OB-GYNE MOD 16

TRANS 3
III: Obstetric Hemorrhage
OUTLINE ABNORMAL FALLOPIAN TUBE ANATOMY
1. Ectopic Pregnancy (Page 1) • Prior tubal surgery such as from a previous ectopic
2. Placenta Previa (Page 2) pregnancy
3. Vasa Previa (Page 5) • Previous surgery on the tubes for ligation purposes
4. Guide in the diagnosis of vaginal bleeding (Page 6) • Tubal reconstruction
5. Simple Task (Page 7) • Salpingitis causes agglutination of mucosal folds (in
6. Cases 2021 (Page 7) the fallopian tube lumen) and reduced ciliation as a
7. Paste 2021 (Page 9) result of scarring due to the infection.
8. Paste 2020 (Page 11) • Peritubal adhesions cause tubal kinking and
narrowing of the lumen. These adhesions may be
ECTOPIC PREGNANCY caused by other conditions like previous surgeries,
The blastocyst normally implants in the endometrium of the pelvic endometriosis, and abdominal infections.
uterine cavity. Implantation anywhere else is an ECTOPIC • Congenital fallopian tube anomalies.
PREGNANCY. Implantation can take place in the ovaries, cervix, • Assisted Reproductive Techniques (ART)
vagina and sometimes even in the abdominal cavity. • Smoking
• Contraceptive method failures

PATHOGENESIS OF TUBAL RUPTURE

Fertilized ovum burrows though the tubal epithelium ®
trophoblast invades the subjacent muscularis ® maternal blood
vessels open (tear open) ® blood pours into the spaces between
trophoblast and adjacent tissue until eventual rupture of the
whole tube takes place.

Figure 1. Ectopic pregnancy

However, 95% of all ectopic pregnancies are implanted in the

FALLOPIAN TUBE, and the most frequent site is the AMPULLA.

FROM UpToDate
An ectopic pregnancy is an extrauterine pregnancy. The majority Figure 2. Histology of tubal rupture
occur in the fallopian tube (96 percent), but other possible sites
include cervical, interstitial (also referred to as cornual), CLINICAL MANIFESTATIONS
hysterotomy (cesarean) scar, intramural, ovarian, or abdominal. The three most common:
In rare cases, a multiple gestation may be heterotopic (include • Amenorrhea
both an intrauterine and extrauterine pregnancy). Rupture of an • Abdominal Pain
ectopic pregnancy can result in life-threatening hemorrhage. o Usually on the hypogastric or adnexal areas
• Vaginal Bleeding
RISK FACTORS
We can sum it all up as abnormal Fallopian tube anatomy.
Because of the latter it retards the passage of the fertilized ovum
into the uterine cavity.

OBSTETRICS AND GYNECOLOGY: III: Obstetric Hemorrhage

Dr. V. Fortun and Dr. F. Salvador 1/12
OB-GYNE: III: Obstetric Hemorrhage
OUTCOMES
If left undiagnosed, ectopic pregnancy outcomes will be as
follows:
• Tubal Rupture
• Tubal Abortion
• Pregnancy Failure with Resolution/Reabsorption of the
products of conception
DIAGNOSIS
LABORATORY DIAGNOSIS
• Complete Blood Count - will give the baseline
hemoglobin and hematocrit
o Expected to go down in a ruptured ectopic
pregnancy
• Serum BhCG Assay - will decrease as time goes on
• Serum Progesterone - rarely done nowadays
• Ultrasound Imaging - ubiquitous and least invasive
Figure 3. Transvaginal Sonogram of Ectopic Pregnancy
(Unruptured, yellow circle)
SURGICAL DIAGNOSIS
An ectopic pregnancy can also be diagnosed surgically
• Laparoscopy – GOLD STANDARD for Surgical
Diagnosis because not only we can diagnose it but at
the same time we can also do surgical treatment for
this condition by means of the operating laparoscope.
• Laparotomy – will give you a diagnosis especially if
rupture has taken place and your facility does not have
laparoscope in it.
• Curettage – sometimes, rarely, we are able to diagnose
ectopic pregnancy because of curettage, there are
some instances when a decidual cast can be passed
out through the vagina, with the patient interpreting that
to be the products of conception but histopath will reveal
otherwise. So, if the histopath will not show decidual
placental tissues then consider ectopic pregnancy
MODULE 16 TRANS 3
TREATMENT
SURGICAL MANAGEMENT
(Definitive) Surgical managements for ectopic pregnancy are
• Salpingostomy – making an incision on the affected
fallopian tube and evacuating the products of
conception
• Salpingotomy – very similar to salpingostomy, except,
the incision site is sutured back.
• Salpingectomy – the whole fallopian tube is removed
from the fimbriated portion to the interstitial portion
MEDICAL MANAGEMENT
• Anti-metabolite methotrexate
PLACENTA PREVIA
Before the advent of sonography, the diagnosis of placenta
previa is suspected among patients with vaginal bleeding, and as
consequent finding a placenta during actual internal examination
leading to torrential blood loss and greater risk of maternal and
fetal death.
Others practice a double set-up, wherein the patient is set-up at
the operating room, and will undergo internal examination, then
if it turns out that the patient has previa, cesarean section will
push through.
FROM UpToDate
Placenta previa refers to the presence of placental tissue that
extends over the internal cervical os. Sequelae include the
potential for severe bleeding and preterm birth, as well as the
need for cesarean delivery.
Placenta previa should be suspected in any pregnant woman
beyond 20 weeks of gestation who presents with vaginal
bleeding. For women who have not had a second-trimester
ultrasound examination, bleeding after 20 weeks of gestation
should prompt sonographic determination of placental location
before a digital vaginal examination is performed because
palpation of the placenta can cause severe hemorrhage.
CASE
• 35 years old G2P1
• 32 weeks AOG
• Vaginal spotting
• Only 1 prenatal checkup during 1st trimester
• Smoker (1-2 sticks per day)
• Previous CS
• Bleeding noted upon waking up
• Normal vital signs
• FHT 150bpm
• No uterine contractions
• Reactive cardiotocogram
• Ultrasound revealed placenta previa
2/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

FROM the Lecturer

A cardiotocogram was done and interpreted as with no
deceleration, no contractions but with acceleration.

PLACENTA PREVIA
• Implanted in the lower segment, over or very near the
internal cervical os
• Expanded 4-5cm nearing 3rd trimester

Figure 6. Partial Placenta Previa

LOW LYING PLACENTA

• The placental edge is within the 2 cm wide perimeter
around the internal os but does not cross over it

Figure 4. Placenta previa

Figure 7. Low lying Placenta

FROM the Lecturer • This condition may change in a 1 cm dilated cervix,

It is when the placenta is implanted in the lower uterine becoming 5 cm in dilatation
segment. The lower uterine segment is the isthmus part of the o The placental edge now becomes partially
corpus during the non-pregnant state. It has expanded 4-5cm attached and is now transformed into a partial
nearing the 3rd trimester placental previa
• Anatomical relationship is not precise in changes as the
CLASSIFICATION pregnancy advances or even during labor.

PLACENTA PREVIA PATHOLOGY

1. Placenta Previa – placenta covers the internal os • Implantation of blastocyst in areas with good blood
completely supply and oxygenation
• Unfavorable conditions lead to development of
placenta previa

FROM the Lecturer

Technically, placenta previa when it bleeds, is premature
separation of an abnormally implanted placenta. The placenta or
portion of it becomes a presenting part. It is from the Latin word
previa which means going before. Early in pregnancy,
implantation of the zygote (blastocyst) prefers locations with a
good blood supply and oxygenation in the decidua basalis.
Unfavorable allow the zygote with the developing trophoblast to
Figure 5. Complete Placenta Previa implant elsewhere.
2. Placenta Previa – placenta partially covers the internal os
(without crossing it)

3/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
PLACENTAL MIGRATION
• Normally, the growth is towards the fundus where there
is a good source of blood supply
o This is called Trophotropism
• In some conditions, placental attachment is favored at FROM the Williams Obstetrics 24th edition
the lower uterine segment (LUS)
• Placental edge encroached internal os, but a repeat Painless bleeding is the most characteristic event with placenta
scan showed absence of encroachment previa. Bleeding usually does not appear until near the end of
the second trimester or later, but it can begin even before mid-
pregnancy. Bleeding from a previa usually begins without
warning and without pain or contractions in a woman who has
had! an uneventful prenatal course. In perhaps 10 percent of
FROM the Lecturer women, particularly those with a placenta implanted near but not
Placental edge is initially assessed to be covering the os. After a over the cervical os, there is no bleeding until labor onset.
repeat scan at around 35 weeks, showed absence of Bleeding at this time varies from slight to profuse, and it may
encroachment. This is called PLACENTAL MIGRATION, but clinically mimic placental abruption.
actually is a misnomer. Widening of LUS towards end of the 3rd
trimester, wherein the placental lies close to the edge but
actually not over the internal os.
DIAGNOSIS: SONOGRAPHY
NORMALLY IMPLANTED PLACENTA
RISK FACTORS
• Maternal age - advance maternal age confounded with
conditions such as altered hormonal or implantation
environment.
• Multiparity - higher parity, probability of having several
uterine procedures like curettage or infertility work ups
• Cigarette smoking – nicotine and carbon monoxide
acts as vasoconstrictors of placental vessels thereby
reducing the oxygenation capacity.
• Leiomyoma – avoids an environment with decreased
oxygenation, so that it bumps off the zygote or the
blastocyst to other implantation sites.
• Prior cesarean delivery (surgery) – at times the lower
uterine segment surprisingly may provide an area with
rich vascular supply since the lower uterine segment is
near the uterine arteries
• Assisted reproductive technology – Inflammatory
mediators and oxidative stress may bring about
defective decidualization of placental vessels and
uterine contractions caused by the pelvic adhesions of Figure 8. Placenta with a normal location. GREEN line outlines
endometriosis which may be associated with placenta the placenta. RED line measures the distance of the placenta to
previa the internal os. YELLOW line marks the internal os.

CLINICAL FEATURES In any vaginal bleeding, after mid-pregnancy, one always

The most important feature of placenta previa is Vaginal
Bleeding
• Painless vaginal bleeding - which begins without any
warning occurring with contractions
• Sentinel bleed - may not be profuse.
• Occurs late in 2nd trimester or later gestation
• Slight or profuse.
consider placenta previa. A digital examination is not allowed
in placenta previa. If the patient is stable, a transabdominal scan
for placenta localization must be requested. If still the placental
edge is not visualized, one may resort to transvaginal scan
which is the gold standard. Now if available in hospital
institution, a color doppler may be more helpful. To label a case
placenta previa, the uterus must have developed a lower uterine
segment, usually around 28weeks AOG.

FROM the Lecturer

Other pregnancies have more bleeding throughout the prenatal
until labor begins.
The internal os dilates, and then some portion of the placenta
separates, since the lower uterine is non-contracting segment,
bleeding is poorly controlled, hence further bleeding continues.

4/12
OB-GYNE: III: Obstetric Hemorrhage
PLACENTA PREVIA
Once it is known that there is placenta previa, NO INTERNAL
EXAMINATION must be done. But one may resort to do
speculum examination to possibly visualize placental tissue.
Figure 9. The cervical canal lined by the RED line. Placental edge
outlined by YELLOW line, showing the placental edges crosses
over the internal os.
Figure 10. Ultrasound with color flow mapping: moderate color
flow uptake signifying vascularities.
Figure 11. Speculum examination of placenta previa showing
placental tissue.
MODULE 16 TRANS 3
FROM the Williams Obstetrics 24th edition
Whenever there is uterine bleeding after midpregnancy, placenta
previa or abruption should always be considered. Diagnosis by
clinical examination is done using the double set-up technique
because it requires that a finger be passed through the cervix
and the placenta palpated. A digital examination should not be
performed unless delivery is planned. A cervical digital
examination is done with the woman in the operating room and
with preparations for immediate cesarian delivery. Even the
gentlest examination can cause torrential hemorrhage.
MANAGEMENT
FROM the Lecturer
The mode of delivery is always cesarean section. For pregnancy
before the period of viability, it has to be temporized.
• Tocolytics to control preterm labor
• Corticosteroids are also instituted to hasten lung
maturity
• Bed rest may also be advised to the patient
• Instances where in the bleeding is still profuse after the
delivery of the placenta:
o Cesarean hysterectomy may be done if the
bleeding compromises the mother
o Correction of anemia may be done even
before the delivery
o Units of blood should be readied during the
actual placenta previa operation
FROM Batch 2021’s Trans 2.2
• Cesarean delivery
o Primarily done to save the baby. If in case the baby
demised, continue CS to reduce risk for mother
(dead baby will not go out spontaneously)
• CS-hysterectomy
o If there is a presence of a morbidly adherent
placenta
o Remember the lower uterine segment is not the
contracting part of the uterus. Very thin siya, walang
myometrium. Also very near the bladder (Width:4-
5cm). That’s where you do the incision in CS.
o For young women, you do not remove the ovaries,
just the corpus.
5/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
• Blood transfusion
• Management is always operative whether the AOG is Type 1 Type 2
28 weeks and the bleeding is profuse. Vessels are part of Vessels span between the
Velamentous insertion where bilobate or succenturiate
the cord is attached to the placenta. There is presence of
membranes and not to the vessels between the main
placental bed placenta and accessory
CASE placenta
• Vaginal bleeding
• No uterine contractions
• Late second trimester or early third trimester
• Bleeding manifested during her rest
• Management: Cesarean section

Figure 12. Type 1 Figure 13. Type 2

FROM the Lecturer Table 1. Types of Placenta Previa
The case presents with vaginal bleeding which is a sentinel
bleed. As reported in the cardiotopogram, the patient initially has
no contractions (that is why it was classified as painless). The RISK FACTORS
ultrasound scans definitely support the diagnosis of placenta
previa. Another feature of the case is that the patient had a • Placenta previa in 2nd trimester – where the lower
bleeding during the time of her rest. So, these are the typical uterine has not fully developed yet.
findings you may find when you take the history of a patient with
• In vitro fertilization
a diagnosis of placenta previa.

VASA PREVIA
CASE
A case of a 28-year-old, primigravid, full term, who came in due
to labor pains. Internal examination revealed 7 cm cervical
dilatations, fully effaced, cephalic in presentation, station 0 with
intact bag of waters. Amniotomy was done with clear AF which
became blood streaked later. Repeat FHT after some time
showed absence of fetal heart rate. She later delivered to a pale,
fresh, stillbirth fetus.
• 28-year-old G1
• Full term
• 7cm dilatation, cephalic, station 0 (+) BOW
• FHT – 140bpm
• Amniotomy done with clear to bloody AF
• Repeat FHT - 0
DIAGNOSIS
• Ultrasound – Color doppler
• Palpate vessel during IE
FROM the Lecturer
Antenatally, Vasa previa can be seen in the initial transabdominal
scan. This can be later confirmed by a presence of vessels at the
internal os using color doppler. If a speculum examination was
done and the cervix is open, one may get lucky so that
visualization of the vessels is possible. If undetected, the
condition is catastrophic to the fetus because of exsanguination;
hence, there should be high index of suspicion. Further diagnostic
tests like color doppler must be requested for low-lying vasa
previa cases or those with cesarean scars.

VASA PREVIA MANAGEMENT

Vessels run along the membranes overlying internal os
• After rupture or amniotomy
• Will lead to fetal exsanguination
• Control of preterm labor – given after 24-28 weeks AOG
because we don’t know when the patient will deliver.
o Tocolytics
o Corticosteroids
• Cesarean section – manner of delivery (always)

FROM the Lecturer

In this condition, vessels travel within the membranes and overly
the cervical os. The vessels can be torn during a spontaneous
rupture or during artificial amniotomy.

6/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

GUIDE IN THE DIAGNOSIS OF VAGINAL BLEEDING

Guide in the diagnosis of the causes of hemorrhages in the
second half of pregnancy.

SIMPLE TASK
*USE AT YOUR OWN RISK
1. Regarding fetal heart rate decelerations, which of the following
statements is correct?
A. Late decelerations are clinically benign.
B. We can appreciate variable decelerations in patients with
Figure 14. Guide for diagnosis of causes of hemorrhage ruptured bag of waters
C. Late decelerations are caused by head compression
D. The nadir of fetal heart rate occurs after the peak of
contraction if the deceleration is early in character.
FROM the Lecturer
2. The type of decelerations produced in a Contraction Stress
Explanation of the diagram
Test should be of ______ in character so that it will be valid for
Vaginal bleeding (Center) can be caused by 3 or 4 conditions.
interpretation.
The first condition: if the patient presents with strong uterine A. Early
contractions, with uterine tenderness and difficult to appreciate B. Variable
fetal heart tones, the BP might be normal or elevated, you think C. Spontaneous
of ABRUPTIO PLACENTA. D. Late

So now if the patient presents with no contractions, but she has 3. The biophysical parameter that is last to appear is the _____
expressed earlier that she had hypogastric pains or labor pains, A. Fetal tone
and placenta previa was ruled out, IE may reveal a non-palpation B. Fetal movement
or a very hard presenting part and fetus might be in distress or C. Fetal heart rate reactivity
with absent fetal heart tone, think of UTERINE RUPTURE. D. Fetal breathing

Now if one is presented with bleeding but with no hypogastric 4. Which of the following types of miscarriage may result in pelvic
pain of any sort, the fetus has normal fetal heart rate and upon inflammatory disease?
palpation of the abdomen, there is really no contraction, think of A. Septic
PLACENTA PREVIA BUT DO NOT DO IE.
B. Complete
C. Incomplete
REFERENCES
D. Threatened
1. References: Video lecture
2. Books
TRANSCRIBERS 5. In which part of the fallopian tube does ectopic pregnancy
1. TRANS GROUP: Meant 2B usually take place?
2. SUBTRANSHEAD: Hannah Clarice Luciano A. Ampulla
B. Interstitial
De La Salle – Health Science Institute College of Medicine C. Isthmus
Batch Twenty Twenty-Two D. Fimbria
“non sibi sed omnibus”
6. Which of the trophoblastic disease is benign?
A. Invasive mole
B. Complete H-mole
C. Epithelioid trophoblastic neoplasia
D. Choriocarcinoma

7. What is the condition when the placenta is implanted in an

abnormal location?
A. Vasa Previa
B. Placenta succenturiata

7/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
C. Placenta Previa What is the most likely diagnosis?
D. Placental Abruption Preeclampsia
3. A 19 year old G1P0 at 36 6/7 weeks AOG complained of
8. What is the condition when placental vessels traverse the vaginal bleeding 1 hour prior to consult. At ER, pertinent PE
internal os? showed BP of 180/110mmHg, HR of 85 bpm, RR of 18 cpm,
A. Placenta Previa IE done after loading dose of Magnesium sulfate given
B. Velamentous Placenta revealed closed cervix uneffaced Abdominal findings
C. Vasa Previa showed uterine contractions every 2 minutes strong. FHT
D. Bilobed Placenta
was 120 bpm. A baseline cardiotocogram done; revealed a
nonreassuring fetal heart rate pattern. Based on this data:
9. What is the surgical procedure when the abdomen is opened
up in the management of uterine rupture?
A. Cesarean section What is the most likely diagnosis?
B. Laparotomy Uterine Rupture
C. Hysterotomy
D. Hysterography What is the management for this case?
Cesarean Delivery
10. What is the most significant risk factor that may lead in the
diagnosis of uterine rupture? 4. A 31 year old G2P1 (0101) 37 weeks AOG known
A. Assisted reproductive technology hypertensive complained of labor pains 2 hours prior to
B. Previous cesarean section consult. Pertinent PE showed BP of 190/120 mmHg, HR of
C. Curettage 93 bpm, RR of 20 bpm, IE done after loading dose of
D. Prior uterine rupture Magnesium sulfate given revealed 9 cm cervical dilatation
fully effaced cephalic station +1 with ruptured BOW thickly
CASES 2021 meconium stained with profuse bleeding. FHT was not
1. A 27 year old G2P1 37 weeks AOG complained of appreciated. At DR patient, delivered to dead baby boy BW
hypogastric pain 30 minutes prior to consult. At ER, pertinent 1.9 kg. Placenta delivered immediately following the baby.
PE showed BP 160/110mm Hg, HR of 89 bpm, RR of 18 Based on this data:
bpm, IE done after loading dose of Magnesium sulfate given
revealed 1-2 cm cervical dilatation uneffaced with minimal Give your diagnosis.
show. Abdominal findings showed strong uterine Abruptio Placenta (severe)
contractions every 1 to 2 minutes. FHT was 110 bpm. Based
Enumerate the salient points supporting your
on this data:
diagnosis.
- Known hypertensive
What is the most likely diagnosis?
- Pre-eclampsia (BP = 190/120)
Abruptio Placenta
- (+) PROM H ruptured BOW thickly meconium stained
Give one differential. - (+) profuse bleeding
Placenta Previa - (+) labor pains 2 hours prior to consult
- Delivered to dead baby boy BW 1.9 kg
2. A 39 year old G6P5 (5005) 38 weeks AOG complained of
hypogastric pain 3 hours prior to consult. At ER, pertinent PE 5. A 31 year old G2P1 (0101) 37 weeks AOG known
showed BP of 200/120 mm/Hg, HR of 91 bpm, RR of 18 hypertensive complained of labor pains 2 hours prior to
cpm, IE done after loading dose of Magnesium sulfate given consult. Pertinent PE showed BP of 190/120 mmHg, HR of
revealed 3 cm cervical dilatation uneffaced with intact BOW 93 bpm, RR of 20 bpm, contractions were strong occurring
cephalic station 0. Abdominal findings showed uterine every 2-3 minutes. IE done after loading dose of Magnesium
contractions every 2 minutes, strong. FHT was 90 bpm. sulfate given revealed 2 cm cervical dilatation fully effaced
Based on this data: cephalic station +0 with ruptured BOW thickly meconium
stained with profuse bleeding. FHT was not appreciated. At
What is the most likely intervention that can be done to DR, patient BP revealed 80/60 mmHg, HR of 119 bpm, and
help in the formulation of your diagnosis? RR of 30 bpm. Patient appeared pale. Based on this data:

Nonstress test/Biophysical profile What is the most likely diagnosis?

- Simple procedure Abruptio placenta
- Uses an ultrasound
- Measure the baby’s breathing, muscle tone, Give your management
movement, and volume of amniotic fluid in the uterus a. cesarean delivery
b. vaginal delivery
A second abnormal blood pressure reading 4 hours after c. replacement of blood loss
the first may confirm suspicion of preeclampsia. Blood and
urine tests may also be done after.

8/12
OB-GYNE: III: Obstetric Hemorrhage
6. A 25 year old G1P0 at 32 weeks AOG consulted
because of vaginal bleeding. Her history was unremarkable.
PE showed a fundic height of 29 cm, FHT of 140 bpm, with
no contractions.
Give the most likely diagnosis.
Placenta Previa
Give your diagnostics.
Sonography
7. A 39 year old G7P5 (5015) at 37 weeks AOG consulted
because of vaginal bleeding. Her history was
unremarkable. PE showed a fundic height of 31 cm, FHT of
140 bpm, with no contractions. Ultrasound revealed
placenta overlying the internal os with presence of
sonolucency at the placental plate. Her blood type is O+.
Give your diagnosis.
Placenta Previa
Give your management.
- Close observation in obstetrical unit
- Cesarean delivery
8. A 19 year old G1P0 at 37 weeks AOG consulted because of
vaginal bleeding. Her history was unremarkable. PE
showed a fundic height of 34cm. FHT of 150 bpm, with no
contractions. Ultrasound revealed placental edge at the
margin of the internal os. Her blood type is A+.
Give the diagnosis
Placenta Previa
Give the management
Deliver via cesarean delivery
9. A 28 year old G2P0 at 39 weeks AOG consulted because of
vaginal bleeding. She has no prenatal check-up. PE showed
a fundic height of 34cm, FHT of 150 bpm, with no
contractions. Ultrasound revealed placental edge 2cm
beyond the internal os. Her blood type is A+.
Give the diagnosis
Complete Placenta Previa
Give the management
- Cesarean Delivery
- Blood transfusion
- Close observation in an obstetrical unit
10. A 26 year old G2P1 38 weeks AOG consulted because
of severe hypogastric pain. She still feels the fetal
movement. Her fundic height was 39 cm and her vital signs
were normal. Initial IE revealed: cervix 8cm dilated cephalic
station 0 intact BOW. After 2 hours she became restless and
complained of severe pain again. Repeat IE showed 8 cm
dilatation but presenting part became floating. FHT is 110
bpm.
MODULE 16 TRANS 3
Give the diagnosis.
Uterine Rupture
Give the management.
- Emergency exploratory laparotomy with Cesarean
delivery
- Depending on the nature of the rupture and the
condition of the patient
11. A 36 year old G3P1 (1011) 36 weeks AOG consulted
because of severe hypogastric pain. Her fundic height
was 41 cm and her vital signs were normal. She
informed that she has an intramural myoma located
anteriorly, Initial IE revealed cervix 5cm dilated cephalic
station 0 intact BOW. During labor she further complained of
increasing pain. Repeat IE after 2 hours showed 5 cm
cephalic station H1. After IE profuse bleeding was noted. BP
then became 80/50 mm Hg. Uterine contraction was not
anymore appreciated
Give the diagnosis
Abruptio Placenta
Give the management
Immediate delivery thru CS, followed by blood transfusion
(packed RBC)
12. A 33 year old G4P3 (3003) 39 weeks AOG consulted
because of labor pains. She has normal vital signs and IE
revealed 9cm dilatation cephalic fully effaced, station +1. At
the DR amniotomy was done after which clear amniotic
fluid was noted followed by bloody tinged AF. Repeat
FHT done revealed 105 bpm. Further monitoring after
hydration revealed FHT of 80 bpm at CTG.
Give your working diagnosis.
Uterine Rupture
Give the management.
Immediate cesarean delivery
PASTE 2021
1. A 20 y/o, G2P1 (1000), 10 weeks pregnant, commercial sex
worker is rushed to the Emergency Room because of pelvic
pains and vaginal spotting. She was pale and tachycardic.
There is direct and rebound abdomen tenderness on the left
lower quadrant. On pelvic examination, a tender cystic mass
measuring 3 by 2 cm was palpated and the posterior fornix
was boggy. How will you manage this patient?
Select one:
a. Give intramuscular methotrexate.
b. Do CT scan of the abdomen.
c. Prepare the patient for exploratory laparotomy
d. Observe the patient for progression of severity of
the pelvic pains
2. A 30 y/o, G1P0, 8 weeks pregnant, consults you for
hypogastric pain. Vital signs are stable. Cervix was closed
and the uterus was slightly enlarged on pelvic examination.
Pelvic sonogram showed an empty uterine cavity. Serum
9/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
BhCG level was 1600 mIU/ml. What is your initial
impression?
Select one: 9. . What is the most common symptom of trophoblastic
a. Missed abortion diseases?
b. Threatened abortion Select one:
c. Ectopic pregnancy a. Vaginal bleeding
d. Hydatidiform mole b. Abdominal pain
c. Headaches
3. A 34 y/o primigravid, 11 weeks AOG, is rushed to the d. Dyspnea
Emergency Room for vaginal bleeding and passage of
tapioca-like material per vagina. On abdominal examination, 10. Which is true about Contraction Stress Test (CST)?
the uterine fundus is at the level of the umbilicus. What is Select one:
your initial impression? a. Patient is placed in supine position
Select one: b. Contractions may be induced either oxytocin drip or
a. Molar pregnancy nipple stimulation
b. Missed abortion c. May be performed in patients who underwent
c. Incomplete abortion myomectomy or with a placenta implanted lower
d. Preterm labor than the fetal presenting part
4. A 43 y/o, G6P5 (3023), 12 weeks AOG, is diagnosed to have d. May or may not perform NST prior to CST
a molar pregnancy on transvaginal sonogram. What is the
11. Which of the following statements is TRUE regarding a
preferred management?
complete h-mole?
Select one:
a. Hysterectomy Select one:
b. Hysterotomy a. Serum BhCG levels are low.
c. Chemotherapy b. It has fewer number of vesicular placental villi.
d. Suction curettage c. Karyotype is triploid.
d. Risk for malignant degeneration is high.
5. MD, 39 year old, G2P1 (1001) consulted the ER for labor
12. Which of the following statements is TRUE regarding
pains. IE was done which revealed a baby in cephalic
laparoscopy in the diagnosis and treatment of ectopic
presentation and a cervix that is dilated to 7 cms, 60 – 80%
pregnancy?
effaced, ruptured BOW. What type of deceleration will you
Select one:
likely observe?
a. Laparoscopy results in longer hospital stay and
Select one:
recovery.
a. Spontaneous deceleration
b. Laparoscopy may be done under local anesthesia.
b. Variable deceleration
c. Laparoscopy is preferred over laparotomy in
c. Early deceleration
hemodynamically unstable patients.
d. Late deceleration
d. Laparoscopy can be used in both surgical and
medical treatment.
6. The components of a biophysical profile include all except
which of the following? 13. A patient presented with scanty bleeding on her 28th week
Select one: of gestation. An ultrasound was done revealing placenta
a. Amniotic fluid volume assessment
previa. What is the most likely immediate management for
b. Fetal breathing
her pregnancy? Select one:
c. Contraction Stress Test
d. Fetal tone a. Secure blood during delivery
b. Placental color flow mapping
c. Administer tocolytics
7. What is the characteristic sonographic picture of a molar d. Request for hepatitis Bs antigen
pregnancy?
14. Which ultrasound finding is a true placenta previa at 35
Select one:
weeks AOG?
a. Predominantly hyperechoic
b. Whorled pattern Select one:
c. Hypoechoic a. Placental edge is at the margin of internal os
d. Snow storm pattern b. Edge of placenta located 1.5 cm from internal os
c. Edge of placenta located 1.0 cm from internal os
8. What is the common site of ectopic pregnancy? d. Placental edge 2 cm beyond the internal os
Select one:
15. The following are risk factors for the development of
a. Ovary
b. Peritoneum placenta previa EXCEPT:
c. Cervix Select one:
d. Fallopian tube a. Assisted reproductive technology

10/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
b. Cigarette smoking a. Cesarean delivery with bilateral tubal ligation
c. Maternal age b. Cesarean delivery but leave the placenta
d. Increase BMI intrauterine
c. Cesarean delivery
16. What is the most cost effective way to diagnose placenta d. Cesarean hysterectomy
previa?
Select one: 22. A 40 year old G2P2 patient was trying to get pregnant after
a. Transabdominal scan 5 years. She underwent assisted reproductive technology
b. MRI and was successful. She had 2 previous cesarean sections.
c. 3D ultrasound For her delivery the risk of placenta previa with accreta is
d. Transvaginal scan higher because of what condition?
Select one:
17. A 16 year old G1P0 on her 28 weeks AOG had a scanty a. Age
bleeding. Placenta previa was signed out in her ultrasound b. Two previous cesarean sections
findings. What would be the management for her case? c. Interval of pregnancy
Select one: d. Relative infertility
a. Give steroids then schedule for cesarean section
b. Temporize pregnancy till 35 weeks AOG 23. What is the abnormality seen that led to the development the
c. Give steroids then tocolyse until the maximum placenta accrete syndrome?
period it can hold pregnancy Select one:
d. Do emergency cesarean section a. Myometrium
b. Placental villi
18. . A 32 year old G3P2 with no prenatal checkup presented at c. Nitabuch layer
the ER because of profuse vaginal bleeding with no note of d. Decidua vera
contraction. Maternal and fetal status were stable. The
fundic height is 33 cm. What is the initial management you 24. A G1P0 term pregnancy on her 5th hour of labor underwent
would request? amniotomy. The amniotic fluid was bloody tinged. After
Select one: which fetus showed fetal bradycardia. What is the most likely
a. Emergency cesarean section working diagnosis for this case?
b. Transvaginal ultrasound Select one:
c. Give tocolytics a. Placenta previa
d. For vaginal delivery b. Uterine rupture
c. Abruptio placenta
19. A 38 year old G4P3 diagnosed with placenta previa located d. Vasa previa
posteriorly on her 34 weeks AOG. She has no more desire
for another pregnancy. What would be the better plan for her 25. A 31 year old G1P0 31 weeks AOG consulted for the first
delivery? time at the OPD. IE was done after other physical
Select one: examinations. There was a note of torrential gush of blood.
a. Classical cesarean section What is the working diagnosis?
b. Cesarean hysterectomy Select one:
c. Low transverse cesarean section with bilateral a. Abruptio placenta
tubal ligation b. Placenta previa
d. Low transverse cesarean section c. Vasa previa
d. Uterine rupture
20. A 41 year old G1P0 on her term pregnancy breech
presentation and with history of infertility was diagnosed with 26. During prenatal check-up, what is the most likely procedure
anterior placenta previa. She was advised to undergo in the diagnosis of vasaprevia?
cesarean section. The main reason for doing the cesarean Select one:
section is________. a. Transabdominal ultrasound with color flow
Select one: mapping
a. History of infertility b. Transvaginal 3-D
b. Breech primigravid c. Transvaginal ultrasound with Doppler velocimetry
c. Age d. Speculum examination
d. Anterior placenta previa
27. . A 15 year old primigravid on her 10th week AOG was
21. . A 36 year old G5P2 was diagnosed with placenta previa diagnosed to have ectopic pregnancy. What is the most
with loss of retroplacental zone between placenta and common site of ectopic pregnancy if the fallopian tube?
uterine musculature during ultrasound. What is the most Select one:
likely manner of delivery for this case? a. Isthmus
Select one: b. Infundibulum
c. Fimbria

11/12
OB-GYNE: III: Obstetric Hemorrhage
d. Ampulla
ANSWER KEY: CCABC-CDDAB-DDBDD-DCBCD-DBCDB-
CD
PASTE 2020
1. A 29-year-old G3P2 (2002) at 32 weeks age of gestation with
overt diabetes mellitus consulted at the OPD due to
decrease fetal movement. Non stress test was requested.
Which of the following findings is considered as reactive non
stress test?
a. Two accelerations of ≥ 15 beats per minute lasting for ≥
15 seconds
b. One deceleration of ≤ 15 beats per minute lasting for ≤
15 seconds
c. One acceleration of ≤ 15 beats per minute lasting for ≤
15 seconds
d. Two decelerations of ≥ 15 beats per minute lasting for ≥
15 seconds
2. A 38-year-old primigravid at 34 weeks age of gestation
complaining of decreased fetal movement. Which of the
following is the best antepartal surveillance for her case?
a. Modified Biophysical Profile
b. Non stress test
c. Fetal movement counting
d. Contraction stress test
3. A 29-year-old G1P0 at 41 weeks AOG came in for prenatal
check-up. Vital signs were normal, FHT: 150 bpm, FH: 34
cm, Leopolds maneuver showed cephalic presentation.
Internal examination revealed that the cervix is 1-2 cm
dilated, 50 % effaced, intact membranes and station 0.
Clinical pelvimetry was adequate. BPS- 8/10 with
oligohydramnios. Contraction Stress test (CST) was
requested and showed there were late decelerations in
every contraction. This trace is a/an __________?
a. Positive
b. Negative
c. Equivocal
d. Unsatisfactory
4. Majority of ectopic pregnancies implant in the ____.
a. Cervix
b. Ovary
c. Peritoneum
d. Fallopian tube
5. How does abnormal fallopian tube anatomy increase the risk
for an ectopic tubal pregnancy?
a. It retards passage of the fertilized ovum into the uterine
cavity.
b. There is less inflammation around the area of the tube
abnormality.
c. Ciliary activity of the tube lumen epithelium is greater.
d. It offers more surface area for blastocyst implantation.
6. A 29 y/o, G3P1 (1011), 11 weeks pregnant, rushes to the
Emergency Room because of pelvic pains. She is pale and
tachycardic. There is direct and rebound abdomen
MODULE 16 TRANS 3
tenderness on the right lower quadrant. On pelvic
examination, a tender cystic mass measuring 4 by 1.5 cm is
palpated on the right adnexal area. Posterior fornix is boggy.
How will you manage this patient?
a. Give intramuscular methotrexate.
b. Observe the patient for progression of severity of pelvic
pains.
c. Do transvaginal sonogram after an hour.
d. Prepare the patient for exploratory laparotomy.
7. A 30 y/o, G3P2 (2002), 9 weeks pregnant, consults you for
vaginal spotting and hypogastric pain. Vital signs are stable.
Cervix is closed on pelvic examination. Pelvic sonogram
shows an empty uterine cavity. Serum beta hCG level was
1100 mIU/ml. What is your initial impression?
a. Hydatidiform mole
b. Phantom HCG
c. Ectopic pregnancy
d. Miscarriage
8. A 36 y/o, G1P0, 11 weeks pregnant, consults for severe
pelvic pains and vaginal spotting. A 3 by 4 cms cystic mass
and peritoneal fluid in the posterior culdesac are seen on
transvaginal sonogram. Culdocentesis done is positive for
nonclotting blood. Which of the following is a radical
treatment for this condition?
a. Methotrexate
b. Salpingectomy
c. Salpingostomy
d. Salpingotomy
9. Which of the following statements describes the use of
laparoscopy in the diagnosis and treatment of ectopic
pregnancy?
a. Laparoscopy is preferred over laparotomy in
hemodynamically-unstable patients.
b. Laparoscopy may be done under local anesthesia.
c. Laparoscopy can be used in both surgical and medical
treatment.
d. Laparoscopy results in longer hospital stay and recovery
10. If the placental edge does not reach the internal os and
remains within a 2 cms wide perimeter around the os, the
placenta is:
A. Normally-implanted
B. Low-lying
C. High-lying
11. A 29 y/o, G3P1 (1011), 33 weeks AOG, is rushed to the
emergency room because of vaginal bleeding. Pelvic
sonogram done showed the placenta to be partiallycovering
the internal cervical os. What is your initial impression?
A. Complete previa
B. Low-lying placenta
C. Placenta previa partialis
D. Placenta previa marginalis
12. A 29 y/o, G2P0 (0010), 36 weeks AOG, in labor, consults
you for vaginal bleeding. Pelvic sonogram shows the
12/12
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
placenta to be partially covering the internal cervical os. The
route of delivery will be:
A. Vaginal
B. Abdominal

13. Which of the following is a risk factor for placenta previa?

A. Patient is 20 years old
B. Patient is a primigravid
C. Patient had a previous cesarean section
D. Patient drinks a glass of wine occasionally

14. The most characteristic clinical feature of placenta previa is:

A. Vaginal bleeding
B. Uterine tenderness
C. Uterus is tetanically contracted
D. Preterm rupture of membranes

15. A 27 y/o, G1P0, 34 weeks AOG, with low-lying placentamay

be closely observed in a maternal intensive care unit,
provided:
A. The presenting part is engaged.
B. Uterine contractions are irregular
C. There is no fetal growth restriction
D. There is no persistent active bleeding.

16. Which of the following is an etiology of vasa previa?

A. Preeclampsia
B. Oligohydramnios
C. Contracted pelvis
D. Previous cone biopsy of the cervix

17. A velamentous insertion of the umbilical cord into the

placenta makes a patient at risk for _________.
A. Uterine hypertetany
B. Chorioamnionitis
C. Maternal hemorrhage
D. Dystocic labor

18. A 22 y/o, G2P1 (2001), 37 weeks AOG, was found to have

vasa previa by transabdominal ultrasound. The route of
delivery of this patient is__________.
A. Vaginal
B. Abdominal

ANSWER KEY: AAADA-DCBCB-CBCAD-CCB

13/12
 OB-GYNE MOD 16
TRANS 3
III: Obstetric Hemorrhage
OUTLINE CLASSIFICATION (PARTIAL VS COMPLETE)
1. Uterine Rupture (Page 1)
2. Placenta Abruptio (Page 6) • Classified based on the anatomic layers
3. Placenta Previa (Page 12)
4. Vasa Previa (Page 16)
5. Guide in the diagnosis of vaginal bleeding (Page 6)
6. Simple Task (Page 17)
7. Cases 2021 (Page 18)
8. Paste 2021 (Page 20)
9. Paste 2020 (Page 22)

UTERINE RUPTURE
Figure 1. Uterine rupture – break in the uterine wall
OBJECTIVES
1. To diagnose correctly the common obstetric PARTIAL
hemorrhages in the second half of pregnancy
2. To correlate the different sonographic features with the • Visceral peritoneum is intact, Uterine dehiscence
diagnosis
3. To describe briefly the pathophysiology of each
condition
4. To identify the risk factors that may contribute or
associated in the development of these conditions FROM Lecturer
The outermost layer is intact, the innermost layer, the endometrium
5. To formulate an acceptable management plan for each
and myometrium separate. This is also called “Uterine Dehiscence”
condition among pregnant women

INTRODUCTION
The lecture is about bleeding in the second half of pregnancy.
Obstetric hemorrhage is one of the top 3 causes of maternal
deaths worldwide and more frequently the single most common
cause of maternal mortality in the developing country like ours
and more so in underdeveloped countries.

Obstetric Hemorrhage: Top 3 causes of maternal deaths:

• Uterine Rupture
Figure 2. (L) Image of partial uterine rupture (R) Image of Uterine
• Abruptio Placenta dehiscence
• Placenta Previa

FROM Lecturer
The common hemorrhages in the second half of pregnancy are
Uterine Rupture, Abruptio Placenta, and Placenta Previa.

CASE Figure 3: Partial uterine rupture in sonography and laparoscopy

32 years old G2P1 Ultrasound result will reveal that the defect in the entire placental
thickness is seen in the area of the CS scar. This may be detected during
39 weeks AOG
prenatal surveillance. If seen, one would notice a defect in the surface of
Labor pains the uterine wall, a depression may be present plus a discoloration of the
Previous CS a year ago lesion.
VS: BP 110/80mmHg (other VS were normal) , FHT was 140bpm
IE: Fully Dilated, Fully effaced, Cephalic, Station +4, (-) BOW
Severe abdominal pain after some time
Repeat BP- 60mmHg palpatory, FHT was not appreciated
Minimal to moderate bleeding per vagina

OBSTETRICS AND GYNECOLOGY: III: Obstetric Hemorrhage

Dr. F. Salvador 1/23
OB-GYNE: III: Obstetric Hemorrhage
COMPLETE
• All layers involved
• The entire 3 layers separate, including the visceral
peritoneum.
Figure 3. Complete uterine rupture
PATHOGENESIS
Figure 4. Pathogenesis of Uterine Rupture
FROM Lecturer
Uterine rupture is brought about by the (1) thinness of the uterine
wall due to prolonged labor, external factors like (2) uterotonics,
and (3) a presence of a scar. The break will either involve the entire
thickness of the uterine wall (endometrium, myometrium and
serosa) or it will only involve the inner 2 layers (endo, myo).
MODULE 16 TRANS 3
ANOTHER TYPES OF CLASSIFICATION (PRIMARY VS
SECONDARY)
PRIMARY
Figure 5. Primary type of uterine rupture
• Conditions like dystocic labor or fundal pressure was
applied over the uterus
• The rent might be along the lateral aspect of the corpus or
it may extend to the cervix or even the bladder
• May happen along the anterior or posterior wall, or it may
extend longitudinally or upward towards the fundus or
towards the entry of the uterine arteries
SECONDARY TYPE
Figure 6: Secondary type of uterine rupture
• There is already an existing or previous scar or incision on
the uterine wall
• Or an injury or a congenital anomaly of the uterus
2/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
To further elucidate, we have two types of Cesarean Section
(CS)
FROM Lecturer
On examination, you will see the fetal part maybe out of the uterus
such us the lower or upper extremity, the fetal head, or sometimes
the whole fetus together with the intact fetal membranes are
extruded out into the abdominal cavity

Figure 8: Types of cesarean section

1. First is the Classical type, wherein the incision is

longitudinal or located at the corpus. The corpus is a
fake muscular structure than can contract. Once the
patient has contractions, this scar has a very strong
tendency to separate.

2. The second one is a low transverse Cesarean section

wherein the incision is located at the lower uterine
segment

Figure 7: Secondary type of uterine rupture FROM Lecturer

PREDISPOSING FACTORS
It is important to note in the history the predisposing factors. It will
be your clue in the diagnosis of uterine rupture.
Risk factors are divided into antepartum and acquired.
In a non-pregnant uterus, what is the counterpart of the lower
uterine segment? ANSWER: It is the isthmus, which is not a
muscular portion of the uterus. This has a lesser tendency to
rupture.

ANTEPARTUM
Surgery involving the myometrium
• Cesarean delivery
• Previous repair of the uterine rupture
• Myomectomy
• Deep cornual resection of interstitial Ectopic
[pregnancy]
• Metroplasty
• Hysteroscopy

1. CESAREAN DELIVERY

FROM Lecturer Figure 9: Previous cesarean section. This is a case of a

The scar may not be adequately repaired or the patient underwent previous cesarean section which upon opening revealed a
prolonged labor before consult was made. So, for our case, in our glistening membrane on the area of the CS scar. This is a
history, if it be recalled that there was a prior cesarean section. uterine dehiscence of a previous CS scar.
Another important data in our history is the interval of the first
pregnancy to the present. The previous pregnancy is less than 18
months or to be exact is one year only. So, the integrity of the scar
at this time may be questionable

3/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
2. REPAIR OF A PREVIOUS UTERINE RUPTURE
• A uterine dehiscence or a rupture of a previous CS with
a repair, has a greater chance of a repeat rupture. This
occurs about 1 to 2 weeks early of the previous event.

Figure 12. Cornual ectopic pregnancy

Figure 10. Rupture of a previous uterine rupture
4. METROPLASTY
3. DEEP CORNUAL RESECTION OF INTERNSTITIAL
ECTOPIC PREGNANCY • This is done to a uterus with a congenital anomaly.

• There are several types of ectopic pregnancy

o Ampullary
o Cervical
o Cornual – focusing on cornual ectopic
pregnancy which is shown in the encircled
picture (figure 11). The procedure is to make
deep incision involving the myometrium near
the lumen of the fallopian tube inside the uterine
cavity, this will create a scar that may be prone Figure 13. Metroplasty of Bicornate uterus with left and right
to rupture. hemicornum. (R) Shows the uterus after metroplasty with scars
o Interstitial and adhesions marking the previous incisions. These lesions are
also prone to rupture.

5. HYSTEROSCOPIC PROCEDURE

Figure 14: Hysteroscopic procedure.

• This procedure is done visualizing the inner uterine
cavity wherein a resection or the removal of the
endometrial polyp or submucous myoma is done.
• When the portion of myometrium is included during the
resection this may also create a weakness in the uterine
wall. This is done transvaginal.
Figure 11. Types of Ectopic Pregnancy

4/23
OB-GYNE: III: Obstetric Hemorrhage
6. COINCIDENTAL TRAUMA
• Abortion with curettage beyond myometrium
o same condition may apply with hysteroscopy; a
portion of myometrial layer may be included
during the curettage.
• Vehicular trauma
o one would note in your history that the patient
figured in a vehicular accident. The countercoup
mechanism of the trauma may be applicable to
the patient, wherein the rupture may occur at the
posterior uterine wall.
Figure 15. Vehicular trauma in uterine rupture
CONGENITAL
• Occurrence of pregnancy in an underdeveloped horn.
Figure 16: Rudimentary horn
FROM Lecturer
Pregnancy may develop in the unprepared congenital lesions like
unicornuate uterus, and pregnancy may develop in the
rudimentary horn. But pregnancy year cannot be supported during
the advancing gestation and most likely may resort to uterine
rupture even in the early gestation.
MODULE 16 TRANS 3
ACQUIRED
• 2nd major type
• Includes:
o Accrete Syndromes
o Presence of Large Myoma (Myoma Uteri)
o Presence of Gestational Trophoblastic
Neoplasia
1. ACCRETE SYNDROMES
• Accrete syndromes or Morbidity Adherent placenta
Figure 17. In accrete syndromes the placenta has developed
beyond the myometrium up to or beyond the serosa.
Figure 18. Sonographically, accrete syndromes can be
diagnosed by some distinct features like presence of
vascularities overlying the placenta. In the scan there are a lot of
colors which represent the arteries and the veins. The uterus will
present with prominent vessels in a thinned out area with the
placenta underneath.
2. PRESENCE OF LARGE MYOMA (MYOMA UTERI)
• For very large myoma, the myoma doesn’t go along with
the myometrial contraction. In the interface of the
junction of the myoma and the normal myometrium
creates a difference in the tension.
• Rupture may happen even antepartum or during labor.
Figure 19. Myoma Uteri
5/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

Figure 20. Sonography (L) and gross (R) myoma uteri.

Figure 22. ECG. Bradycardia HR-60bpm

3. PRESENCE OF GESTATIONAL TROPHOBLASTIC
NEOPLASIA

DIAGNOSIS

• A high index of suspicion FROM Lecturer

o Based on a good clinical history about previous
delivery and uterine operations may strongly During cadiotocogram, there will be signs of fetal distress. A non-
reassuring fetal heart rate pattern maybe recognized. Initially, from
point to the development of uterine rupture.
a normal heart rate of 120-160bpm to severe fetal heart rate
o During internal examination, the presenting part
deceleration pattern may be present which gradually may
is not appreciated transform into a prolonged bradycardia, then finally undetectable
heart rate. There will be cessation of uterine contractions. See the
left most arrow in Figure 22. The uterus cannot be anymore
palpated abdominally
FROM Lecturer
• Feto-maternal compromise
Four our case, the patient felt a severe pain. A repeat IE revealed
absence of the presenting part (big arrow in figure 21) from the
station of +4, the presenting part becomes floating, or cannot be
digitally examined. The fetus with the uterine contents may be totally
or partially extruded out in the abdominal cavity. FROM Lecturer

Before the occurrence circulatory collapse in a gravid patient the

maternal tachycardia and hypovolemia will be noted. Even if there
is no bleeding from the vagina because of the hemorrhage that will
occur within the abdominal cavity otherwise the condition maybe
presents with profuse vaginal bleeding.

The outcome of the baby is usually not good there is an increase

perinatal morbidity or mortality and sometimes if the fetus survives
there might be a neurological deficit due to prolonged hypoxia.

Figure 21. Absence of presenting part MANAGEMENT

• Laparotomy- deliver
• Non-Reassuring fetal heart rate pattern o (Immediate) Laparotomy or opening the
• Loss of uterine contraction abdomen requires very quick decision to deliver
the baby once a uterine rupture is recognized.
o It should be less than 17 minutes.
• Repair/hysterectomy
o for uterine preservation for patients with low parity
and young. If the rupture can be repairable once
the degree of rupture has been assessed, do
hysterorrhapy.
o Hysterectomy can be done in multiple gravidas if
the patient has completed his reproductive
career.

6/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
• Replacement of blood loss
o correction of anemia, due to acute blood loss, by
blood transfusion of the necessary blood
components is always part of the management.

KEY POINTS
• A good clinical history and a complete physical
examination must be done on the patient.
• High index of suspicion
o Support from the sonography and other ancillary
procedures like the cardiotocogram may be requested
• The immediate decision to deliver the fetus must be
taken into consideration to save the baby and the mother
from adverse outcomes.
o Note: Know the predisposing factors and have the Figure 23. Types of Abruptio Placenta
proper timing to refer the patient to a specialist.
TYPES OF HEMORRHAGE
PLACENTA ABRUPTIO • External
o Blood is extruded out of the uterus or the vagina
INTRODUCTION o Bleeding insinuates
The incidence of abruptio placenta remains the same despite the
• Concealed
decrease of fetal deaths from all other causes. The perinatal o Blood is retained between the placental plate and
mortality rate of abruptio placenta is higher than the combined
uterine wall
perinatal rates in the general population.
o Does not escape out
o Seen less commonly

CASE SCENARIO

• 24-year-old G1P0
• Full term
• Hypogastric pain
• VS – 170/110 mmHg, FHT not appreciated
• Abdominal findings: (+) tenderness, strong,
contractions q 1-2 min
• IE: cervix is 1-2 cm dilated, 50% effaced, cephalic, (+)
BOW, station 0 with no bleeding
We have a case of 24-year-old G1P0, term pregnancy who
complains of severe hypogastric pain. Her blood pressure is
170/110 mmHg. Fetal Heart Tone was not appreciated.
Contractions occurred every 1-2 min, strong, lasting for 60
seconds. Internal examination revealed cervix was soft 1-2
cm anterior, uneffaced or 2.5 cm long, cephalic in
presentation, intact bag of water, station 0 with no bleeding.
Figure 24. Type of Hemorrhage
(L) External hemorrhage; (R) Concealed hemorrhage
PATHOLOGY
• It is initiated by the rupture of the spiral artery to cause
hemorrhage in the decidua basalis.
• It is followed by the formation of the retroplacental clot.
• It may separate the decidua basalis from the myometrium
that may happen at the periphery or at the central portion of
the placenta.
• Lastly, the retroplacental hematoma compresses the
placental plate.

PLACENTA ABRUPTIO
Placenta Abruptio is the separation of the placenta from its
normal implantation before the delivery of the fetus.

CLASSIFICATION
• Partial
o Portion or some of the cotyledons are detached.
• Complete/Total
o Entire placenta is separated

Figure 3. Pathogenesis of Abruptio Placenta

7/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
severe, the formation of the blood clot, it will entirely
separate the attachment of the placenta and from
the uterine cavity it will compress outwards the
placenta until it detaches out into the cervix and out
into the vaginal vault.

• Macro view of placental separation

o Myometrium retraction of placental surface
forces blood out into the decidua basalis
placenta sheared off of its attachment
o The process of abruptio usually coincides when there
is a condition which promotes myometrial contraction.
o There will be a retraction of the placental surface since
there will be a maintained site of the permanently
positioned placenta (because of the immovability of
Figure 4. Pathogenesis of Abruptio Placenta placental plate) while there is decreasing site on the
First is the rupture of the spiral artery then there is formation of the myometrium (since the myometrium can retract or
retroplacental clot. The retroplacental clot separates at the decidua expand during myometrial contraction).
basalis from the myometrium and at one point in time the clot can now
compress the placental site or the placental bed.
CLASSIFICATION: BASED ON SEVERITY
• In 2019, the various classification of abruptio placenta
was proposed based on severity.

FROM William’s Obstetrics Table 1. Classification of Abruptio Placenta

1. Discovery of blood Class 0
• Etiopathogenesis clot Asymptomatic
o Partial or total separation of the placenta from the 2. Diagnosis is made
implantation site before delivery. retrospectively
o Latin term aburptio placentae.
o Symptoms may be absent at early stages.
o Initiated by hemorrhage into the decidua basalis. The
1. No sign or small Class 1
decidua basalis then splits, leaving a thin layer
amount of vaginal Mild
adhered to the myometrium. Consequently, the
bleeding
process begins as a decidual hematoma and expands
2. Slight uterine
to cause separation and compression of the adjacent
tenderness
placenta. Inciting causes of many cases have been
3. Maternal BP and HR
posited. The phenomenon of impaired trophoblastic
are normal
invasion with subsequent atherosis is related in some
4. No signs of fetal
cases of preeclampsia complicated by abruption
distress
(Bronsens, 2011).
o Inflammation or infection may be contributory 1. No sign or with a Class 2
(Mhatre,2016; Nath,2017). moderate amount of Moderate
o Histological finding cannot be used to determine timing vaginal bleeding
of the abruption (Chen, 2017) 2. Significant uterine
tenderness w/ tetanic
contractions
3. Maternal BP and HR
are normal
4. Evidence of Fetal
FROM 2021 distress
(same lecturer) 5. Hypofibrinogenemia
1. No sign to heavy Class 3
• Process of abruptio amount of vaginal Severe
o Rupture of spinal artery Hematoma (or a blood bleeding
clot) Separation Compression 2. Tetanic contractions/
o It will take some time to create a blood clot. If it is board-like rigidity
very recent you will not see any depression of the 3. Maternal hypovolemic
cotyledon (on the maternal side). But if it is shock
prolonged then you will see a depression on the 4. Hypofibrinogenemia
cotyledon. That’s why abruption is actually after a and coagulopathy
few hours of the formation of the blood clot. If it’s so 5. Fetal death

8/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

Past Trans
(same lecturer)

• Vaginal bleeding – Class I is None to Mild

o None – concealed type
o Mild – may be an external type of abruption
• Uterine tenderness
o Difficult to monitor pregnant women with labor
pains or uterine contractions. You must have a few
minutes to observe the patient to notice if the
patient is at the peak, onset, or the end of
contraction or in noncontracting status Figure 25. Friedman’s curve
Labor course divided functionally on the basis of dilatation and descent
o Contracting state: Filipinos can tolerate up to 5 cm
curves. (William’s Obstetrics 24th Ed.)
cervical dilatation (with discomfort, tolerable pain)
o For some with as early as 2 cm dilatation, pain RISK FACTORS
grade is at 8 or 9/10. Pain is intolerable It is important to know the risk factors present in the patient. This
o For moderate to severe: the slightest touch is might give a lead in the working impression of the case.
already painful and then goes into relaxation
o In normal early labor, 1-2 cm dilatation cannot feel • Prior Abruptio
any pain and the patient is comfortable. If you find o A history of a previous abruption might be a
a patient with pain at 1cm, you may suspect guide. This occurs 1-3 weeks early than the
abruptio because 1 cm is not compatible with a first abruption.
severe degree of pain. You have to think about the • Increased parity and maternal age
congruence of dilatation and degree of pain. o They are likely to experience more than the
o Most painful is usually at 8-10cm and in younger women
Friedman’s curve, the fetus must be descended on
• Preeclampsia
the pelvic cavity already at 8cm. The pain is more o There is an increase pressure noted in the
than the early part of labor. inferior trophoblastic invasion in the case of
o Very tender – abdomen does not relax. It has a preeclampsia. The spiral arteries elicit medial
board-like rigidity on palpation layer contractions.
o Contractions only lasts for seconds. Average: 50-
• Chronic hypertension
60 seconds, longest may be 90 seconds
o There is a greater risk because of the reduced
o After, there are periods of relaxation for blood to
intravascular fluid volume on top of the
flow into the uterine artery to go into the placenta. hypertension.
For abruptio placenta, it is very firm all throughout
• Chorioamnionitis
the abdomen.
o Inflammation or infection leads to weakened
o How to know if firm or not: Firm – feel the knees or
membranes.
any bony prominence; Soft – depress the cheek or
• Preterm/premature rupture of membranes
deltoid area
o Tensile strength of the membranes is
• Maternal Vital signs
decreased
o Class III: the patient will be pale, BP will drop below
• Multiple gestation
80, and patient cannot be talked to. Before, there
o The principles of uterine stretch leads to
will be a period of restlessness. This happens
activation of contraction associated proteins or
when patients go into shock, restless -> becomes
CAP. Which may also lead to uterine activation
unconscious (because the patient is hypotensive).
and cervical ripening.
This condition might be irreversible at this time.
• Low birthweight
• Presence of coagulopathy
• Polyhydramnios
o Normal fibrinogen levels: 150-350 mg/dL
o Also uses the principles of uterine stretch.
o Abruptio: factors would be less than 150 mg/dL
• Cigarette smoking
o Class III- fibrinogen levels are lower. The
o There is an association BUT mechanism is
coagulopathy that could happen is DIC.
unknown.
• Fetal Status
o Maybe it is due to the decreased placental
o Class I: no fetal distress or normal HR
blood.
o Class II: fetal distress or w/ tachycardia
o Nicotine has vasoconstrictive effects on
o Class III: fetus might be dead already
uterine and umbilical arteries as well as
increase in carboxyhemoglobin concentration
that hinders oxygenation.

9/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
o Micro infarctions may develop in the placenta 2. Fibrinogen level
leading to formation of thrombus or necrotic 3. D-dimer
foci. 4. Cardiotocography
o Evidences of hypoxia such as fibrin and 5. Blood work-up
thrombus were demonstrated by Kanitzky et al
during the 2008. ULTRASOUND
• Cocaine use • Limited
o Produces dose dependent hypertension and • What would you like to search in the ultrasound?
uterine vasoconstriction. o We have to look for the thickened area in the
• Presence of myoma if unusually large and located at placenta or hypoechoic area in the placenta which
the submucous area can cause a disparity in the may represent the retroplacental clot
contraction of the uterus on both sides of the opposite • Sonographic findings:
sides of the myoma. o Thicker placenta
o Hypoechoic areas
SIGNS AND SYMPTOMS

• Pregnant women present with sudden onset of abdominal

pain not compatible with the late stage of labor on
examination uterine contractions (hypertonic) are tetanic
and very strong and they do not attain the baseline non
conducting State.
• There is uterine tenderness upon palpation of the
abdomen. Internal examination usually presents an early
dilatation finding.
• A lot of cases have a non-reassuring fetal status. Which
means either the fetus could be tachycardic and/or
extremely bradycardic.
• There can be also vaginal bleeding where patient may
appear pale representing circulatory compromised.
Figure 27. Sonographic findings
DIAGNOSIS This picture shows the findings in the ultrasound of a recent abruption in
which you would see a thicker placenta. There is a darker than usual
area around that area (YELLOW CIRCLE) in which we call that a
• The diagnosis for severe type of abruption is not difficult the hypoechoic area which may represent the retro placental hematoma.
presence of sudden abdominal pain, uterine tenderness
and board like rigidity of the abdomen are common. FIBRINOGEN LEVEL
There are also possibilities of frequent uterine • (301-696 mg/dl) late
contractions, non-reassuring fetal status/ fetal
• You can have a lower amount of fibrinogen level to as low
distress.
as 150 or 250 mg/dl because the normal value in the third
• The profuse vaginal bleeding is common to others but in the trimester of pregnancy is 300-600 mg/dl. This could also be
instances of mild abruption with minimal symptoms the a late finding.
diagnosis is by exclusion.
D-DIMER
• This may also confirm your abruptio placenta

CARDIOTOCOGRAPHY
• Late
• You would be able to appreciate the non-reassuring fetal
heart rate pattern such as tachycardia or bradycardia
• Cardiotocogram
o Fetus showing bradycardia to loss of fetal heart rate

Figure 26. Placental Abruption

DIAGNOSTIC MODALITIES

Aside from a thorough history, the diagnostics that may be of

value are the following:
1. Ultrasound

10/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

COMPLICATIONS
CONSUMPTIVE COAGULOPATHY
• Since there is a release of thromboplastin into the maternal
circulation, one of the complications is consumptive
coagulopathy
• Causes consumption of procoagulant factors, leading to the
activation of the clotting
• Increase levels of D-dimers
• Decrease levels of fibrinogen, or higher levels of fibrinogen
products

END-ORGAN FAILURE
• Acute kidney injury (AKI)
Figure 28. Cardiotocogram o Due to severe hypotension, wherein the blood supply
This picture shows the cardiotocogram findings. The result of the fetus to the important organs are compromised
is showing bradycardia to even the loss of the fetal heart rate • Sheehan’s syndrome
o Hypoperfusion of the pituitary
BLOOD WORK-UP o Loss of axillary and pubic hair
• CBC o Difficulty to breastfeed
• Blood typing o Episodes of oligomenorrhea to amenorrhea
• Prothrombin time o Weight gain
• Activated partial thromboplastin time
• Other blood parameters COUVELAIRE UTERUS
• Uterus is visualized with a seepage of extravasated blood
into the myometrium, fallopian tubes, ovaries, and broad
ligament serosa
• Not an indication for hysterectomy
FROM Williams Obstetrics 24th ed.

• Unfortunately, there are no laboratory tests or other

diagnostic methods to accurately confirm lesser
degrees of placental separation.
• Sonography has limited use because the placenta and
fresh clots have similar imaging characteristics.
• Negative findings with sonographic examination do not
exclude placental abruption.
• Conversely, magnetic resonance (MR) imaging is highly
sensitive for placental abruption, and if knowledge of
this would change management, then it should be
considered. Figure 30. Couvelaire Uterus
• With abruption, intravascular coagulation is almost
universal. Thus, elevated serum levels of D-dimers may MATERNAL AND FETAL MORTALITY
be suggestive, but it has not been adequately tested.
• Hypovolemic shock, if severe enough, may cause
maternal and fetal mortality

William’s Obstetrics 24th ed.

Consumptive coagulopathy
• An important consequence of intravascular coagulation
is the activation of plasminogen to plasmin, which lyses
fibrin microemboli to maintain microcirculatory patency.
With placental abruption severe enough to kill the fetus,
there are always pathological levels of fibrinogen–fibrin
Figure 29. A recently delivered placenta wherein there is still an degradation products and d-dimers in maternal serum.
attached retroplacental clot (labelled C) on the maternal side of the
placenta

11/23
OB-GYNE: III: Obstetric Hemorrhage
Acute Kidney Failure
• In obstetrics, it is most commonly seen in cases of
severe placental abruption in which treatment of
hypovolemia is delayed or incomplete.
Sheehan’s Syndrome
• Rarely, severe intrapartum or early postpartum
hemorrhage is followed by pituitary failure.
• Findings include failure of lactation, amenorrhea, breast
atrophy, loss of pubic hair and axillary hair,
hypothyroidism, and adrenal cortical insufficiency.
Couvelaire Uterus
• At the time of cesarean delivery, it is not uncommon to
find widespread extravasation of blood into the uterine
musculature and beneath the serosa.
• Effusions of blood are also seen beneath the tubal
serosa, between the leaves of the broad ligaments, in
the substance of the ovaries, and free in the peritoneal
cavity.
Hypovolemic Shock
• Caused by maternal blood loss
• Massive blood loss and shock can develop with a
concealed abruption.
• Prompt treatment of hypotension with crystalloid and
blood infusion will restore vital signs to normal and
reverse oliguria from inadequate renal perfusion.
MANAGEMENT
• Depends on:
o How advance the labor is
o Age of Gestation
o Maternal indication
o Fetal Indication
§ Whether there is compromise or not
§ Whether the pregnancy can be prolonged
FROM William’s Obstetrics 24th ed.
• Treatment of the woman with a placental abruption
varies depending primarily on her clinical condition, the
gestational age, and the amount of associated
hemorrhage.
• With a living viable-size fetus and with vaginal delivery
not imminent, emergency cesarean delivery is chosen
by most.
EARLY AMNIOTOMY
• When seen early, this procedure has always championed
the initial management of placental abruption.
o Advantages:
§ Decreases the intrauterine pressure
§ Better spiral artery compression
MODULE 16 TRANS 3
• Useful decrease in implantation site
bleeding
§ There is membrane rupture which may hasten
delivery
§ Achieves better uterine contraction
§ Reduces thromboplastin release into the
maternal circulation
IMMEDIATE DELIVERY
• If the fetus is still alive, immediate delivery should be done.
o In early labor, cesarean might be done
o In cases of possible imminent delivery, may wait for
vaginal delivery
o In cases of non-viable fetus, (or not alive), might wait
for vaginal delivery, especially when the mother is
stable.
Williams Obstetrics 24th ed.
• Cesarean Delivery. The compromised fetus is usually
best served by cesarean delivery, and the speed of
response is an important factor in perinatal outcomes.
• If the fetus has died, then vaginal delivery is usually
preferred.
• Placental implantation site depends primarily on
myometrial contraction and not blood coagulability.
Thus, after vaginal delivery, uterotonic agents and
uterine massage are used to stimulate myometrial
contractions.
• There are exceptions for which vaginal delivery may not
be preferable even if the fetus is dead. For example, in
some cases, hemorrhage is so brisk that it cannot be
successfully managed even by vigorous blood
replacement.
• Obstetrical complications that prohibit vaginal delivery
such as a term fetus with a transverse lie are another
example.
REPLACEMENT OF BLOOD LOSS
• Replacement of blood loss can be done by using plasma
expanders.
FROM Williams Obstetrics 24th ed.
• Experiences indicate that maternal outcome depends
on the diligence with which adequate fluid and blood
replacement therapy are pursued rather than on the
interval to delivery.
• Women with severe abruption who were transfused for
18 hours or more before delivery had similar outcomes
to those in whom delivery was accomplished sooner.
12/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
PREVENT OTHER COMPLICATIONS
• There is prevention of complications (initiated by the
hypoperfusion or the hypovolemia of the patient) to avoid
FROM UpToDate
injuries to the important organs of the patient.
Placenta previa refers to the presence of placental tissue that
extends over the internal cervical os. Sequelae include the
potential for severe bleeding and preterm birth, as well as the
need for cesarean delivery.

CASE SCENARIO Placenta previa should be suspected in any pregnant woman

beyond 20 weeks of gestation who presents with vaginal
• 24-year-old G1P0 bleeding. For women who have not had a second-trimester
• Full term ultrasound examination, bleeding after 20 weeks of gestation
• Hypogastric pain should prompt sonographic determination of placental location
• VS – 170/110 mmHg, FHT not appreciated before a digital vaginal examination is performed because
• Abdominal findings: (+) tenderness, strong, palpation of the placenta can cause severe hemorrhage.
contractions q 1-2 min
• IE: cervix is 1-2 cm dilated, 50% effaced, cephalic, (+) CASE
BOW, station 0 with no bleeding • 35 years old G2P1
• 32 weeks AOG
What will be the management for this case? First what will • Vaginal spotting
you do? Since it is 1-2 cm dilated and then you do not know • Only 1 prenatal checkup during 1st trimester
if the fetal heart tone can be appreciated so you do • Smoker (1-2 sticks per day)
amniotomy, so you release intrauterine pressure. • Previous CS
• Bleeding noted upon waking up
What will be expected if you do amniotomy? • Normal vital signs
• You will note the character of amniotic fluid. • FHT 150bpm
• If it’s clear maybe the baby has not yet pass out • No uterine contractions
meconium so maybe the baby might be okay. • Reactive cardiotocogram
• It could be stained, or it could be blood tinged • Ultrasound revealed placenta previa
because of the retroplacental clot mixed with the
amniotic fluid so it depends on what is the character
of the amniotic fluid.

Once you release the intrauterine pressure you might be able

to appreciate the real status of the baby so will there be a
fetal heart tone or no fetal heart tone? If there is a fetal heart
tone what will you do?
• Since this is only 1-2 cm, you’ll do cesarean
section.
• If the case is about 9 or 10cm dilatation station plus
3 you just wait for vaginal delivery.
With the blood pressure of 170/110 mmHg you might give
antihypertensive drugs and magnesium sulfate.
FROM the Lecturer
A cardiotocogram was done and interpreted as with no
deceleration, no contractions but with acceleration.
PLACENTA PREVIA
• Implanted in the lower segment, over or very near the
internal cervical os
• Expanded 4-5cm nearing 3rd trimester

PLACENTA PREVIA
Before the advent of sonography, the diagnosis of placenta
previa is suspected among patients with vaginal bleeding, and as
consequent finding a placenta during actual internal examination
leading to torrential blood loss and greater risk of maternal and
fetal death.

Others practice a double set-up, wherein the patient is set-up at

the operating room, and will undergo internal examination, then
if it turns out that the patient has previa, cesarean section will
push through.

Figure 31. Placenta previa

13/23