bleeding in Early & Late

pregnancy

Dr. Rabi Narayan Satapathy

Asst. Professor
Dept. of Ob. & Gynae.
SCB Medical College, Cuttack
Mob. 09861281510
 Causes of early bleeding in pregnancy

Ectopic pregnancy
Abortion Hydatidiform mole
 Abortion/Miscarriage

 Definition: any fetal loss from conception until the time of

fetal viability at 24 weeks gestation.
OR:
Expulsion of a fetus or an embryo weighing 500 gm or less
 Incidence: 15 - 20% of pregnancies total reproductive losses
are much higher if one considers losses that occur prior to
clinical recognition.
 Classification:

1. spontaneous:
occurs without medical or mechanical means.
2. induced abortion
 Pathology

 Haemorrhage into the decidua basalis.

 Necrotic changes in the tissue adjacent to
the bleeding.
 Detachment of the conceptus.
 The above will stimulate uterine
contractions resulting in expulsion.
 Causes of miscarriage

 Fetal causes:
 Chromosome Abnormality:
- 50% of spontaneous losses are associated with fetal chromosome
abnormalities.
- autosomal trisomy (nondisjunction/balanced translocation): is the
single largest category of abnormality and → recurrence.
- monosomy (45, X; turner): occurs in 7% of spontaneous abortions
and it is caused by loss of the paternal sex chromosome.
- triploids: found in 8 to 9% of spontaneous abortions. it is the
consequence of either dispermy or failure of extrusion of the
second polar body,
 Causes of miscarriage
 Maternal causes:
1. Immunological:
- alloimmune response: failure of a normal immune response in the
mother to accept the fetus for a duration of a normal pregnancy.
- autoimmune disease: antiphospholipid antibodies especially lupus
anticoagulant (LA) and the anticardiolipin antibodies (ACL)
2. uterine abnormality:
- congenital: septate uterus → recurrent abortion.
- fibroids (submucus): → (1) disruption of implantation and
development of the fetal blood supply, (2) rapid growth and
degeneration with release of cytokines, and (3) occupation of space
for the fetus to grow. Also polyp > 2 cm diameter.
- cervical incompetence: → second trimester abortions.
 Causes of miscarriage

 Maternal causes:
3. Endocrine :
- poorly controlled diabetes (type 1/type 2).
- hypothyroidism and hyperthyroidism.
- Luteal Phase Defect (LPD): a situation in which the endometrium is
poorly or improperly hormonally prepared for implantation and is
therefore inhospitable for implantation. (questionable).
4. Infections (maternal/fetal): as TORCH infections, Ureaplasma
urealyticum, listeria
 Environmental toxins: alcohol, smoking, drug abuse, ionizing
radiation……
 Types of abortion

 Threatened abortion.
 Inevitable abortion.
 Incomplete abortion.
 Complete abortion.
 Missed abortion
 Septic abortion: Any type of
abortion, which is complicated by
infection
 Recurrent abortion: 3 or more
successive spontaneous abortions
 Clinical features/management

 Threatened abortion:
- Short period of amenorrhea.
- Corresponding to the duration.
- Mild bleeding (spotting).
- Mild pain.
- P.V.: closed cervical os.
- Pregnancy test (hCG): + ve.
- US: viable intra uterine fetus.
 Management
- reassurance.
- Rest.
- Repeated U/S
 Inevitable abortion

 Clinical feature:  Management:

- Short period of amenorrhea. - fluids…..blood.
- heavy bleeding accompanied - ergometrinn & sentocinon.
with clots (may lead to shock). - evacuation of the uterus
- Severe lower abdominal pain. (medical/surgical).
- P.V.: opened cervical os.
- Pregnancy test (hCG): + ve.
- US: non-viable fetus and blood
inside the uterus.
 Incomplete abortion

 Clinical feature:  Treatment

- Partial expulsion of as inevitable abortion
products
- Bleeding and colicky pain
continue.
- P.V.: opened cervix…
retained products may be
felt through it.
- US: retained products of
conception.
 Complete abortion

- expulsion of all products of conception.

- Cessation of bleeding and abdominal pain.
- P.V.: closed cervix.
- US: empty uterus.
 Missed abortion

 Feature:  Treatment
- gradual disappearance of - Wait 4 weeks for spontaneous
pregnancy Symptoms Signs. expulsion
- evacuate if:
- Brownish vaginal discharge.  Spontaneous expulsion does not
- Milk secretion. occur after 4 weeks.
- Pregnancy test: negative but  Infection.
it may be + ve for 3-4 weeks  DIC.
after the death of the fetus. - Manage according to size of
uterus
- US: absent fetal heart
pulsations. - Uterus < 12 weeks : dilatation
and evacuation.
 Complications - Uterus > 12 weeks : try
- Infection (Septic abortion) Oxytocin or PGs.
- DIC
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
 Placenta Previa
 Abruption
Life-Threatening
 Ruptured vasa previa
 Uterine scar disruption
 Cervical polyp
 Bloody show
 Cervicitis or cervical ectropion
 Vaginal trauma
 Cervical cancer
 Prevalence of Placenta Previa
 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 Previa
 Previous cesarean delivery
 Previous uterine instrumentation
 High parity
 Advanced maternal age
 Smoking
 Multiple gestation
 Morbidity with Placenta Previa
 Maternal hemorrhage
 Operative delivery complications
 Transfusion
 Placenta accreta, increta, or percreta
 Prematurity
Patient History – Placenta Previa
 Painless bleeding
 2nd or 3rd trimester, or at term
 Often following intercourse

 May have preterm contractions

 “Sentinel bleed”
 Physical Exam – Placenta Previa
 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 Previa
 Hematocrit or complete blood count
 Blood type and Rh
 Coagulation tests

 While waiting – serum clot tube taped to wall

 Ultrasound – Placenta Previa
 Can confirm diagnosis
 Full bladder can create false appearance of
anterior previa
 Presenting part may overshadow posterior previa
 Transvaginal scan can locate placental edge and
internal os
 Treatment – Placenta Previa
 With no active bleeding
 Expectant management
 No intercourse, digital exams

 With late pregnancy bleeding

 Assess overall status, circulatory stability
 Full dose Rhogam if Rh-
 Consider maternal transfer if premature
 May need corticosteroids, tocolysis,
amniocentesis
 Double Set-Up Exam
 Appropriate only in marginal previa with vertex
presentation
 Palpation of placental edge and fetal head with set
up for immediate surgery
 Cesarean delivery under regional anesthesia if:
 Complete previa

 Fetal head not engaged

 Non-reassuring tracing

 Brisk or persistent bleeding

 Mature fetus
 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
 Hypertensive diseases of pregnancy
 Smoking or substance abuse (e.g. cocaine)
 Trauma
 Overdistention 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 include 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
 “uteroplacental apoplexy” or “Couvelaire” 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 bloody 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 loss
 Maternal abdomen
 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
 Complete blood count
 Type and Rh
 Coagulation tests + “Clot test”
 Kleihauer-Betke not diagnostic, but useful to
determine Rhogam dose
 Preeclampsia labs, if indicated
 Consider urine 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 - without coagulopathy (2/3)
 III B - with coagulopathy (1/3)
 Treatment – Grade II Abruption

 Assess fetal and maternal stability

 Amniotomy
 IUPC to detect elevated uterine tone
 Expeditious operative or vaginal delivery
 Maintain urine output > 30 cc/hr and
hematocrit > 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
hemorrhage
 Coagulopathy with Abruption
 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 cesarean incision most common
reason for scar disruption
 Other causes: previous uterine curettage or
perforation, inappropriate oxytocin usage,
trauma
 Risk Factors – Uterine Rupture

Previousuterine surgery Adenomyosis

Congenital uterine Fetal anomaly
anomaly
Uterine overdistension Vigorous uterine
pressure
Gestational trophoblastic Difficult placental
neoplasia removal

Placenta increta or
percreta
 Morbidity with Uterine Rupture
 Maternal
 Hemorrhage with anemia
 Bladder rupture
 Hysterectomy
 Maternal death
 Fetal
 Respiratory distress
 Hypoxia
 Acidemia
 Neonatal death
Patient History – Uterine Rupture

 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 evaluate uterine wall
 MRI to confirm possible placenta accreta
 Treatment
 Asymptomatic scar disruption – expectant
management
 Symptomatic rupture – emergent cesarean
delivery
 Vasa Previa
 Rarest cause of hemorrhage
 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

 Color doppler ultrasound

 Palpate vessels during vaginal examination

 Diagnostic Tests – Vasa Previa
 Apt test – based on colorimetric response of
fetal hemoglobin
 Wright stain of vaginal blood – for nucleated
RBCs
 Kleihauer-Betke test – 2 hours delay prohibits its
use
 Management – Vasa Previa
 Immediate cesarean delivery if fetal heart rate is
non-reassuring
 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