Antepartum Hemorrhage

Antepartum Hemorrhage

• Vaginal bleeding after 20 weeks of gestation that isn't related to labor is defined as antepartum hemorrhage
• The most common causes are placental abruption placenta previa, vasa previa, and uterine rupture

Diagnosis

• Placental abruption and uterine rupture are diagnosed clinically
• Placenta previa and vasa previa are usually diagnosed via midtrimester ultrasound
• Digital exams should be avoided in women with placenta or vasa previa
• Maternal and/or fetal hemorrhage can result, necessitating an emergency cesarean delivery and maternal and/or fetal resuscitation

Epidemiology and Etiology

• Antepartum hemorrhage occurs in approximately 5% of pregnancies
• The most common etiologies are placental abruption (30%) and placenta previa (20%)
• The etiology is often not determined

Causes of Antepartum Bleeding by Location:

• Placenta: Placental abruption, placenta previa, vasa previa
• Uterus: Uterine rupture
• Cervix: "Bloody show", cervicitis, cervical ectropion, polyps, carcinoma
• Vagina and vulva: Varicosities, vaginitis, lacerations, carcinoma

Placenta Previa

• Placenta previa is the abnormal implantation of the placenta near or over the internal os
• Placenta previa is a common cause of bleeding in the 3rd trimester
• Placenta previa occurs in 1 in 200–250 births
• Placenta previa is associated with <1% maternal mortality, <10% perinatal mortality

Placenta Previa Definitions

• Placenta previa involves the placenta implanting in the lower uterine segment and covering the internal cervical os
• Low-lying placenta means the placental edge is < 2 cm from (but not covering) the internal os and is managed the same way as placenta previa
• Marginal and partial placenta previa are older terms to be avoided

Placenta Previa Clinical Relevance

• Dilation of the cervix beneath the placenta can cause shearing forces resulting in placental detachment and bleeding
• Never perform a digital cervix exam: it can cause severe hemorrhage

Placenta Previa Epidemiology Stats

• A midtrimester ultrasound will reveal placenta previa in 4 per 1000 births in up to 2% of women
• About 90% of placenta previas identified at < 20 weeks resolve by delivery
• The lower uterine segment lengthens from 0.5 cm at 20 weeks to over 5 cm at term
• This lengthening moves the placenta away from the os
• Complete placenta previa is much less likely to resolve when ≥ 2.5 cm covers the internal os in the midtrimester

Placenta Previa Risk Factors

• Previous placenta previa and previous CD (risk increases with each additional CD)
• Multiple gestation, previous curettage, previous or recurrent abortions, and infertility treatment
• Advanced maternal age (> 35 years old) as well as multiparity
• Uterine structural anomaly, smoking, and cocaine use are also risk factors

Placenta Previa Clinical Presentation

• Includes painless vaginal bleeding and fetal distress
• Usually asymptomatic until cervical dilation begins after 30 weeks

Placenta Previa Diagnosis

• Transvaginal ultrasonography is used in diagnosis
• Transvaginal ultrasonography shows placenta near or covering the cervical os and is usually diagnosed on routine midtrimester ultrasound
• Assessing placental location is a recommended part of routine obstetric care
• Assess fetal well-being with a NST or a period of fetal monitoring
• Avoid digital exams on a woman with placenta previa

Placenta Previa Management:

• All individuals with placenta previa need to deliver via CD
• Asymptomatic antenatal management:
  • Pelvic rest
  • Avoid strenuous exercise and heavy lifting
  • Monitor placental location with serial ultrasounds
  • Plan to deliver at 36–38 weeks, prior to the onset of labor
  • When an exam is required, visual assessment with a speculum only

Placenta Previa - If bleeding:

• Assess the hemodynamic stability of the mother and resuscitate as needed
• Continuous fetal monitoring
• Corticosteroids for fetal lung maturity (if no emergent delivery)
• Anti-D immunoglobulin for Rh-negative mothers indications for delivery (regardless of gestational age)
  • Active labor
  • Nonreassuring fetal monitoring
  • Continued bleeding and/or hemodynamic instability
  • If bleeding is mild and resolves, observation may be an option

Placenta Previa Types

• Grade 1: Low lying placenta previa
• Grade 2 - Marginal placenta previa
• Grade 3 - Partial placenta previa
• Grade 4 - Complete or total placenta previa

Placenta Previa Etiology

• Dropping down theory
• Persistent chorionic activity
• Defective decidua
• Big surface of placenta

Placenta Previa Signs and Symptoms

• Painless vaginal bleeding, increased bleeding in labor, and ultrasound imaging results are signs and symptoms

Placenta Previa - Degree of Urgency

• Threat to fetal life/fetal asphyxia
• Threat to maternal life, hypovolemic shock ( >15MMHG systolic/diastolic BP and >15 beats/min)

Placenta Previa - Diagnostic Tests

• Simplest and safest test for the localization of the placenta, with an accuracy rate of 95% for the diagnosis of placenta previa
• Ultrasound examination
• Double-set up digital examination
  • Digital palpation of the placenta through cervical os and is done at operating room

Placenta Previa Management

• Caesarian section; assess the extent of blood loss, visual estimates
• Blood pressure and pulse
  • Overt hypertension/tachycardia
• Tilt test; urine flow (reflects renal perfusion)
• Manage bleeding episodes
  • Keep on NPO
  • Monitor V/S, FHR, and vaginal bleeding
  • Maintain absolute bed rest and fluid replacement if necessary
• Watchful waiting, if fetus is still immature to be delivered and woman is placed on bedrest
  • Ritodrine hydrochloride and magnesium sulfate could be administered
  • Amniocentesis can be carried out

Placenta Previa Delivery Management:

• Cesarian Section
• Presence and severity of bleeding
• Consider gestational age of the fetus and presence of labor

Placenta Previa Management Scenarios

• Minimal/no bleeding, premature gestational age: Managed with expectant management and severe restriction of physical activity, goal to get fetal maturity and resolution of placenta previa
• Minimal/no bleeding, mature gestational age: Amniocentesis for fetal lung maturity
  • Caesarian section if mature is the route of delivery and blood should be available
• Minimal bleeding associated with premature labor
  • Administration of tocolytic drugs, and expectant management if labor is successfully stopped
  • Caesarian section if labor is not stopped and bleeding continues
• Severe bleeding, any gestational age: Caesarian section

Placental Abruption/ Abruptio Placentae

• Placental abruption involves the separation of normally implanted placenta before delivery of the fetus
• Placental abruption also referred to as abruptio placentae
• Common cause of bleeding in the third trimester -- but can happen after weeks of gestation
• Affects approximately 1 in 150 deliveries, perinatal mortality rate 15 to 20%

Placental Abruption - Overview

• Placental abruption involves the complete or partial premature detachment of a normally implanted placenta before the birth of the infant
• Clinical relevance: A detached placenta means the infant is no longer able to get oxygen and maternal and fetal hemorrhage occurs through the placenta, so it is an obstetric emergency that usually requires immediate delivery
• Epidemiology: Approximately 2–10 per 1000 births, more common in women < 20 and > 35 years of age
• Gestational age at abruption:
  • Term: 60%
  • 32–36 weeks: 25%
  • < 32 weeks: 15%

Placental Abruption - Risk Factors

• Previous abruption is a major risk factor as well as hypertension (preeclampsia or poorly controlled chronic hypertension) as well as trauma to the abdomen
• Cocaine or tobacco use, quick decompression of the uterus, or uterine anomalies are also risk factors
  • Quick decompression caused by rupture of membranes in a pregnancy with polyhydramnios
  • Delivery of the 1st infant in a multiple gestation can also cause quick decompression
• Fetal growth restriction may suggest a small chronic partial abruption

Placental Abruption Etiology

• Largely unknown, but likely related to to chronic placental disease processes and abnormalities in the development of placental vasculature
• Direct abdominal trauma is a less common cause

Placental Abruption Causes

• Maternal hypertension, advanced maternal age, grand multiparity
• Trauma to the uterus, PPROM, or short umbilical cord
• Cigarette smoking and cocaine use
• Uterine leiomyoma or anomaly
• History of placental abruption

Placental Abruption Pathophysiology

• Rupture of maternal vessels in the decidua basalis causes accumulation of blood which splits the decidua
• A thin layer of decidua is separated off with its placental attachment
• Thrombin triggers uterine contractions because blood clotting in the decidua means the uterine is working

Placental Abruption Categories: Complete or Partial

• Complete (or nearly complete) abruption is caused by high-pressure arterial hemorrhage in the center of the placenta
  • Symptoms develop rapidly and are life-threatening for fetus and mother
• Partial abruption: Caused by low-pressure venous hemorrhage, usually at the periphery of the placenta
  • Separates in a limited way
  • Symptoms develop slowly and can lead to “chronic abruption” throughout the remainder of pregnancy

Placental Abruption Clinic Presentation

• Includes bleeding from placental separation that be external visible vaginal bleeding in (80%), or concealed blood pools behind the placenta without vaginal bleeding (20%)

Placental Abruption with Pain

• Painful bleeding caused by abdominal and/or back pain can also range from mild to life-threatening
• Contractions (often hypertonic or high-frequency), uterine tenderness, and fetal distress/decreased fetal movement
• Small partial abruptions manifest in smaller amounts of bleeding over time as well as oligohydramnios and intrauterine fetal growth restriction

Placental Abruption Diagnosis Tests

• A diagnosis is usually clinical, based on the history, exam, and fetal monitoring
• Includes fetal nonstress test (NST), ultrasonography, and laboratory review

Fetal Nonstress Test (NST)

• Tests that assess fetal heart rate and uterine contractions in order to assess fetal status
  • Signs of fetal distress include fetal bradycardia, decreased heart rate variability, and late decelerations
  • Toco metry can also be done

Ultrasonography in Diagnosis

• Excludes placental previa and may show a retroplacental hematoma
• Low sensitivity, but decent specificity

Laboratory Analysis

• Laboratory: type and cross to determine anemia degrees of anemia and potential isoimmunization and or need for transfusion as well to determine the coagulation levels

Placental Abruption Management

• Severe abruption: Manage individuals with DIC, hypovolemic shock, and/or nonreassuring fetal status with stabilization (airway management and IV fluids) and emergent Cesarean Section
• Mild or chronic abruption: Monitor the mother to ensure abruption remains stable.
• Manage frequent assessments of fetal well-being. Manage preterm infant lung maturity with Corticosteroids (Betamethasone)
• Delivery methods depend on the type of delivery and gestational age/stability
• Give anti-D immunoglobulin to rH-negative mothers to prevent isoimmunization

Placental Abruption and Deliveries:

• All individuals with placenta previa need to deliver via CD
• Asymptomatic antenatal management:
  • Pelvic rest; avoid strenuous exercise and heavy lifting
  • Monitor placental location with serial ultrasounds, Plan to deliver at 36–38 weeks, prior to the onset of labor, when exam is required, visual assessment with a speculum only

Placental Abruption-If Bleeding

• Assess hemodynamic stability of mother and resuscitate if needed
• Manage any continued fetal monitoring and or give corticosteroids for fetal lung maturity (if no emergent delivery)
• Anti-D immunoglobulin for Rh-negative mothers is a possible treatment

Placental Abruption Threat

• Can cause fetal demise, fetal life risk, premature delivery and maternal maternal life

Types of Abruptio Placentae

• Covert/central abruptio placentae: Separation begins at the placenta resulting in blood trapped behind the placenta
• Overt/marginal abruptio placentae: Separation begins at the edges of placenta allowing blood to escape from uterus cavity

Subchorionic Abruption

• Bleeding between myometrium and placental membranes

Retroplacental Abruption

• Bleeding between myometrium and placenta

Preplacental Abruption

• Bleeding between placenta and amniotic fluid

Intraplacental Abruption

• Bleeding within or inside the placenta

Placenta Abruption: Signs and Symptoms

• Vaginal bleeding
• Abdomen boardlike abnormal tenderness
• Signs of shock and fetal distress
• Dark red bleeding indicates a covert type and bright red bleeding indicates an overt type

Management Strategies:

• Hospitalization and or bedrest on their side Monitor blood loss of fetus.
• Deliver vaginally and institute schock measure to treat distress
• Initiate a C section if the fetus cannot be immediately delivered with a vaginal method

Placenta Abruption: Medical Management

• Expectant management, delivery, induction of labor, transfusion, and hysterectomy are possible management solutions

Expectant Management

• Expectant if placental abruption is determined to be mild with minimal bleeding and there is no indication of Fetal Distress , maternal is stable and not in shock

Induction of Labor and Vaginal Delivery

• It is possible to induce labor and vaginally deliver the baby only if the if not severely in jeopardy and show not fetal distress

C-Section

• Use a Caesarian Section if The Status: Fetal distress is shown or degree abruption

Transfusion Guidelines

• Blood should be treated with a transfusion if any problems from platelets or plasma.
• Transfusion of blood products: red blood cells, platelets, fresh frozen plasma, cryoprecipitate

Postpartum Hysterectomy

• Only an Option if there is persistent postpartum bleeding - performed only if there is severe
  • Not responsive correction to the administration oxytocin and prostaglandin

Placenta Abruption Complications

• Couvelaire Uterus
• hemorrhage
• DIC
• Renal failure
• Infection

Placental Abruption: Complication Uterus

• Couvelaire - The uterus can be called as, utero
• Also called Utero-placental apoplexy - Also is first describe the muscular and blood cannot flow

Vasa Previa Overview

• Vasa Previa Definition: The vessels internal on umbilical
• Also can disrupt Wharton’s with ruptures

The Importance of Clinical Significance/Treatment

• Fetal with blood loss because uterus can be ruptured or distress can happened (no treatment)

Epidemiology of Vessels in the Previa

• Also with gestation or twins in mono of placenta can be a risk

Diagnoses of Vasa Previa

• Clinical can be painless or bleeding
• Loss blood with fetus
• And be or not be known for trama
• With or without ultrasound can confirm by 20 weeks

Vasa Previa Medical Strategy - Delivery Types:

• C sections can prevent vaginal
• With rest, lung and labor can happen fast

Uterine Definition

• When Clinical can not be determine scar or any other cases

Epidemic Overview from Doctors

• If a vaginal can only can be 0.5% and or it will be rare 20,000 pregnancies

Risk Factors

• Previous or the current prior reasons of c section

Clinical Presentation

• Constant abdominal pain vaginal bleeding for high rates

Management

• C if distress for mother or baby
• And/to stabilized or not hysterectomy the uterus can not be saved