use

Management Vasa Previa

Immediate cesarean delivery if fetal heart rate is non-reassuring Administer normal saline 10 20 cc/kg bolus to newborn, if found to be in shock after delivery

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