LATE-PREGNANCY BLEEDING

ETIOLOGY
The most common cause of late-pregnancy bleeding is a problem with the PLACENTA :
Placenta Praevia Abruptio Placentae Vasa Praevia

Less common causes of late-pregnancy bleeding include :

Uterine Rupture Injuries or lesions of the CERVIX and VAGINA, Polyps, cancer, and Varicose

Inherited bleeding problems, such as :

HEMOPHILIA, are very rare, occurring in 1 in 10,000 women.

PLACENTA PRAEVIA
The placenta, can PARTIALLY or COMPLETELY cover the cervical opening Late in pregnancy called the cervix, THINS AND DILATES (widens) in preparation for labor, some blood vessels of the placenta stretch and rupture. This causes about 20% OF THIRD-TRIMESTER BLEEDING and happens in about 1 in 200 pregnancies. Risk factors for placenta previa include these conditions:
Multiple pregnancies Prior placenta previa Prior Cesarean delivery

CLASSIFICATION
COMPLETE PLACENTA PREVIA refers to the situation in which the placenta completely covers the opening from the womb to the cervix. PARTIAL PLACENTA PREVIA refers to the placenta that partially covers the cervical opening (since the cervical opening is not dilated until time for delivery approaches, this type of placenta previa occurs after the cervix has begin to dilate). MARGINAL PLACENTA PREVIA refers to a placenta that is located adjacent to, but not covering, the cervical opening. The term LOW-LYING PLACENTA or LOW PLACENTA has been used to refer both to placenta previa and marginal placenta previa.

The terms ANTERIOR PLACENTA PREVIA and POSTERIOR PLACENTA PREVIA are sometimes used after ULTRASOUND EXAMINATION to further define the exact position of the placenta within the uterine cavity.

PLACENTA PREVIA

PLACENTA PREVIA SYMPTOMS

VAGINAL BLEEDING after the 20th week of gestation is the primary symptom of placenta previa. Although the bleeding is typically PAINLESS and Recurrent and the more intense Can be associated with other complications of pregnancy including: PLACENTA ACCRETA occurs when the placental tissues grows too deeply into the womb, attaching to the muscle layer, Can cause LIFE-THREATENING BLEEDING and commonly requires HISTERECTOMY. Placenta accrete occurs in 5% to 10% of women with placenta previa. PRETERM PREMATURE RUPTURE OF THE MEMBRANES (PPROM) Other abnormalities of the placenta or umbilical cord BREECH or ABNORMAL PRESENTATION OF THE FETUS. a REDUCTION IN FETAL GROWTH associated with placenta previa.

PLACENTAL ABRUPTION
A normal placenta separates from the wall of the uterus prematurely and blood collects between the placenta and the uterus. Such separation occurs in 1 in 200 of all pregnancies. The cause is unknown.

CLASSIFICATION OF PLACENTAL ABRUPTION

Classification of placental abruption is based on : EXTENT OF SEPARATION (ie, partial vs complete) and LOCATION OF SEPARATION (ie, marginal vs central). Clinical classification is as follows: Class 0 - Asymptomatic Class 1 - MILD (represents approximately 48% of all cases) Class 2 - MODERATE (represents approximately 27% of all cases) Class 3 - SEVERE (represents approximately 24% of all cases)

DIFFERENTIAL DIAGNOSIS
ABDOMINAL TRAUMA ACUTE APPENDICITIS DISSEMINATED INTRAVASCULAR COAGULATION TORSION OVARIAN CYST PLACENTA PREVIA ECTOPIC PREGNANCY

A DIAGNOSIS OF CLASS 0 IS MADE RETROSPECTIVELY BY FINDING AN:

ORGANIZED BLOOD CLOT OR A DEPRESSED AREA ON A DELIVERED PLACENTA.

CLASS 1 : MILD
CHARACTERISTICS 1. No vaginal bleeding to mild vaginal bleeding 2. Slightly tender uterus 3. Normal maternal BP and heart rate 4. No coagulopathy 5. No fetal distress

CLASS 2 : MODERATE
CHARACTERISTICS 1. No vaginal bleeding to moderate vaginal bleeding 2. Moderate to severe uterine tenderness with possible tetanic contractions 3. Maternal tachycardia with orthostatic changes in BP and heart rate 4. Fetal distress 5. Hypofibrinogenemia (ie, 50-250 mg/dL)

CLASS 3 : SEVERE
CHARACTERISTICS No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, < 150 mg/dL) Coagulopathy Fetal death

A. CONCEALED BLEEDING

B. REVEALED BLEEDING C.MIXED BLEEEDING

COMPLICATION
Potential MATERNAL COMPLICATIONS include the following: 1. Hemorrhagic shock 2. Coagulopathy/disseminated intravascular coagulation (DIC) 3. Uterine rupture 4. Renal failure 5. Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary)

COMPLICATION
Potential FETAL COMPLICATIONS include the following: 1. Hypoxia 2. Anemia 3. Growth retardation 4. CNS anomalies 5. Fetal death

LAB STUDIES IN ABRUPTIO PLACENTAE

Hemoglobin Hematocrit Platelets Prothrombin time/activated partial thromboplastin time Fibrinogen Fibrin/fibrinogen degradation products Blood type

ULTRASONOGRAPHY and MRI

Ultrasonography helps to determine the location of the placenta in order to EXCLUDE PLACENTA PREVIA. Ultrasonography is NOT VERY USEFUL in diagnosing placental abruption (and normal ultrasonographic findings do not exclude the condition).[4] RETROPLACENTAL HEMATOMA may be recognized in 2-25% of all abruptions.
This recognition depends on the degree of hematoma and on the operator's skill level.

MRI is DIAGNOSTICALLY EFFECTIVE and can ACCURATELY depict placental abruption.

Consider using MRI in cases where ultrasonography findings in the presence of late pregnancy bleeding are negative, but positive diagnosis of abruption would change patient management.[7]

MANAGEMENT
Initial Management of Abruptio Placentae 1. Begin continuous external fetal monitoring for the fetal heart rate and contractions. 2. Obtain intravenous access using 2 large-bore intravenous lines. 3. Institute crystalloid fluid resuscitation for the patient. 4. Type and crossmatch blood. 5. Begin a transfusion if the patient is hemodynamically unstable after fluid resuscitation. 6. Correct coagulopathy, if present.

VAGINAL DELIVERY
This is the preferred method of delivery for a fetus that has DIED secondary to placental abruption. The ability of the patient to undergo vaginal delivery depends on her remaining HEMODYNAMICALLY STABLE. Delivery is USUALLY RAPID in these patients secondary to increased uterine tone and contractions.

CESAREAN DELIVERY
Is often necessary for fetal and maternal stabilization. While cesarean delivery facilitates rapid delivery and direct access to the uterus and its vasculature, it can be complicated by the patient's coagulation status.
Because of this, a vertical skin incision, which has been associated with less blood loss, is often used when the patient appears to have DIC. The type of uterine incision is dictated by the GESTATIONAL AGE of the fetus, with a vertical or classic uterine incision often being necessary in the preterm patient.

If hemorrhage cannot be controlled after delivery, a CESAREAN HYSTERECTOMY may be required to save the patient's life.
Before proceeding to hysterectomy, other procedures, including
correction of coagulopathy, ligation of the uterine artery, administration of uterotonics (if atony is present), packing of the uterus, and other techniques to control hemorrhage, may be attempted.

UTERINE RUPTURE
An abnormal splitting open of the uterus, causing the baby to be partially or completely expelled into the abdomen. About 40% of women who have uterine rupture had prior surgery on their uterus, including Cesarean delivery. The rupture may occur before or during labor or at the time of delivery. Other risk factors for uterine rupture are these conditions:
More than four pregnancies (MULTIPARITY) Trauma Excessive use of OXYTOCIN (Pitocin), a medicine that helps strengthen contractions A baby in any position other than head down Having the baby's shoulder get caught on the pubic bone during labor Certain types of forceps deliveries

FETAL VESSEL RUPTURE

Occurs in about 1 of every 1,000 pregnancies. The baby's blood vessels from the umbilical cord may attach to the membranes instead of the placenta. The baby's blood vessels pass over the entrance to the birth canal.
This is called VASA PREVIA and occurs in 1 in 5,000 pregnancies

PLACENTA BILOBATA

PLACENTA SUCCENTERIATA

DIAGNOSIS
The classic triad of the vasa praevia is:
Membrane rupture, Painless vaginal bleeding and Fetal bradycardia.

This is rarely confirmed before delivery but may be suspected when antenatal sono-gram with color-flow Doppler reveals a vessel crossing the membranes over the internal cervical os.[2][3] The diagnosis is usually confirmed after delivery on examination of the placenta and fetal membranes MOST OFTEN THE FETUS IS ALREADY DEAD when the diagnosis is made; because the blood loss (say 300ml) constitutes a major bulk of blood volume of the fetus (80-100ml/kg i.e. 300ml approx for a 3kg fetus)[citation needed].

dr.Bambang Widjanarko, Sp OG
Dept.Obstetri Gynecology School of Medicine & Health Muhammdiyah University of Jakarta

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