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Antepartum/ third trimester Bleeding| EK- ASUSM

Antepartum Hemorrhage/ Third trimester Bleeding


Vaginal Bleeding occurring from 24 weeks gestation to delivery

Incidence: ~2-5 % of all Pregnancies Placental Abruption 40% ~1% of all Pregnancies Unclassified 35% Placenta Previa 20% ~.5% all pregnancies Lower Genital Tract Lesion 5% Other Etiology Cervical: Contact bleed Inflammation Effacement and dilatation Placental o Abruption o Previa o Marginal Sinus rupture Vasa Previa Other: abnormal coagulation Diagnostic Procedure 1. 2. 3. 4. 5. H & P : NO digital exam U/S Fetal monitoring Speculum Labs: non-diagnostic but beneficial for management

I.

Placental abruption: a. Premature separation of normally implanted placenta tearing of placental blood vesselshemorrhage into separated space b. Risk Factors Maternal Hypertention Abdominal trauma Cocaine use Previous abruption Overdistended uterus Smoking Increased 2nd trimester MSAFP

Antepartum/ third trimester Bleeding| EK- ASUSM

Subchronic hematoma c. Classification: Totalfetal death Partial: fetus tolerate up to 30-50% abruption i. Class 0: diagnosed retrospectively- organized blood clot or depressed area on delivered placenta ii. Class 1: mild iii. Class 2: moderate iv. Class 3: severe b. Presentation: i. Painful unremitting vaginal bleeding ii. Contractions iii. fetal distress iv.tender uterus, irritability or tetanic uterus

Concealed: blood within uterine cavity (more likely to be complete) Complications: DIC; uterine tetany; fetal hypoxia; fetal death; Sheehan syndrome External: blood drains through cervix Usually smaller with minimum complications Treatment: Cesarean Delivery: Uncontrollable Maternal hemorrhage Rapidly expanding concealed hemorrhage

Antepartum/ third trimester Bleeding| EK- ASUSM

Fetal distress Rapid placental separation Vaginal deliveries: Placental separation limited Reassuring FHR Seperation extensive and fetus is dead

2. Placenta Previa: Abnormal implantation over the cervical os Risk factors: Previous C/S Previous uterine surgery Multiple gestations Previous placenta previa Large number of D&C High Parity Presentation: Painless vaginal bleeding Sentinal bleed: first bleed and is usually very mild Subsequent bleeds are usually much heavierhypovolemic shockDeath Physical Exam: Soft uterus with readily palpable fetal parts Abnormal lie with high presenting parts (if engangement of fetal head is just about pubic symphysisprevia can be ruled out) Diagnostic test: Transabdominal U/S False +ve associated with distended bladder Marginal: covers margin of the os Vaginal delivery possible if Maternal hemorrhage not too great and fetal head exerts enough pressure on placenta to push out of way and tamponade bleeding

Antepartum/ third trimester Bleeding| EK- ASUSM

Complete: covers entire osimpossible for fetal passage thru canal without maternal hemorrhageC/S Low-lying: located near the internal os

Treatment: Reserved for large volume bleeding or drop in hematocrit Strict pelvic rest and nothing put into vagina Immediate C/S: Unstoppable labor; severe hemorrhage; fetal distress Prepare for life threatening bleed by type and screen of blood, CBC and prothrombin time Associated with placental invasion Complications: Hemorrhage, Placental acretta, malpresentation, & PPROM, septicemia, thrombophlebitis

3. Vasa Previa: fetal vessels running through the membranes over cervical os and under fetal presenting part Velamentous insertion: cord running through the membrane May insert in a possible accessory placental lobe Rupture of fetal vesselsfetal exsanguination and death Fetal blood volume ~80-100mL/kg i.e. loss of even small amouts of blood can be disasterous

Antepartum/ third trimester Bleeding| EK- ASUSM

Risk Factors: Low lying placenta (if low lying in 2nd trimester ~20% remain so in 3rd trimester) Accessory lobes Multiple gestations IVF Diagnosis: Rupture of membrane vaginal bleeding and fetal distress or death U/S Management: C/S prior to ROM 4. Previa Acretta Adherence of placenta to endometrial cavity Increta-Myometrium Percreta-myometrium and serosa Incidence/ Risk Factors: 5% occur with unscarred uterus 25% with 1 prior C/S 64% with 3 prior C/S (prior C/S with previa) Diagnostic test: U/S or MRI U/S: moth eaten or swiss cheese appearance Increased levels of MSAFP during 2nd trimester Suspect in patient with previa and history of C/S Management: Abdominal total hysterectomy Embolization Methotrexate

Antepartum/ third trimester Bleeding| EK- ASUSM

Complications: Bladder involvement (predelivery hematuria) DIC Need for hysterectomy Surgical injury of ureters, bladder ARDS Renal Failure Spontaneous Uterine rupture

5.Uterine Rupture Life threat to fetus and mother (usually occurs during labor) Risk factors: Previous C/S Trauma (esp MVA) Uterine myomectomy Uterine over distention Placenta previa Presentation: Sudden onset of extreme abdominal pain Abnormal bump in abdomen No Uterine contractions Regression of fetus Management: Immediate laparotomy with delivery of fetus C/S not done because baby may be located outside of uterus

Antepartum/ third trimester Bleeding| EK- ASUSM