Bleeding pregnancy, labor, puerperium_.pptx

Bleeding in pregnancy

1. Bleeding in I, II and III trimester, during labor and puerperium . Lecturer – ass. prof. Kosolapova Natalya Vladimirovna

2. Frequency of obstetrical bleeding is about 8 - 11% and doesn’t have tendency to decrease.

3. The obstetrical causes of bleeding in the first half of pregnancy : s pontaneous abortion ; e ctopic pregnancy ; cervical polyp ; cervical cancer ; hydatidiform mole .

4. Placental Abruption Placental separation from its implantation site before delivery has been variously called placental abruption ( abruptio placentae ) . The cumbersome term premature separation of the normally implanted placenta is most descriptive.

5. The bleeding of placental abruption typically insinuates itself between the membranes and uterus, ultimately escaping through the cervix, causing external hemorrhage . Less often, the blood does not escape externally but is retained between the detached placenta and the uterus, leading to concealed hemorrhage . Placental abruption may be total or partial . Concealed hemorrhage carries much greater maternal and fetal hazards.

6. The frequency with which placental abruption is diagnosed varies because of different criteria, the reported frequency averages 1 in 160 – 1 in 290 deliveries.

7. Risk Factors for Placental Abruption: Preeclampsia, Chronic hypertension, Prior abruption, Hydramnios , Preterm ruptured membranes, Multyfetation , Large fetus, Kidney diseases, Isoimmune conflict between mother’ and fetus’ blood, Cardiovasculary diseases, Diabetes mellitus, Connected tissue diseases, Inflammation of uterus and placenta, Malformations and tumors of uterus, Cigarette smoking, Cocaine use, Thrombophilias , Short umbilical cord, Pathological contractibility of uterus, Trauma.

8. Pathology Placental abruption is initiated by hemorrhage into the decidua basalis . Consequently, the process in its earliest stages consists of the development of a decidual hematoma that leads to separation, compression, and ultimate destruction of the placenta adjacent to it. In its early stage, there may be no clinical symptoms. In some instances, a decidual spiral artery ruptures to cause a retroplacental hematoma. The area of separation reaches the margin of the placenta. The escaping blood may dissect the membranes from the uterine wall and eventually appear externally or may be completely retained within the uterus.

9. Clinical Diagnosis The signs and symptoms of placental abruption can vary considerably. The symptoms of placental abruption are: vaginal bleeding, uterine tenderness or back pain, sharply painful palpation of uterus, local pain, fetal distress or intrauterine fetal death, preterm labor, frequent uterine contractions, persistent uterine hypertonus or tetania , blood in amniotic fluid.

10. Sonography frequently confirms the diagnosis of placental abruption. With severe placental abruption, the diagnosis generally is obvious. Milder and more common forms of abruption may be difficult to recognize with certainty. Unfortunately, neither laboratory tests nor diagnostic methods are available to detect placental separation accurately. Therefore, with vaginal bleeding in a pregnancy, it often becomes necessary to exclude placenta previa and other causes of bleeding by clinical and sonographic evaluation.

11. Specific complication: Couvelaire Uterus . There may be widespread extravasation of blood into the uterine musculature and beneath the uterine serosa . First described by Couvelaire as uteroplacental apoplexy, it is now termed Couvelaire uterus . Such effusions of blood are also occasionally seen beneath the tubal serosa , between the leaves of the broad ligaments, in the substance of the ovaries, and free in the peritoneal cavity. Couvelaire Uterus needs for urgent uterine extirpation without appendages.

12. Management Treatment for placental abruption varies depending on gestational age and the status of the mother and fetus. With a fetus of viable age, and if vaginal delivery is not imminent, then emergency cesarean delivery should be chosen. In case of placental abruption with massive external bleeding, intensive resuscitation with blood plus crystalloid and prompt delivery to control hemorrhage are lifesaving for the mother and for the fetus. If the diagnosis is uncertain and the fetus is alive but without evidence of compromise, then close observation can be practiced in facilities capable of immediate intervention. Cesarean delivery . Rapid delivery of the alive fetus practically always means cesarean delivery. Cesarean Delivery should include visual revision walls of uterus for Couvelaire Uterus exclusion. Amniotomy . Rupture of the membranes as early as possible has long been championed in the management of placental abruption.

13. Placenta Previa Placenta previa is used to describe a placenta that is implanted over or very near the internal cervical os . Total placenta previa —the internal os is covered completely by placenta. Partial placenta previa —the internal os is partially covered by placenta. Marginal placenta previa —the edge of the placenta is at the margin of the internal os . Low-lying placenta —the placenta is implanted in the lower uterine segment such that the placental edge does not reach the internal os , but is in close proximity to it, low placenta margin is less than 7 cm above the internal os . Vasa previa —the fetal vessels course through membranes and present at the cervical os .

14. Digital palpation in an attempt to ascertain these changing relations between the placental edge and internal os as the cervix dilates usually causes severe hemorrhage!!!

15. Incidence . According to different data, placenta previa complicated 1 in 300 – 1 in 390 deliveries. Associated Factors : Advancing maternal age (older than 35), multiparity , prior cesarean delivery or another uterine surgery, prior uterine infections and inflammations, prior multiple abortions, utering malformations and tumors, smoking cigarettes, otherwise unexplained elevated levels of maternal serum alpha-fetoprotein (MSAFP).

16. Clinical Findings The most characteristic event in placenta previa is painless hemorrhage , which usually does not appear until near the end of the second trimester or after. However, bleeding may begin earlier, and some abortions may result from such an abnormal location of the developing placenta. With many previas , bleeding begins without warning and without pain in a woman who has had an uneventful prenatal course. The cause of hemorrhage is reemphasized: when the placenta is located over the internal os , the formation of the lower uterine segment and the dilatation of the internal os result inevitably in tearing of placental attachments. The bleeding is augmented by the inherent inability of myometrial fibers of the lower uterine segment to contract and thereby constrict the avulsed vessels. Hemorrhage from the implantation site in the lower uterine segment may continue after placental delivery because the lower uterine segment contracts poorly.

17. Diagnosis Placenta previa or abruption should always be suspected in women with uterine bleeding during the latter half of pregnancy. The possibility of placenta previa should not be dismissed until sonographic evaluation has clearly proved its absence. The diagnosis can seldom be established firmly by clinical examination unless a finger is passed through the cervix and the placenta is palpated . Such digital cervical examination is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery—even the gentlest digital examination can cause torrential hemorrhage.

18. Placental "Migration“. Placentas that lie close to the internal os —but not over it—during the second trimester or early third trimester are unlikely to persist as a previa by term. The likelihood that placenta previa persists after being identified sonographically before 28 weeks is greater in women who have had a prior cesarean delivery.

19. Management of Placenta Previa Women with a previa may be considered in one of the following categories: The fetus is preterm and there are no other indications for delivery The fetus is reasonably mature Labor has ensued Hemorrhage is so severe as to mandate delivery despite gestational age. Management with a preterm fetus, but without persistent active uterine bleeding, consists of close observation. For all women, prolonged hospitalization may be ideal.

20. Delivery Cesarean delivery is necessary in practically all women with placenta previa . Because of the poorly contractile nature of the lower uterine segment, there may be uncontrollable hemorrhage following placental removal. When bleeding from the placental bed cannot be controlled by conservative means, other methods can be attempted. In some women, bilateral uterine or internal iliac artery ligation may provide hemostasis . If such conservative methods fail, and bleeding is brisk, then hysterectomy is necessary. For women whose placenta previa is implanted anteriorly in the site of a prior hysterotomy incision, there is an increased likelihood of associated placenta accreta and need for hysterectomy. Women with marginal placenta previa only are possible to be delivered vaginally with early amniotomia if fetus’ presented part, descended after it, press the placental margin and stop bleeding.

21. Maternal and Perinatal Outcomes Placenta previa is an important cause of maternal morbidity and mortality. In the review, cite an approximately threefold increased maternal mortality ratio. Preterm delivery as a result of placenta previa is a major cause of perinatal death.

22. Third-Stage Bleeding Some bleeding is inevitable during the third stage of labor as the result of transient partial separation of the placenta. As the placenta separates, blood from the implantation site may escape into the vagina immediately—the Duncan mechanism of placental separation ( б) . Alternately, it may be concealed behind the placenta and membranes until the placenta is delivered—the Schultze mechanism (а) .

23. Placenta Accreta , Increta , and Percreta Infrequently, detachment of placenta is delayed because the placenta is unusually adhered to the implantation site. In these cases, the decidua is scanty or absent, and the physiological line of cleavage through the decidual spongy layer is lacking. As a consequence, one or more placental lobules, also termed cotyledons , are firmly bound to the defective decidua basalis or even to the myometrium . When the placenta is densely anchored in this fashion, the condition is called placenta accreta . Varying degrees of accreta cause significant morbidity and at times, mortality from severe hemorrhage, uterine perforation, and infection.

24. Definitions The term placenta accreta is used to describe any implantation in which there is abnormally firm adherence to the uterine wall. As the consequence of partial or total absence of the decidua basalis , placental villi are attached to the myometrium in placenta accreta . With placenta increta , villi actually invade into the myometrium . Finally, with placenta percreta , villi penetrate through the myometrium . The abnormal adherence may involve all lobules— total placenta accreta . Or, it may involve only a few to several lobules— partial placenta accreta . All or part of a single lobule may be attached— focal placenta accreta .

25. Incidence Over the past few decades, the incidences of placenta accreta , increta , and percreta have increased. This is because of the increasing cesarean delivery rate. The American College of Obstetricians and Gynecologists estimated that placenta accreta complicates 1 in 2500 deliveries. Various forms of accreta are a substantive cause of maternal deaths from hemorrhage.

26. Risk Factors Decidual formation is commonly defective in the lower uterine segment over a previous cesarean delivery scar or after uterine curettage. There are risk factors for placenta accreta that have come to light with MSAFP screening for neural-tube defects and aneuploidies . There is an increased risk for accreta in women with placenta previa . The risk for accreta is increased threefold when maternal age is 35 years or older.

27. Clinical Course and Diagnosis In many cases, placenta accreta is not identified until third-stage labor. In this setting, an adhered placenta, is encountered. Elevated serum D- dimer levels may predict significant blood loss and morbidity in women with placenta accreta . This perhaps reflects trophoblastic invasion into the myometrium and adjacent tissues.

28. Clinical Course and Diagnosis Efforts are ongoing to better identify placental ingrowth antepartum . With sonographic Doppler color flow mapping there are two factors are highly predictive of myometrial invasion: a distance less than 1 mm between the uterine serosa -bladder interface and the retroplacental vessels, and (2) identification of large intraplacental lakes.

29. MRI diagnostics of placenta accreta

30. Placenta accreta

31. Clinical management for Third-Stage Bleeding Algorithm: Peripheral vein catheterization. Urinary bladder catheterization and urine evacuation. Check signs of placenta separation. If positive – external uterine massage, external methods for placenta evacuation ( Crede-Lazarevich , Abuladze , Henter ).

32. Clinical management for Third-Stage Bleeding Algorithm: If negative – in case of bleeding absence waiting during 30 minutes, after – manual placental removal with adequate (usually intravenous) anesthesia. In case of bleeding start – immediate manual placental removal with intravenous anesthesia. If manual placental removal is effective – diagnosis is placenta accreta . At times, traction on the umbilical cord inverts the uterus.

33. Clinical management for Third-Stage Bleeding Algorithm: If manual placental removal is not effective – diagnosis is placenta increta , laparotomy and hysterectomy (uterine extirpation without appendages) should be performed. Uterotonic Agents use: 10-20 IU Oxytocin i /v with 400 ml of physiological solution (40 drops per minute). Estimation of blood loss and it’s adequate replacement. Successful treatment depends on immediate blood replacement therapy, and nearly always prompts hysterectomy. Other measures include uterine or internal iliac artery ligation, balloon occlusion, or embolization .

34. Management after Placental Delivery The fundus should always be palpated following either spontaneous or manual placental delivery to confirm that the uterus is well contracted. If it is not firm, vigorous fundal massage is indicated. Typically, 10 U of oxytocin in 500 mL of lactated Ringer or normal saline proves effective when administered intravenously at approximately 10 mL /min—(200 mU of oxytocin per minute)—simultaneously with effective uterine massage.

35. Technique of Manual Placental Removal Adequate analgesia is mandatory, and aseptic surgical technique should be used. After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located, and the border of the hand is insinuated between it and the uterine wall. Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that used in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the decidua , using ring forceps to grasp them as necessary. Another method is to wipe out the uterine cavity with a laparotomy sponge.

36. Postpartum hemostasis is performed by two mechanisms: Myometrium Contraction and retraction ; Clots formation in placental site vessels. Violation of any of the mechanism lead to the bleeding start.

37. Uterine Hypo/ Atony (Hypo/ Atonic postpartum uterine bleeding) Failure of the uterus to contract properly following delivery is the most common cause of obstetrical hemorrhage. In many women, uterine atony can at least be anticipated well in advance of delivery. Although risk factors are well known, the ability to identify which individual woman will experience atony is limited. Causes of early postpartum bleeding Hypotonic or atonic uterus; Retained Placental Fragments; Traumatic lacerations of the birth canal; Blood coagulation disorders; Prior blood diseases.

38. Causes of Uterine Hypo/ Atony The overdistended uterus is prone to be hypotonic after delivery. Thus, women with a large fetus, multiple fetuses, or hydramnios are prone to uterine atony . The woman whose labor is characterized by uterine activity that is either remarkably vigorous or barely effective is also likely to bleed excessively from postpartum atony . Similarly, labor either initiated or augmented with oxytocics is more likely to be followed by atony and hemorrhage. High parity may be a risk factor for uterine atony . Another risk is if the woman has had a prior postpartum hemorrhage, preeclampsia, leyomyoma , scar on the uterus, chronic DIC-syndrome, intrauterine fetal death.

39. Two types of postpartum bleeding: Bleeding starts immediately after birth, is profuse (massive), uterus is hypotonic, hypovolemia and hemorrhagic shock progress fastly . Bleeding starts after a period of uterine contraction, blood stands out in small portions, blood loss increases gradually. Alternate with periods of uterine hypotension and recovery uterine tone.

40. Clinical management for Hypo/ Atonic postpartum uterine bleeding (Algorithm of the first aid) Urinary bladder catheterization and urine evacuation. External massage of the uterus through the abdominal wall. Peripheral vein catheterization (not less than two). 10-20 IU Oxytocin i /v with 400 ml of physiological solution (40 drops per minute). Correction for hypovolemia (infusion of colloids and crystalloids). I/m administration 0.5-1.0 metilergometrin or 800 mkg mizoprostol . On the lower abdomen - ice (local hypothermia). Manual examination of the uterine cavity for retained placental and membrane fragments and clots removal, uterine walls control. Bimanual uterine compression (uterine massage on the fist). Speculum inspection of birth canal and it’s lacerations reparation. Tampon with ether into posterior fornix of vagina. If bleeding continues and loss of blood amount 1000 ml – prepare operating room. If bleeding continues and loss of blood is about 1000-1200 ml – start operation.

41. Surgical Management of Uterine Atony With intractable atony unresponsive to the above measures, surgical intervention can be lifesaving. Surgery – hysterotomy with uterine artery ligation or internal iliac artery ligation . Uterine Compression Sutures B-Lynch . A number of modifications of the B-Lynch technique have been described. In addition to B-Lynch compression sutures, the woman also had bilateral ligation of uterine, uterovarian , and round ligament arteries . UterinePacking . This technique should be considered in women with refractory postpartum hemorrhage related to uterine atony who wish to preserve fertility.

42. THANK YOU FOR YOUR ATTENTION!!!