obstetric 1 antinatal care for midwifery].pdf

lecture note ambo university college of health

1. BLEEDING IN LATE PREGNANCY
Mr. Fikadu Wondimu(Bsc, MSc)
1

2. Session objectives
By the end of this session students will be able to
Introductions to bleeding in late pregnancy
Recognize pathophysiology of bleeding in late
pregnancy
Describe the major types of bleeding in late
pregnancy
Familiar with the risk factors for bleeding in late
pregnancy
Explain DDX, Complications and management
2

3. Introduction
3
Maternal mortality ratio:
The number of maternal deaths per 100 000 live births.
Maternal mortality is widely acknowledged as a general
indicator of the overall health of a population, of the
status of women in society and of the functioning of the
health system.

4. Causes of maternal mortality
What are the causes of maternal mortality globally?
(5Minutes)

4

5. Causes of maternal mortality…
There are two major causes:- direct and indirect causes
1.Direct causes(80%)
Hemorrhage
Hypertensive dis-orders
Infection/sepsis
Obstructed labor
Unsafe abortion
2.Indirect causes (20%)
Existing cardiovascular diseases
Malaria
HIV/AIDS
Anemia, etc


5

6. Causes of maternal mortality…
6

7. Contributing factors to mortality
Timing is critical in preventing maternal and new-born
death and disability
The ‘three delays’ model. Source: UNFPA, 2014
7

8. Vaginal bleeding in late pregnancy
Definition :-
Vaginal bleeding that occurs:

After 28 weeks of pregnancy (late)

During labor before childbirth

8

9. QUESTION ???
What are the most common causes of bleeding
in late pregnancy?
9

10. Bleeding in Late Pregnancy
(ANTEPARTUM HAEMORRHAGE)
Abruptio placenta
Placenta previa
Vasa Praevia
Others: Uterine rupture, Cervical, Vaginal diseases

10

11. Abruptio placenta
What is an abruptio placenta?
11

12. Abruptio placenta
Abruptio placenta is defined as:-
the premature separation of the placenta
either partially or totally from its implantation
before fetus is delivered.
It is a significant cause of third-trimester
bleeding associated with fetal and maternal
morbidity and mortality
12

13. ABRUPTIO PLACENTA
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REVEALED
CONCEALED

14. ABRUPTIO PLACENTA
the left is total placental
abruption with concealed
hemorrhage.

the right is a partial abruption
with blood and clots that
dissect between membranes
and decidua to reach the
internal cervical os and then
the vagina
14

15. Epidemiology of Abruptio placenta
One third of antepartum bleeding is due to AP.
Incidence ranging from 1 in 75 up to 1 in 225 births
AP recurs in 5-17% of pregnancies after one prior
episode
Up to 25% after two episodes
15

16. Risk factors
The primary cause of placental abruption is usually
unknown, but multiple risk factors have been identified.
Maternal hypertension (44% of all causes)
Maternal trauma
Maternal substance abuse(Cigarette smoking, alcohol
consumption and cocaine use)
Short umbilical cord
Sudden decompression of the uterus (eg, premature
rupture of membranes, delivery of first twin)
Retroplacental bleeding from needle puncture (ie, post-
amniocentesis)


16

17. Risk factors…
Idiopathic (probable abnormalities of uterine blood
vessels and decidua)
Elevated alpha-fetoprotein ((MSAFP)): associated with
up to a 10-fold increased risk of abruption
Previous placental abruption
Chorioamnionitis


Prolonged rupture of membranes (18hours or longer)
Maternal age younger than 20 or 35 years or older
Male fetal sex
Low socioeconomic status

17

18. 18

19. Classification of abruption placenta
Placental abruption can be classified into different
grades (grade 0-3) based on its severity.
I.Grade 0 (Asymptomatic):- incidental finding
of retro placental clot.
II.Grade 1 (Mild)
III.Grade 2 (Moderate)
IV.Grade 3 (Severe)
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Partial placental abruption
with a dark adherent clot

20. Classification of abruption placenta
20

21. Severe abruptio placenta
21
Defining placental abruption severity is problematic
severe placental abruption as displaying one or
more of the following:
I.maternal sequelae that include disseminated
intravascular coagulation (DIC), shock, transfusion,
hysterectomy, renal failure, or death
II.fetal complications such as NRFHBP,IUGR, or death
III.neonatal outcomes that include death, preterm
delivery, or growth restriction

22. Diagnosis of Abruptio Placenta
Vaginal bleeding:
menstrual-like (dark),
totally concealed or
the amount is less than
the degree of the
shock
Sudden on set of
intermittent or constant
abdominal pain/ (uterine)
tenderness
Symptoms sometimes
present:
Shock
TENSE/TENDER UTERUS
NRFHRP or absent fetal heart beat
Fetal distress or absent fetal
heart sounds
Ultrasound – to rule out
placenta previa
Coagulation defect: frank
bleeding (epistaxis,
ecchymosis, petechiae).
22

23. Diagnosis…
Consumptive Coagulopathy
Couvelaire Uterus
End-organ Injury
Acute kidney injury (AKI)
Sheehan syndrome
23

24. 24
Couvelaire uterus from total placental abruption after
cesarean delivery, Blood markedly infiltrates the
myometrium to reach the serosa.(from William 26 edition)

25. Diagnosis…
less severe forms are not always recognized and the
diagnosis becomes one of exclusion.
no laboratory tests or other diagnostic methods
accurately confirm lesser degrees of placental
separation
elevated serum levels of D-dimers may be
suggestive


25

26. Diagnosis…
Magnetic resonance imaging (MRI) is highly
sensitive for placental abruption and should be
considered
U/s has limited use because the placenta and
fresh clots may have similar imaging
characteristics
26

27. LABORATORY INVESTIGATIONS
27
HCT
 Blood group and Rh
Coagulation profile: Platelet count, PT, PTT,
fibrinogen or bedside clotting and bleeding tests
Ultrasound: Fetal assessment, retroplacental clot
and for exclusion of placenta previa

28. COMPLICATIONS
Hemorrhagic shock
End organ injury:- acute kidney injury, congestive
heart failure, Sheehan syndrome etc
DIC (Consumptive Coagulopathy)
Couvelaire Uterus
IUGR, fetal distress or IUFD
chronic abruption oligohydramnios sequence(CAOS)
PPH
28

29. Bleeding in Late Pregnancy:
General Management
SHOUT FOR HELP.
Make a rapid evaluation of the general condition of the
woman including vital signs.
Note:- Vaginal or rectal examination should not be done as it
can aggravate bleeding.
Open IV line with N/S or R/L.
If shock is suspected, immediately begin treatment.
Start an IV infusion and infuse IV fluids.
 All cases of APH should be managed in a facility with set
up for cesarean delivery; therefore refer urgently while
continuing resuscitation and supportive care.
29

30. Specific management: Delivery
varies depending on maternofetal clinical condition,
gestational age, and amount of associated
hemorrhage
A.Immediate delivery:
GA >37 weeks or estimated fetal weight is
>2.5 Kg
Deranged vital signs
heavy bleeding or established labor
 NRFHRP, IUFD or malformed fetus
30

31. Specific Management: Delivery…
Cesarean Delivery:-The compromised fetus is
usually best served by cesarean delivery
Vaginal Delivery:-If the fetus has died or if it is not
considered sufficiently mature to live outside the
uterus, vaginal birth is preferable for the mother
Cervical ripening and induction of labor,
amniotomy
31

32. Treatment…
Expectant Management:-delaying delivery may
benefit an immature fetus
Dexamethasone 6 mg IM BID or Betamethasone
12 mg IM every 24 hrs for 48 hours.
 Anti D 300µg IM if Rh -ve and not sensitized.
Closely monitor maternal and fetal conditions.
Prevent and treat anemia
32

33. PLACENTA PREVIA
What is placenta previa?
33

34. PLACENTA PREVIA
Placenta previa is defined as the presence of
placental tissue over or adjacent to the cervical os
Placenta previa describes a placenta that is
implanted somewhere in the lower uterine
segment, either over or very near the internal
cervical os.
Placenta previa is associated with development of
lower uterine pole in the 3
rd
trimester.
34
The Latin previa means going before

35. Incidence of placenta previa
35
The incidences approximately 4-5cases per 1000
pregnancies
In 80% cases, it is found in multiparous women
The incidence is increased in previous c/s, black
and Asian women and advanced maternal
age(>35 years)

36. Classification of Placenta Previa
National Institutes of Health (NIH) recommends the
following classification.
Two types:
1.Placenta previa: the internal os is covered
partially or completely by placenta
2.Low-lying placenta: implantation in the lower
uterine segment is such that the placental edge
does not cover the internal os but lies within a
2-cm wide perimeter around the os.
36

37. Image of placental previa
37

38. 38
A: Normal placenta. B. Low implantation.
C: Partial placenta previa. D: Complete placenta previa.

39. Risk factors
39
Scarred uterus: previous uterine surgery (CS,
myomectomy), uterine curettage
Previous history of placenta previa
Large placenta: multiple pregnancy, diabetes,
smoking, syphilis, Rh incompatibility
Multiparity

40. Risk factors…
40
Black and Asian women
Advanced maternal age(>35 years)
Assisted reproductive technology (ART)
Uterine leiomyomas
Higher altitude

41. QUESTION ???
How would you diagnose placenta previa?
What are the symptoms and signs?
41

42. Diagnosis of Placenta Previa
Vaginal bleeding:
Bright red, painless
and recurrent after
28 weeks gestation
Double setup
examination: Used
only in areas where
U/S is not
available/or the
U/S is not done by
experienced person
Symptoms sometimes present:
Shock
Bleeding may be precipitated by
intercourse
Soft, relaxed uterus and non-tender
Fetal presentation not in
pelvis/lower uterine pole feels
empty
Normal fetal condition
Ultrasound(trans abdomen or
transvaginal):- Confirms diagnosis 42

43. Complications of placenta previa
43
PPH
Hemorrhagic shock
Adherent placenta(especially placenta accreta
spectrum in prior cesarean section )
Fetal distress or IUFD
Coagulopathy rarely complicate placenta previa

44. ADHERENT PLACENTA
44
Placenta accreta involves abnormal trophoblastic invasion
beyond the Nitabuch’s layer.
Placenta increta is the term used to describe invasion into the
myometrium.
Placenta percreta describes invasion through the serosa with
possible invasion into surrounding tissues such as the bladder.
The optimum time for planned delivery for a woman with
suspected adherent placenta and placenta previa is at 36wks

45. General Management of placenta previa
SHOUT FOR HELP.
Make a rapid evaluation of the general condition of the
woman including vital signs.
Note:- Vaginal or rectal examination should not be done as it can aggravate
bleeding.
Open IV line with N/S or R/L.
If shock is suspected, immediately begin treatment.
Start an IV infusion and infuse IV fluids.
 Two or more units of bank blood should be typed, cross-
matched, and ready for transfusion
All cases of APH should be managed in a facility with set up
for cesarean delivery; therefore refer urgently while continuing
resuscitation and supportive care.
45

46. General Management of placenta previa
Care with placenta previa is individualized, and
influenced by three prominent factors:-
1.Fetal maturity
2.Associated labor
3.Bleeding severity
46

47. Question???
47
Which one of the following is recommended during
the management of placenta previa?
I.use of tocolytic agents
II.Digital palpation
III.Activities restriction
IV.Sexual intercourse
V.Antenatal corticosteriod
VI.Frequent ultrasound scanning
placental migration due to trophotropism

48. Specific Management of placenta previa
Expectant management:
If GA is < 37 weeks, patient in stable condition and
reassuring fetal condition
Give dexamethasone 6 mg IM BID or betamethasone
12 mg IM every 24 hours for 48 hours if GA < 37 wks
Anti D 300µg IM if Rh negative and not sensitized
Closely monitor maternal and fetal conditions with APH
chart.
Prevent and treat anemia
48

49. Specific Management of placenta previa
Immediate delivery:(vaginal or cesarean section)
Gestational age is >or equal to 37 weeks,
deranged vital signs
heavy bleeding
NRFHRP or IUFD or lethal congenital anomaly of
the fetus
established labor
49

50. Comparison
50
Manifestation Placenta previa Abruptio placenta
•Onset Insidious Sudden
•Type of bleeding Always visible, slight
then more profuse
Can be concealed or
visible
•Blood description Bright red Dark
•Discomfort/ pain Painless Constant, uterine
tenderness
•Uterine tone Soft and relaxed Firm to rigid
•Fetal heart rate Usually in normal Fetal distress or absent
•Coagulation
defects
Rare Associated, but infrequent
DIC often severe when
present

51. Summary
Vaginal bleeding the late pregnancy and labor
can be catastrophic:
Evaluate rapidly
Resuscitate if patient in shock
Refer urgently to a hospital continuing resuscitation.
51

52. Vasa previa
52
vessels travel within the membranes and overlie the
cervical os.
There, they can be torn with cervical dilation or
membrane rupture, and laceration can lead to
rapid fetal exsanguination.
rates are 1 case in 338 to 365 pregnancies

53. UTERINE RUPTURE

54. Definition of Uterine Rupture
•Uterine rupture is a when the muscular wall of
the uterus tears during pregnancy or childbirth.
•Uterine rupture has become a rare obstetric complication
due to increasing access of women to antenatal and
skilled intrapartum care
•It is however still prevalent in low-resource settings where
skilled childbirth care is mostly unavailable, e.g. SSA
•Increasing rates of caesarean deliveries also increase the
possibility of a rise in rates of scar dehiscence in the
future.
•Uterine rupture frequently is catastrophic and leads to high
maternal and perinatal loss

54

55. Classifications of Uterine Rupture
Extent
•Complete rupture- tearing of myometrium and serosa
•Incomplete uterine rupture- tearing of myometrium but with
intact serosal cover
Etiology
•Spontaneous uterine rupture- uterine rupture without any
external trauma
•Traumatic uterine rupture- uterine rupture following
iatrogenic or accidental trauma



55

56. Classifications of uterine rupture…
Timing
•Antepartum uterine rupture- uterine rupture before the
onset of labor – usually scar dehiscence
•Intrapartum uterine rupture- uterine rupture during labor

Presence of Scar
•Rupture of an unscarred uterus (primary uterine rupture)
•Rupture of a scarred uterus – “Uterine Scar Dehiscence”
(secondary uterine rupture)
56

57. Etiology of Uterine Rupture
Abnormal labor: OL, precipitated labor, titanic uterine
contraction
Trauma: accident, domestic violence
Uterine scar: previous repaired rupture; previous uterine
perforation, previous C/S.
Spontaneous: Certain antepartum or intrapartum ruptures
occur without any obvious explanations; extremely rare
occurrence.
Iatrogenic: Uncontrolled induction and augmentation,
inappropriate instrumental delivery,….







57

58. Etiology of Uterine Rupture…
Uterine over distension:- polyhydramnios, multiple
pregnancies
Internal version of second twin
Breech extraction
Fetal anomaly distending lower uterine segment
Difficult manual removal of placenta
Placenta accret syndrome
Uterine congenital malformation: defective
connective tissue- Marfan or Ehlers- Danlos syndrome

59. CLINICAL FINDINGS
The classic signs and symptoms of complete uterine
rupture are:
Sudden onset tearing abdominal pain (sudden feeling
of something giving way)
Cessation of uterine contractions
Easily palpable fetal parts
Abnormal uterine contour
Signs of intra-abdominal hemorrhage

60. CLINICAL FINDINGS…
Tender abdomen
Absent fetal heart sounds
Vaginal bleeding
Recession of the presenting part
Haemorrhagic shock- dizziness, weakness, sweating,
coma
Copious bright red blood through the catheter
indicates involvement of the bladder

61. Diagnosis of Uterine Rupture…Summary
Symptoms Signs
•Symptoms of hypovolemia and
shock – dizziness, weakness,
sweating, coma,
•In labor- cessation of typical
labor pains and replacement
with diffuse generalized severe
abdominal pain
•Vaginal bleeding
•Cessation of fetal movement
•Respiratory difficulty
•Fever, chills, rigors
•History of previous uterine
surgery in some mothers

•Hypovolemia and shock
•Acute cardio respiratory distress
•Pallor
•Dry mucosal surfaces
•Tender abdomen
•Easily palpable fetal parts
•Fetal distress or death
•Evidence of fluid in abdomen
•Features of obstructed labor on
vaginal exam
•Bloody vaginal discharge
•Bloody urine on bladder
catheterization
61

62. Complications of Uterine Rupture
Hypovolemic shock
Septic shock
Stillbirth and early neonatal death
Hysterectomy and loss of fertility
Bladder injury
Post partum anemia
Maternal mortality

62

63. Management of Uterine Rupture
Resuscitation Surgical Management
•Administer oxygen by face mask
•Open wide bore IV access,
resuscitation with crystalloids
•Administration of broad
spectrum antibiotics
•BG and cross match blood for
possible transfusion
•Catheterize bladder and
monitor input-output.
•Insert NG tube if food ingested
recently or labor prolonged for
days to avoid aspiration
•Administer antacids
•Prepare for emergency surgery
or refer
Immediate Laparotomy
Type of surgery depends on:
•Parity and future fertility needs
•Hemodynamic status and ability to
withstand prolonged anesthesia
•Site and extent of rupture
•Presence or absence of overt
uterine and intra abdominal
infection
Types of Surgery
• Total abdominal hysterectomy
• Subtotal abdominal hysterectomy
• Repair of Ux with tubal ligation
• Repair without tubal ligation

64. Thank you!