approach to patient vaginal bleeding in 2nd half of pregnancy

history
examination
sign and symptoms
management

1. Vaginal bleeding in 2 nd Half of pregnancy (Ante-partum hemorrhage) Yahyia Al- Abri 90440

2. Objectives Antepartum hemorrhage Definition Causes Case scenario Placenta previa Placental abruption Vasa previa Uterine rupture

3. Definition Bleeding from or in to the genital tract, occurring from 24 + weeks of pregnancy and prior to the birth of the baby. (Royal College of Obstetricians and Gynecologists ) Uterine bleeding after 20 weeks of gestation that is unrelated to labor and delivery. (UPTODATE)

4. Causes Common Abruptio placentae Placenta previa Preterm labor Uncommon Uterine rupture Vasa previa Cervical lesion (cervicitis, polyp, ectropion, cervical cancer) Other:coagulopathy . Hacker and moore

5. Case scenario H is 30 years old lady pramigarvida at 30 week of gestation she presented to the A/E with P/V bleeding. LMP: 11/5/2016 EDD : 15/2/2017  Admission : 09/12/2016 The bleeding started 1 hour ago low in amount. She noted the bleeding while she was passing urine. She had two episodes in less than 24 hours. no abdominal pain no dysuria No fever No other complain good fetal movements

6. Case scenario Past medical :   GDM on Insulin (N15/8 units, R5/5 units) and Metformin 500 mg BID. No HTN No bleeding disorder Family history not remarkable Gyne Regular period every 28 days bleeding for 4 -5 days Never used of contraceptive No pap smear done Obstetric Planed pregnancy .Anomaly scan on 13/10/2016 no gross anomaly seen     Family history:  - mother diabetic

7. Case scenario On examination: Looks well. Vitally stable. T: 36.5 P: 88 BP: 130/80 saturation 98% Patient abdomen: soft, relaxed uterus, no tenderness. Patient cervix : no bleeding, os closed.

8. Placenta previa

9. Definition Abnormal location of placenta near , partially , or completely over the internal cervical os . Epidemiology: 0.5% of all pregnancies .

10. Risk factors Multiparty. Increasing maternal age. History of prior placenta previa . Multiple gestation

11. Placenta previa in referral hospital in oman

12. Classifications Placenta Previa is classified according to the relationship of the placenta to the internal cervical os .

13. Complete placenta previa placenta totally covers the cervical os . Central anterior Posterior depending on where the center of the placenta is located relative to the os .

14. Partial placenta previa placenta partially covers the internal cervical os .

15. Marginal placenta previa The edge of the placenta extends to the margin of the internal cervical os .

16. Low-lying placenta The placental margin is within 2 cm of the endocervical os .

17. Ultrasound classification of placenta previa Grade I: (low lying placenta) placenta lies in lower uterine segment but its lower edge does not Join the internal cervical os ( i.e lower edge 0.5-5.0 cm from internal os ). Grade II: (marginal praevia ) placental tissue reaches the margin of the internal cervical os , but does not cover it Grade III: (partial praevia ) placenta partially covers the internal cervical os Grade IV: (complete praevia ) placenta completely covers the internal cervical os

18. Clinical features PAINLESS bright red vaginal bleeding ( recurrent ) Shock/anemia correspond to degree of apparent blood loss. Uterus soft and non-tender Malpresentation , failure of the fetal head to engage. FHR usually normal Do NOT perform a vaginal exam until placenta previa has been ruled out by U/S

19. Investigations (laboratory) CBC ( hemoglobin, platelet ). Coagulation profile(INR/ aPTT ). Blood group type and Cross match. CTG ( fetal monitoring )

20. Radiological Ultrasound Transvaginal U/S is more accurate than transabdominal U/S at diagnosing placenta previa at any gestational age.

21. Placenta previa Treatment: Asymptomatic placenta previa: monitor placental position with ultrasound examination as an outpatient avoid vaginal intercourse, digital examination, avoid exercise Advise to seek immediate medical attention if contractions or vaginal bleeding occur Delivery by C-section at 37 weeks

22. Management Symptomatic Stabilize and monitor Maternal stabilization: large bore IV lines with hydration, O2 for hypotensive patients. M aternal monitoring: vitals, urine output, blood loss. CTG. U/S assessment: D etermine fetal viability. Placental status/position.

23. Management GA <37 weeks and minimal bleeding: Expectant management Admit to hospital Limited physical activity, no douches, enemas, Consider corticosteroids for fetal lung maturity Delivery when fetus is mature or hemorrhage is excessive GA ≥37 weeks, and/or bleeding is excessive: Delivery must be accomplished by C-section regardless of gestational age!

24. Complications * postpartum hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth. Fetal Maternal Perinatal mortality Prematurity Maternal mortality <1% Sheehan syndrome* Placenta accreta Hysterectomy Acute renal failure

25. Placental Abruption

26. Definition Premature separation of normal implanted placenta from the uterine wall before the delivery of the fetus. Epidemiology : 0.5 % to 1.5 % of all pregnancies.

27. Abruptio placenta Pathophysiology: hemorrhage into the decidua basalis Decidua splits Decidual hematoma formation Separation and compression of the placenta adjacent to it destruction of placental tissue.

28. Perinatal mortality in Oman

29. Risk factors Maternal hypertension (most common factor). History of placental abruption in a prior pregnancy. Trauma. Premature rupture of membranes. Short umbilical cord. Smoking.

30. Partial Vs Complete

31. Visible Vs Concealed

32. Clinical features PAINFUL (80%) vaginal bleeding bleeding not always present if abruption is concealed . Pain sudden onset, constant, localized to lower back and uterus .

33. Clinical features O/E General condition depends on the amount of bleeding (shock/anemia out of proportion to apparent blood loss) Uterus is Hard and Tender nonreassuring FH, reduced or absent fetal movements, fetal distress

34. Investigations U/S not sensitive for diagnosing abruption (sensitivity = 15 %) Classical US finding is retroplacental clot.

35. Management S tabilization & monitoring : M aternal stabilization: large bore IV with hydration, O2 for hypotensive patients. M aternal monitoring: vitals, urine output, blood loss. CTG. Blood products on hand , because of DIC risk.

36. Management Mild abruption GA <37 weeks: use serial Hct to assess concealed bleeding, deliver when fetus is mature or when hemorrhage is excessive. GA ≥37 weeks: stabilize and deliver. Moderate to severe abruption Immediate delivery. Vaginal delivery if no contraindication and no evidence of fetal or maternal distress OR fetal demise. C/S if there is fetal or maternal distress.

37. Complications Fetal Maternal Perinatal mortality Prematurity Intrauterine hypoxia Maternal mortality DIC (in 20% of abruptions) Acute renal failure Anemia Sheehan syndrome Abruptio placentae is the most common cause of DIC in pregnancy

38. Vasa previa

39. Definition U nprotected fetal vessels pass over the cervical os ; Associated with velamentous insertion of cord into membranes of placenta.

40. Clinical Features PAINLESS vaginal bleeding . F etal distress.

41. Vasa previa Investigations Apt test ( alkai denaturation test) to determine if the source of bleeding is fetal. TVS examination with color Doppler Treatment: emergency C/S (since bleeding is from fetus, a small amount of blood loss can have catastrophic consequences)

42. Uterine rupture

43. Definition C omplete separation of the uterine musculature through all of its layers, with all or a part of the fetus being extruded from the uterine cavity. Epidemiology: 0.5% of all pregnancies. A prior uterine scar is associated with 40% of cases .

44. Risk factors Previous C\S (types and number). Previous uterine myomectomy. Congenital uterine anomalies. Multiparty. Fetal macrosomia. Labor induction. Uterine instrumentation\ trauma.

45. Clinical features highly variable. S udden onset of intense abdominal pain. V aginal bleeding . Shock (Profound maternal tachycardia and hypotension) Fetal parts may be more easily palpated abdominally.

46. Management I mmediate laparotomy In most cases, total abdominal hysterectomy is the treatment of choice. Debridement of the rupture site and primary closure may be considered in women of low parity who desire more children . fluid and blood transfusion