Sangrados de la 2ª.

Mitad del Embarazo

Dr. Meraz MM
Profesor e Investigador
ESM IPN
octubre del 2014
 Hemorragia Obstetrica

 Hemorragia durante la primera mitad del embarazo:

 Aborto
 Embarazo ectópico
 Embarazo molar
 Hemorragia Obstetrica

 Hemorragia durante la segunda mitad del embarazo:

 DPPNI
 IBP
 Hipotonía Uterina
 Laceraciones del canal del parto
 Placenta acreta, increta, percreta
 Ruptura Uterina
 TABLE 35-1 Causes of 763 Pregnancy-related Deaths Due
to Hemorrhage

 Causes of Hemorrhage and Number (%)

 Placental abruption 141 (19)
 Laceration/uterine rupture 125 (16)
 Uterine atony 115 (15)
 Coagulopathies 108 (14)
 Placenta previa 50 (7)
 Uterine bleeding 47 (6)
 Placenta accreta/increta/percreta 44 (6)
 Retained placenta 32 (4)
 Obstetrical Hemorrhage

Placenta acreta o adherente: cuando el tejido placentario (vellosidades

coriales) contactan con el musculo uterino.

Placenta increta o penetrante: cuando el tejido placentario penetra en el

miometrio.

Placenta percreta o perforante: cuando el tejido placentario atraviesa

completamente el miometrio hasta la serosa y a veces hasta órganos
adyacentes como la vejiga.
Clasificación de la placenta (por
grado de penetración):

 Placenta Acreta (80%): la vellosidad uterina

está adherida al miometrio sin penetrar en él.

 Placenta Increta (15%): penetra el miometrio,

pero no lo atraviesa. La extracción produce
sacabocado.

 Placenta Percreta: atraviesa el miometrio,

pudiendo llegar al peritoneo y vejiga.
 Obstetrical Hemorrhage

 Even though hospitalization for delivery

and the availability of blood for transfusion
have dramatically reduced the maternal mortality rate,
death from hemorrhage
still remains a leading cause of maternal mortality.
Diagnostico
 Diagnostico

 La ecografía doppler a color se utiliza para identificar el

acretismo placentario
 TABLE 35-2 Conditions That Predispose to or Worsen Obstetrical
Hemorrhage
Abnormal Placentation Uterine Atony
   Placenta previa    Overdistended uterus
   Placental abruption       Large fetus
   Placenta accreta/increta/percreta       Multiple fetuses
   Ectopic pregnancy       Hydramnios
   Hydatidiform mole       Distention with clots (coágulo)

Trauma During Labor and Delivery Anesthesia or analgesia

   Episiotomy    Halogenated agents
   Complicated vaginal delivery    Conduction analgesia with hypotension
   Low- or midforceps delivery    Exhausted myometrium
   Cesarean delivery or hysterectomy       Rapid labor
   Uterine rupture—risk increased by:       Prolonged labor
      Previously scarred uterus       Oxytocin or prostaglandin stimulation
      High parity       Chorioamnionitis
      Hyperstimulation    Previous uterine atony
      Obstructed labor    Coagulation Defects—Intensify Other Causes
      Intrauterine manipulation    Placental abruption
      Midforceps rotation    Prolonged retention of dead fetus

Small Maternal Blood Volume Amnionic fluid embolism

   Small women    Saline-induced abortion
   Pregnancy hypervolemia not yet maximal    Sepsis syndrome
   Pregnancy hypervolemia constricted    Severe intravascular hemolysis
      Severe preeclampsia    Massive transfusions
      Eclampsia    Severe preeclampsia and eclampsia

Other Factors Congenital coagulopathies

   Obesity    Anticoagulant treatment      
   Native American ethnicity
   Previous postpartum hemorrhage
 ANTEPARTUM HEMORRHAGE

 PLACENTAL ABRUPTION

 Definition
 The separation of the placenta from its site of implantation before
delivery has been variously called placental abruption, abruptio
placentae, and in Great Britain, accidental hemorrhage.

 placental abruption may be total or partial.

 ANTEPARTUM HEMORRHAGE

 FIGURE 35-1. Hemorrhage from premature placental separation.

 Upper left: Extensive placental abruption but with the periphery of the
placenta and the membranes still adherent, resulting in completely
concealed hemorrhage.

 Lower: Placental abruption with the placenta detached (separada)

peripherally and with the membranes between the placenta and
cervical canal stripped from underlying decidua, allowing external
hemorrhage.

 Right: Partial placenta previa with placental separation and external

hemorrhage.
FIGURE 35-1. ANTEPARTUM HEMORRHAGE
ANTEPARTUM HEMORRHAGE
 PLACENTAL ABRUPTION

 Etiology
 The primary cause of placental abruption is unknown, but
there are several associated conditions.
 Some of these are listed in Table 35-3.
 TABLE 35-3 Risk Factors for Placental Abruption

Risk Factor Relative Risk

Increased age and parity 1.3–1.5

Preeclampsia 2.1–4.0

Chronic hypertension 1.8–3.0

Preterm ruptured membranes 2.4–4.9

Multifetal gestation 2.1

Hydramnios 2.0

Cigarette smoking 1.4–1.9

Thrombophilias 3–7

Cocaine use NA

Prior abruption 10–25

Uterine leiomyoma NA

NA = not available.
 Clinical Diagnosis
 Signs and Symptoms Determined Prospectively in 59 Women with
Abruptio Placentae Sign or SymptomFrequency (%)

 Vaginal bleeding 78
 Uterine tenderness or back pain 66
 Fetal distress 60
 Preterm labor 22
 High-frequency contractions 17
 Hypertonus 17
 Dead fetus 15
Diagnostico
USG
FIGURE 35-2. Total placental abruption with concealed
hemorrhage. The fetus is now dead.
 PLACENTAL ABRUPTION

 Consumptive Coagulopathy
 One of the most common causes of clinically significant consumptive
coagulopathy in obstetrics is placental abruption.

 Couvelaire Uterus
 There may be widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa (Fig.
( 35-5).
Fig. 35-5. Couvelaire Uterus
Fig. 35-5. Couvelaire Uterus
Fig. 35-5. Couvelaire Uterus
 PLACENTAL ABRUPTION

 FIGURE 35-5. Couvelaire uterus with total placental abruption

before cesarean delivery.
 Blood had markedly infiltrated much of the myometrium to reach the
serosa.
 After the infant was delivered and the uterus closed, the uterus
remained well contracted despite extensive extravasation of blood
into the uterine wall.
 PLACENTAL ABRUPTION

 first described by Couvelaire in the early 1900s, is now frequently

called Couvelaire uterus.

 These myometrial hemorrhages seldom (raramente) interfere with

uterine contractions sufficiently to produce severe postpartum
hemorrhage and are not an indication for hysterectomy.
 CLASIFICACION DEL DPPNI

Se clasifica de acuerdo al grado de desprendimiento:

 GRADO I: -30%, sangrado ligero, irritabilidad uterina, hipotonia
discreta, no riesgo fetal, hematoma retroplacentario.

 GRADO II: 30 a 50%, sangrado leve a moderado, irritabilidad y

contracción uterina, pulso materno acelerado, hematoma de 150 a
500 mL, sufrimiento fetal, fibirinogeno disminuido.

 GRADO III: +50%, sangrado moderado a severo, útero tetánico,

doloroso, pulso materno acelerado, hipotensión, choque, pérdida
fetal, trastornos de coagulación por fibrinógeno bajo y
trombocitopenia.
 Placenta Previa
Etiología ?????????
 Placenta Previa (PP)

Factores de riesgo
Puede estar asociada a vascularización anómala endometrial.
PP en embarazo anterior
Cesárea anterior
Cirugía uterina previa
Multiparidad
Edad avanzada
Consumo de cocaína, tabaquismo.
 PLACENTA PREVIA
 Es cuando la placenta se inserta en el segmento inferior del útero.
CLASIFICACION HGO 4 IMSS

l. Placenta Previa Central

a) Parcial: Cuando la placenta cubre en forma parcial el Orificio Cervical

Interno (OCI).

b) Total: Cuando la placenta cubre completamente el OCI.

al. Placenta Previa Marginal El borde placentario llega al margen del OCI

bl. Inserción Baja de Placenta (IBP): Cuando el borde placentario se encuentra a

menos de 2 cm del OCI.
 Placenta Previa
 Placental migration” of 0.54 cm per week in the third
trimester is reported [6].

 The distance from the internal os to the placenta for a

diagnosis of placenta previa has been arbitrarily selected as
5.8 cm, 3.0 cm and 3.5 cm by various authors [1,2,6].

 In the present study, the maximum os to placental distance

was 5.8 cm, and the results suggest that a distance of N3.5
cm from the internal os need not be considered previa.
 Placenta Previa
 References
 [1] Oppenheimer LW, Farine D, Ritchie JW, Lewinsky RM,
Telford J,Fairbanks LA. What is a low-lying placenta? Am J
Obstet Gynecol 1991;165:1036-8.

 [2] Dawson WB, Dumas MD, Romano WM, Gagnon R,

Gratton RJ, Mowbray RD. Translabial ultrasonography and
placenta praevia:does measurement of the os–placenta
distance predict outcome? J Ultrasound Med 1996;15:441-6.

 [3] Leerentveld RA, Gilberts EC, Arnold MJ, Wladimiroff JW.

Accuracy and safety of transvaginal sonographic placental
localization. Obstet Gynecol 1990;76:759-62.
 Placenta Previa
 [4] Sherman SJ, Carlson DE, Platt LD, Medearis AL.
Transvaginal ultrasound: does it help in the diagnosis of
placenta previa? Ultrasound Obstet Gynecol 1992;2:256-60.

 [5] Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B.

Placental edge to internal os distance in the late third trimester
and mode of delivery in placenta praevia. BJOG
2003;110:860-4.

 [6] Oppenheimer L, Holmes P, Simpson P, Holmes N,

Dabrowski A.Diagnosis of low-lying placenta: can migration in
the third trimester predict outcome? Ultrasound Obstet
Gynecol 2001;18:100-2.
Ill la lb
IBP Placenta Previa Placenta Previa
Central Parcial Central Total
classification
Diagnostico
 Placenta Previa

 Diagnostico:
 Clínico: sangrado t/v en la 2ª mitad del embarazo, rojo rutilante, sin
coágulos, “sangrado fresco” y NO doloroso.

 Sin actividad uterina

 Feto con compromiso por hipoxia y SFA

 Gabinete: USG abdominal o t/v

Placenta Previa
Placenta Previa
 Tratamiento
Placenta Previa
 Paciente con stv leve-moderado-severo: SE HOSPITALIZA
 Paciente sin stv manejo ambulatorio CON INDICACIONES DE
URGENCIAS
 Laboratorio exámenes prenatales, TP, TPT, plaquetas, cruzar y tipar
 Edad gestacional y localización placentaria por USG T/V
 Reposo relativo o absoluto
 Inductores de madurez pulmonar de la semana 28 a 33 DG
 Tratamiento
Placenta Previa
 Amniocentesis a la 34ª SDG para valorar madurez pulmonar
 Hematínicos
 USG t/v seriado (mensual o antes)
 PSS semanal o antes
 PBF cada 2 semanas o antes
 Tratamiento
Placenta Previa
 Paciente con stv leve-moderado-severo:

 “Código Rojo”
 Evitar Tacto Vaginal y Especuloscopia
 Reposo absoluto
 APP Indometacina 100 mg vía rectal cada 12 hrs hasta 4 dosis (antes
de la semana 32)
 Nifedipina (Adalat) 20 mg VO cada 8 hrs
 Tratamiento
Placenta Previa

Inductores de madurez pulmonar

Corticosteroides entre la 24 a 34 SDG.

Esquema único :

Betametasona (celestone soluspan fco amp 3 mg= 1 mL)

Aplicar 2 amp (6 mg.) i.m. Cada 24 hr x 2 dosis.

Dexametasona (decadron, alin) 6 mg im c/12 hr x 4 dosis.

Amniocentesis a la 34ª SDG para valorar madurez pulmonar

Hb < 10 gr se transfunde paquete globular

 Características de la PP y el DPPNI

Característica Placenta Previa (PP) DPPNI

Dolor abdominal Ninguno Variable
Sangrado transvaginal Presente y variable Ausente o presente
FCF Normal Taquicardia inicial
Bradicardia
Defectos de la coagulación NO Asociados CID (poco
frecuente)
Infiltración hemática del NO SI. Útero de Couvelaire
miometrio
Actividad Uterina Normal Dolorosa.
(contracciones)
Antecedentes asociados Ninguno Traumatismo
abdominal
Estados Hipertensivos
Asociados al Embarazo
Bibliografía
1. Normas y Procedimientos en Obstetricia. Hospital de Gineco-
Obstetricia “Luis Castelazo Ayala” I.M.S.S. 2005.
2. Dewhurst’s Textbook of Obstetrics. Ed. Edmonds, London, UK.
Seventh edition 2007. McGraw-Hill
3. Obstetricia Williams 23 th edition 2009. McGraw-Hill