Late Pregnancy Bleeding

Makmur Sitepu
 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
 Ruptured vasa previa Life-
 Uterine scar disruption Threatening

 Cervical polyp
 Bloody show
 Cervicitis or cervical ectropion
 Vaginal trauma
 Cervical cancer
 Placenta Previa
 Definition

 Main cause of obstetrical hemorrhage

 Classification
• Complete placenta previa

• Partial placenta previa

• Marginal placenta previa

• Low Laying placenta previa

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
Low-Lying Marginal Complete
Etiology

 Uncertain
 High risk factors
 Etiology
1. Endometrial abnormality

2. Placental abnormality

3. Delayed development of
trophoblast
 Manifestation
 Painless hemorrhage
1. The most characteristic symptom
2. Time: late pregnancy (after the 28th
week) and delivery
3. Characteristics: sudden, painless and
profuse
4. Cause of bleeding
Manifestation

 Anemia or shock

 Abnormal fetal position

Diagnosis

 History
 Signs
 Speculum examination

 Limited vaginal examination (seldom used)

 Rectal examination is useless and dangerous

Diagnosis
 Ultrasonography

 MRI
 Check the placenta and
membrane after delivery
Diagnosis
Diagnosis
Placenta accreta
 Accreta  adherent to endometrial cavity
 Increta  placental tissue invades myometrium
 Percreta  placental tissue grows through
uterine wall
 Placental abruption

 Vascular previa
 Abnormality of cervix
Treatments

 Expectant therapy
 Treatments

 Termination of pregnancy
 Treatments

2. Vaginal delivery
Management
 Placental Abruption
• Occurs in 1-2% of pregnancies
• 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
 Risk Factors for Abruption
 Hypertensive disorders of pregnancy

 MgSO4 to treat preeclampsia reduces abruption by 27%

 Smoking or substance abuse (e.g. cocaine)

 Trauma
 Over-distention of the uterus
 Previous abruption
 Placental insufficiency
 Thrombophilias / metabolic abnormalities
Altman D et al.; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their
babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-
controlled trial. Lancet. 2002;359:1877-1890
 Bleeding from Abruption
1. Externalized hemorrhage
2. Bloody amniotic fluid
3. Retroplacental clot
a. 20% occult

b. “uteroplacental apoplexy” or “Couvelaire”

uterus

4. Look for consumptive coagulopathy

Diagnosis
 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
Risk factors
Trauma, hypertension, drugs
 Physical Exam - Abruption
Signs of circulatory instability
Mild tachycardia

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

Retroplacental echolucency

Abnormal thickening of placenta

“Torn” edge of placenta

Ultrasound - Abruption
 Sher’s Classification - Abruption
Grade I

Grade II

Grade III
III A
III B

Sher G, Statland BE. Abruptio placentae with coagulopathy: a rational basis for
management. Clin Obstet Gynecol 1985;28(1):15-23.
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, hematocrit >
30%
• Prepare for neonatal resuscitation
Treatment – Grade III Abruption
 Conclusion

Characteristic Previa Abruption

Amt. Blood loss Variable Variable
Duration Usu. 1-2 hrs. Usu. Continuous
Abdominal pain None Usu. Present
FHR Pattern Normal Often Abnormal
Coag. Defects Rare DIC possible, but
infrequent
Assoc. history None See risk factors
 Vasa Previa

1. Rarest cause of hemorrhage

2. Associated with
 In vitro fertilization
 Placenta previa in 2nd or 3rd
trimester
 Bilobed and succenturiate lobe
placentas
 Velamentous insertion of the cord
Umbilical cord

Placental disk

Membranes

Lower uterine segment

Velamentous Insertion
Partially dilated cervix, seen from above
Velamentous Insertion
Vasa Previa

1. Bleeding occurs with membrane

rupture
2. Blood loss is fetal
1. 56% mortality when undetected
before onset of labor
2. 3% mortality when detected
prenatally
Antepartum Diagnosis – Vasa Previa
1. Amnioscopy
2. Ultrasound
a. Vasa previa is highly associated with placenta
previa on 2nd trimester US
b. Perform follow-up US with color-flow Doppler to
R/O vasa previa
3. Palpate vessels during vaginal
examination
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
 Summary
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