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Third Trimester Bleeding

In any women with vaginal bleeding, evaluate maternal and fetal status immediately. Stabilize mom hemodynamically (large-bore IVs, serial CBCs, cross-match blood and intracardiac monitoring if especially unstable). Watch UOP-gives a good idea to volume status. Pregnant women have antepartum blood expansion and may lose lots of blood before vital signs changes are seen. Some causes of third trimester bleeding: 1. Placenta Previa-abnormal location of the placenta over, or in close proximity to the cervical os. If the entire os is covered it is called complete or total; partial if the edge of the placenta covers part of the os; marginal if the placenta is lying near the os; and lowlying if the placenta is simply lying near the cervical os. Etiology is unknown. Thought to be associated with abnormal areas of vascularization at other parts of the uterus (the placenta would prefer to be at the fundus-if it cant get good vascularization it moves lower). Risk factors include-increasing maternal age, increasing parity, uterine abnormalities, and previous c-sections. Incidence=1 in 250 pregnancies as an average. Much lower in nulliparas vs. mulitparas. 4-8% chance of previa in women with hx of previous placenta previas. Signs and symptoms-will first see bleeding around 29 to 30 weeks. Caused by separation of part of placenta from lower uterine wall and cervix, probably from mild contractions. The patient will report sudden onset of painless bleeding without any apparent antecedent signs. Note that the blood is most likely to be maternal. Diagnosis-NEVER DO DIGITAL EXAM in suspected previa until ruled out. Usually ultrasonography can accurately diagnose placenta previa or by localizing placenta away from source of bleeding can rule out previa. A posterior placenta makes diagnosis by ultrasound more difficult. Treatment-Initial hospitalization with hemodynamic stabilization. If fetus is thought to be mature by gestational age or amniocentesis delivery shouldnt be delayed. In the case of an immature fetus, ideal tx would be continuous hospitalization with strict bed rest until fetal maturity (either by age or steroid-induced fetal lung maturity) allows delivery. However, degree of bleeding must always be taken into account when making these decisions. With use of blood transfusion and cesarean birth the maternal mortality rate is <1% and perinatal mortality rate is <10%. If location of placenta cant be accurately determined by ultrasound can attempt delivery with a double setup examination. Involves examining the cervix in the operating room with preparation for rapid cesarean delivery if placental tissue is seen or felt at the os. Other tidbits of information-Placenta previa are associated with a nearly doubling of the rate of congenital malformations-usually major anomalies of CNS, GI tract, CV system and resp system. Be sure to check for other anomalies when placenta previa is diagnosed. Can occasionally see placenta previa accretta-the lower uterus is not as suitable for placenta implantation. The trophoblast of placenta invades the decidua of the uterus.5-010% of previas have this complication. Results in poor separation of the

placenta from the uterus leading to severe bleeding at time of delivery, often requiring a hysterectomy. 2. Abruptio placentae -premature separation of the normally implanted placenta. Occurs when there is bleeding into deciduas of uterus leading to placental separation which causes more bleeding. Associated with maternal hypertension and sudden decompression of uterus in ROM of polyhydramniotic patient. Other risk factors include delivery of multiple fetuses, cocaine use (causes vasoconstriction) or following trauma, even if fairly mild. Signs and Symptoms-The amount of vaginal bleeding can vary from very heavy to fairly light depending on where the placenta separated. If along the side, blood can leak to the os, if the abruption is central and the margins of the placenta are intact the blood can be concealed and wont escape into the vagina. Bleeding in to basalis causes stimulates uterine contractions causing a pain and tenderness to palpation (this is the major way to distinguish from previa in which the bleeding is painless). If the bleeding into the uterine musculature is excessive at c-section the entire uterus has a purplish appearance known as the Couvelaire uterus. The separation of the placenta causes poor oxygenation of fetus so often see fetal distress signs on the external fetal monitor. Fetal demise isnt uncommon. Abruption is most common cause of consumptive coagulopathy-will see increased fibrin degradation products, increased PT and PTT, and possibly thrombocytopenia. Basically there is retroplacental coagulation; also the intravascular fibrinogen is converted to fibrin due the extrinsic clotting cascade. See treatment for type of blood replacement. Diagnosis-Ultrasound does little except to rule out previa. You may see large retroplacental clots or you may not, also some women have echogenic areas behind the placenta, but dont have abruption. Diagnosis is made by classic presentation of vaginal bleeding, tender uterus, and frequent uterine contractions with evidence of fetal distress. The abruption is classified by the amount of maternal surface area is covered by the clot (usually classified at delivery) Ex. 50% abruption Treatments-If fetus is mature, stabilize hemodynamically and deliver. Pay close attention to coag status. If the fetus is not mature and abruption is mild-not causing severe fetal or maternal distress, you may be able to simply monitor closely until delivery is more favorable. If transfusion is done, it needs to include clotting factors as well as RBCs. Fresh whole blood carries RBCs and all procoagulants but is often difficult to obtain. Cyroprecipitate contains fibrinogen and factors VIII and XIII. FFP-all procoags, no platelets. Pick and choose what you need based on lab results.

3. Vasa Previa-rare but significant risk to fetus. The umbilical cord inserts into the membranes of the placenta (rather than into the central mass). As the umbilical cord vessels travel from insertion to central placenta it passes over the os. Similar to previa in

that later in pregnancy will see vaginal bleeding. In this case the blood is from the fetus, which lacks a large reserve. Signs and Symptoms-will see a small amount of vaginal bleeding with fetal tachycardia. Diagnosis-Test to differentiate between maternal and fetal blood. Can due KleihauerBetke test or Apt test which distinguishes maternal from fetal RBCs based on changes in pH. Treatment-emergency c-section is only thing that will save fetus. 4. Other Causes-lower genital tract trauma, cervical cancer, polyps or infection.