Download bleeding during pregnancy should be investigated by examination

Zareh.F.MD
All bleeding during
pregnancy should be
investigated by examination
and imaging studies
• 1/4 of women who
bleed at 14-26 w
had pp or ap.
• 1/3 of pregnancy with vag
bleeding after 26 w had
poor outcome.
Unexplained vag.bleeding
at term must be
considered for
delivery.
etiologies
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Placenta previa
Placenta abruption
Vasa previa
Cervical lesions
(carcinoma,polyps)
• Vaginal laceration
(trauma,carcinoma)
• Uterine rupture or dehiscence
Placenta previa
incidece
• 0.5-1% of all pregnancies
• Fatal 0.03% of cases
• Incidence in multipar :1/20
• Incidence in nulipar : 1/1500
difinition
• Dillated cervix:
complete previa
partial previa
marginal previa
low lying
• Closed cervix:
complete
partial / marginal
<1 cm from int.os
1-2 cm from int.os
>2 cm from int.os
pathophysiology
• Abnormal endometrial tissue
less favorable location for
implantation:
poor vascularization
thinner myometrium
• Uterine trauma from c/s (6 fold)
Risk factors
• Perior c/s
• Black , minority
• Older women >35 y
• High gravidity & parity
• Cigarette smoking 2.6-4.4 fold
• Previous abortion
diagnosis
• Abdominal sonography
misdiagnosis :
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full distended bladder
lower ut segment contraction
pp in 2nd trimester 90-95% resolved
by the 3rd trimester (but no central)
3 dimensional scanning
transvaginal scan
Transperineal scan
Double set up examination
MSAFP>2 MoM
Clinical features
• Asymptomatic
• Vaginal bleeding
variable
intermittent
red to brownish
maternal origin
• the
fetus usually not in jeopardy
complication
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•
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Hospital stay
c/s
Abruptio placenta
Malpresentation
Post partum hemorrhage
Growth restriction
Placenta accreta
pp+previous c/s10-35% +multiple c/s 60-65%
• Coagulation defect
Other complications
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•
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•
A.T.N
Sheehan syndrome
Maternal mortality<1%
Perinatal mortality <5%
outcome
• IUGR ?
• Preterm birth
• Congenital anomaly
• Respiratory distress syndrome
• Anemia
• Recurrence rate 2-3%(6-8 fold)
management
no bleeding
• 2nd trimester
intercourse avoid
usual activity
repeat sonography
• 3rd trimester
decrease physical activity
travel away from home
prolonged bed rest
management
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with Bleeding
Evaluation of the patient
Fetal status
IV fluid
Blood cross match
RHoGam if necessary
Steroid if 24-34 W
Delivery after 34-36W
management
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Severe hemorrhage
Medical team for immediate
delivery
2 large bore IV line
Blood cross match
Foley catheter
Coagulation panel
Continuous Fetal monitoring
delivery
Premature separation
of placenta.
• 0.5-1% of deliveries
• Perinatal mortality is 20-25%
• Preterm birth is 40%
• Cause of 15% of stillbirth
Definition
Preplacental or subamniotic
retroplacental
Risk factors
Socioeconomic:
• High parity
• low education
• infertility
Risk factors
Uterine:
• ut.malformation
• ut.septum
• Myoma
Risk factors
Medical:
• Diabete pregestational
• Hypertension _chronic&gestational
• PROM with chorioamnionitis
Risk factors
Thrombophilias
• Antiphospholipid syndrome
• Prothrombin 20210A mutation
• Hyperhomocysteinemia
• Factor V leiden mutation
• Activated protein C resistance
• Protein C and S deficiency
• dysfibrinogenemia
Risk factor
iatrogenic
• Sudden decompression(amniocentesis)
• External cephalic version
• Cigarette smoking
• Cocaine abuse
• Blant trauma
• Heavy physical activity
pathophysiology
• Blunt trauma : forceful
shearing effort
• Majority of other case : cell death
(apoptosis) induced through
ischemia ,hypoxia.
• Thrombophilia : thrombose in
decidua basalis
• Chorioamnionitis: infectious agents
(lipopolysacharids & endotoxins)
cytokines,superoxide
ischemia and hypoixia
Pathophysiology
cont.
• Nicotine(cigarete) and cocaine
vasoconstriction
ischemia
placental
lesions(infarction,oxidative
stress,appoptosis and necrosis)
• Circumvalate placenta(chorion
leave don’t insert at the edge of
placenta)
A.P,IUGR,PROM,preterm labor
diagnosis
Clinically
• vaginal bleeding
• Uterine pain
• tetanic contraction
• fetal heart abnormality
sinusoidal pattern
diagnosis
Paraclinic
• Ultrasound
• MRI
• Doppler
• Biochemical test
Unexplained elevated of MSAFP
AP>10 fold
Preterm labor+AFP>2MoM = AP (67%)
Preterm labor+AFP>2MoM+bleeding= AP
(100%)
HCG
Inhibin A
Fetal Hb
management
• Marginal Abruptio
hospitalize a patient with any
bleeding after fetal viability
• Large retroplacental
usually require acute &
aggressive management
Large bleeding
• Continues fetal monitoring
• Foley catheter
• Frequent maternal v/s
• Steroid therapy (24-34w ,
membrane intact)
• Folic acid 1mg ,vit B12 ,vit B6
discharge
• Mild bleeding :
2-5 days without any further bleeding
• Large bleeding :decision is difficult
with any bleeding , pain ,
contraction
no discharge
Tocolytic use
• Now become acceptable to
consider a short course of
tocolytic therapy for:
stable patient ,
limited abruptio ,
established fetal well being,
preterm G.age
Which tocolytic
• B mimetics (terbut,ritod): mask
cardiovascular response to
volume depletion
• Ca channel blockers (nifidipine):
reduce BP
• Mgso4 : most acceptable agents
delivery
Vaginal or c/s
Depending on the:
Degree of bleeding
Presence or absence of:
Active labor
Fetal distress
complications
• c/s 50% of case
• Shock
• DIC
• Renal failure
• Couvelaire uterus
• Recurrence : 10 fold
Fetal outcome
• Mortality:
term babies 25 fold
• Prematurity: 40%
Thrombophilia defects
• Anticardiolipin antibodies
• Lupus anticoagulant
• Pr c, Pr s and antithrombin 3 deficiencies
• Factor v leiden “activated pr c resistance”
• Metilentetrahydrofulate reductase gene
mutation
• Prothrombin 20210A gene mutation
• Congenital dysfibrinogenemia
Factor V leiden
• Activated protein C resistance
• Most common genetic factor
predisposing to thrombosis
• Most common identifiable causes
• Substitution of adenine for guanine
• “
Amino acid arginine for
glutamine
• Increased tendency to form clots
hyperhomocysteinemia
Methionine
metabolise
homocysteine
Remethylate
damage
vascular
endothelium
MTHFR
folate
vit.B12 , vit. B6
Methionine