Download Vaginal Bleeding in Late Pregnancy

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
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Placenta Praevia
Life-threatening
Abruption
Ruptured vasa praevia
Uterine scar disruption
Cervical polyp
Bloody show
Cervicitis or cervical ectropion
Vaginal trauma
Cervical cancer
Prevalence of Placenta Praevia
• 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
Praevia
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Previous caesarean delivery
Previous uterine instrumentation
High parity
Advance maternal age
Smoking
Multiple gestation
Morbidity and Placenta
Praevia
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Maternal haemorrhage
Operative delivery complications
Transfusion
Placenta accreta, increta or percreta
Prematurity
Patient History – Placenta
Praevia
• Painless bleeding
– 2nd or 3rd trimester, or at term
– Often following intercourse
– May have preterm contractions
• “Sentinel bleed”
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Physical Exam – Placenta
Praevia
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 Praevia
• Haematocrit or complete blood count
• Blood type and Rh
• Coagulation tests
Ultrasound – Placenta Praevia
• Can confirm diagnosis
• Full bladder can create false appearance
of anterior praevia
• Presenting part may overshadow
posterior praevia
• Transvaginal scan can locate placental
edge and internal os
Treatment – Placenta Praevia
• With no active bleeding
– Expectant management
– No intercourse, digital exams
• With late pregnancy bleeding
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Assess overall status, circulatory stability
Full dose Rhogam if RhConsider maternal transfer if premature
May need corticosteroids, tocolysis,
amniocentesis
Double Set-Up Exam
• Appropriate only in marginal praevia with
vertex presentation
• Palpation of placental edge and fetal head
with set up for immediate surgery
• Caesarean delivery under regional
anaesthesia if:
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complete praevia
fetal head no engaged
non-reassuring tracing
brisk or persistent bleeding
mature foetus
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
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hypertensive diseases of pregnancy
smoking or substance abuse (e.g. cocaine)
trauma
overdistension 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 inculde 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
– “Couverlaire” 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 blood 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 test
• Maternal abdomen
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Fundal height
Leopold’s 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
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Complete blood count
Type and Rh
Coagulation tests
Kleihauer-Betke not diagnostic, but
useful to determine Rhogam dose
• Preeclampsia labs, if indicated
• Consider using drug screen
Sher’s Classification Abruption
Grade I
mild, often retroplacental clot
identified at delivery
Grade II
tense, tender abdomen and live fetus
Grade III with fetal demise
III A
III B
- without coagulopathy (2/3)
- with coagulopathy (1/3)
Treatment – Grade II
Abruption
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Assess fetal and maternal stability
Amniotomy
IUPC to detect elevated uterine tone
Expeditious operative or vaginal
delivery
• Maintain urine output > 30cc/hr and
haematocrit > 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 haemorrhage
Coagulopathy with Abruption
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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 caesarean incision most common
reason for scar disruption
• Other causes: previous uterine curettage
or perforation, inappropriate oxytocin
usage, trauma
Risk Factors – Uterine
Rupture
• pervious uterine
surgery
• congenital uterine
anomaly
• uterine
overdistension
• gestational
trophoblastic
neoplasia
• adenomyosis
• fetal anomaly
• vigorous uterine
pressure
• difficult placental
removal
• placenta increta or
percreta
Morbidity with Uterine
Rupture
• Maternal
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haemorrhage with anaemia
bladder rupture
hysterectomy
maternal death
• Fetal
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respiratory distress
hypoxia
acidaemia
neonatal death
Patient History – Uterine
Rupture
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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 elevate uterine wall
– MRI to confirm possible placenta accreta
• Treatment
– Asymptomatic scar disruption – expectant
management
– Symptomatic rupture – emergent caesarean
delivery
Vasa Praevia
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Rarest cause of haemorrhage
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
– colour doppler ultrasound
– palpate vessels during vaginal examination
Diagnostic Tests – Vasa
Praevia
• Apt test – based on colorimetric
response of fetal haemoglobin
• Wright stain of vaginal bleed – for
nucleated RBCs
• Kleihauer-Betke test – 2 hour delay
prohibits its use
Management – Vasa Praevia
• Immediate caesarean delivery if fetal
hear rate non-assuring
• 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