Bleeding Inlatepregnancy.pdf4646576555766

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1. BLEEDING IN LATE
PREGNANCY
MAGDY ABDELRAHMAN MOHAMED
LECTURER OF OB/GYN
2016

2. Definition
•Bleedinginlatepregnancyversusantepartum
hemorrhage??.
•Bleedingfromgenitaltractduring3
rd
trimester.(or
aftergestationalageofviability).

3. Causes
•Placental causes (commonest):
•Placenta previa.
•Accidental Hge.
•Vasa previa.
•Local gynecological causes.
•Heavy show??

4. PLACENTA PREVIA

5. Placenta previa
•Definition:
•Placentalocatedintheloweruterinesegment
aftergestationalageofviability.
•Incidence:
•1:200

7. Etiology
•Unknown?
•Scarred uterus.
•High parity.
•Multiple pregnancy.

8. Degree
•1
st
degree:
•The lower edge within 5 cm from internal os.
•2
nd
degree:
•The lower edge of the placenta is just reaching the
internal osbut not covering it.
•3
rd
degree:
•The placenta cover the closed internal os.
•4
th
degree:
•The placenta completely cover the internal oseven
when dilated.

10. Mechanism of bleeding
•Formation&elongationofloweruterine
segmentduring3
rd
stagewhiletheplacentais
notstretchable.
•Thisleadtounavoidableseparation&bleeding.

11. Clinical picture
•Symptoms:
•Vaginal bleeding ( causeless, painless & recurrent)
…………. Exception???
•Signs:
•Vital signs
•Pallor
•No vaginal examination ( u/s first to exclude placenta
previa)

12. Investigation
•U/S:
•( Trans-abdominal versus Transvaginal)
•Confirm diagnosis & degree of P.P.
•Viability, biometry …… etc.
•HB level & HCT value.
•MRI:
•When placenta accreta is suspected.

15. Treatment
•Resuscitation:
•I.V.line&fluid,crossmatchedblood.
•Indicationoftermination:
•Maturefetus(after37w).
•Deadfetusorcongenitalmalformation
incompatiblewithextrauterinelife.
•Activelabourpain.
•Attackofseverebleeding.

16. Methods of termination
•The role by CS except:
•1
st
degree placenta previa.
•2
nd
degree placenta previa (anterior).
????
•Cross matched blood should be available.
•Consent for hysterectomy.

17. Conservative management
•Inmildattackortheattackhasstoppedand
Gestationalagelessthan37wwithlivingfetus.
•Hospitalization.
•Crossmatchedblood.
•Antenatalcorticosteriod.
•Tocolytics.???
•AntiDforRh-vemother.

18. Effect of P.P. on pregnancy & labour
•Increase incidence of:
•Malpresentation.
•Preterm labour.
•CS.
•Placenta accreta.
•Postpartum hemorrhage.

19. ACCIDENTAL HEMORRHAGE
(ABRUPTIO PLACENTA)

20. Accidental hemorrhage
•Definition:
•Prematureseparationofnormallyimplanted
placenta.
•Incidence:
•1%

22. Etiology
•Idiopathic.
•Pre-eclampsia.
•Trauma.
•Sudden drop of intrauterine pressure due
to PROM.
•Smoking.
•Myomain placental bed.

23. Types
•Revealed:
•Marginal(peripheral)detachmentofplacenta.
•Externalhemorrhage.
•Concealed
•Centralseparationwithadherenceofedge.
•Retroplacentalhematomaprovokemoreseparation.
•Bloodmaydissectthroughthemyometriumbetween
musclefiberstoreachperitonealcavity
(couvelaire’suterus)
•Mixed.

26. Clinical picture
•A-concealed accidental Hge.
•Severe abdominal pain.
•Shock ( hemorrhage & pain).
•Abdominal examination.
•Tender & rigid abdomen.
•Fundal level higher than period of amenorhea.
•B-Revealed accidental Hge.
•Vaginal bleeding.
•Mild abdominal pain.
•Signs hypovolemic shock.

27. Investigation.
•U/S:
•Exclude placenta previa.
•Viability of fetus.
•Retroplacentalhematoma.
•Urine analysis:
•Proteinurea.

29. Differential diagnosis
•Concealed type:
•Rupture uterus.
•Hypertonic inertia.
•Revealed & mixed type:
•Other causes of antepartum Hge.

30. Complication of concealed type
•Fetaldeath.
•Acutetubularnecrosis&acuterenal
failure.
•DIC&consumptivecoagulopathy.
•Escapeofthromboplastin-likesubstances
intothematernalcirculation.
•PostpartumHge.

31. Management
A-Concealed&mixedtypes:
•Correctionofshock.
•Terminationusuallybyamniotomy&induction
oflabour.
•CSindicatedonlyin:
•Livingfetus.
•Deteriorationofmaternalconditioninspiteof
resuscitativemeasures.
•Otherobstetricsindication.

32. Management
B-Revealedtype:
•Severehge:
•CorrectionofshockfollowedbyCS.
•MildHge.
•Hospitalization.
•Carefulmonitoringofmaternal&fetalcondition.
•AntiDforRh-vemother.
•Tocolyticscontraindicated.

33. Vasa previa
•Veryrare.
•Bleedingoffetalorigin.
•Occurduetovelamentousinsertionofthecord
&somefetalvesselspassneartheinternalos.
•Itleadstoearlyfetaldistress.
•TreatmentbyimmediateCS.

37. SUMMARY OF
MANAGEMENT