Antepartum hemorrhage Flashcards
Placenta previa
Complete, partial, marginal
Most common reasons for peripartum hysterectomy?
Uterine atony FORMERLY, now it’s placenta previa w/ associated accreta (2/3 of them need hysterectomy)
Placenta increta
Placenta invades myometrium
Placenta percreta
Placenta invades thru myometrium INTO the serosa…or even beyond!
Differential of antepartum bleeding?
- Placenta previa, placental abruption, vasa previa
- Uterine rupture
- Fetal vessel rupture
BLEEDING USUALLY FRANK
Placenta accreta
Adheres to the UTERINE WALL.
Velamentous placenta
When blood vessels insert between the amnion and chorion. Vessels largely unprotected and vulnerable to compression or injury.
Placenta previa epidemiology
0.5% of pregnancies
20% of all antepartum hemorrhage
Placenta previa w/ accreta incidence?
5% of placenta pre via cases
Rules about placenta previa?
1) The later in pregnancy its diagnosed, the higher the likelihood of persistence to delivery
2) Low-lying placenta in 2nd trimester is a risk factor for developing VASA PREVIA…use u/s to check later in pregnancy
Predisposing factors for placenta previa?
1) History of placenta previa
2) Prior uterine scar (eg. prior c/s), prior uterine surgery eg. myometctomy
- Multiparity
- Multiple gestation
- Erythroblastosis
- Smoking
- Increasing maternal age
- Uterine anomaly
Diagnosis of placenta previa?
ULTRASOUND
Transvaginal is better bc of fewer false positives. It’s not dangerous with its placement.
Treatment of placenta previa?
Strict pelvic rest (no sex) and modified bed rest.
Some hospitalize right away.
Others, no hospitalized bed rest until large bleed, or drop in Hct of > 3 points.
When should you DELIVER NO MATTER GESTATIONAL AGE?
- Unstoppable labor
- Fetal distress
- Life-threatening hemorrhage
Which placenta abnormality patients should get c/s? Vaginal considered for which?
C/S= PLACENTA 2 cm from os)
Recent decision regarding planning delivery in placenta previa?
34 up until 37 at the latest is probably optimal AND amnio isn’t that useful for determining fetal lung maturity
What do you need to do with ACUTE SETTING of vaginal bleeding and suspected previa or accreta?
1) Stabilize patient- IV catheters, labs of HCT, type cross, RhoGAM after a Kleihaur-Betke test
2) Prepare for catastrophic hemorrhage- transfusions are usually given to maintain Hct of 25% or more
3) Prepare for preterm delivery- give steroids; be cautious with tocolytics
Plan when you’re dealing with known placenta previa or accreta?
1) Plan for TAH at the time of cesarean (esp with accreta)
2) Schedule delivery for 34-37 wks
3) Plan ahead and have backup available like blood products
Placental abruption definition
Premature separation of normally implanted placenta from the uterine wall. Hemorrhage between wall and placenta.
Concealed vs. external hemorrhage?
20% concealed
80% frank bleeding on outside of body
Predisposing factors to placental abruption?
-Hypertension #1 (whether chronic, preeclampsia, or cocaine/methamphetamine induced)
- Previous one
- Advanced maternal age
- Multiparity
- Uterine distension
- Multiple pregancy
- Polyhydramnios
- Vascular deficiency
- Diabetes
- Collagen vascular disease
- Cocaine or methamphetamine use
- Cigarette smoking
- Alcohol use
- Circumvallate placenta
- Short umbilical cord
Precipitating factors for placental abruption?
- Trauma
- External/internal version
- MVA, abdominal trauma
- Sudden uterine volume loss (eg. delivery of first twin)
- Rupture of membranes with polyhydraminos
- PPROM
Epidemiology of placental abruption
0.5-1.5% of pregnancies
Incidence increases with number of gestations but the MORTALITY is greatest among SINGLETONS!
Classic presentation of placental abruption?
Third trimester vaginal bleeding associated with severe abdominal pain and/or frequent strong contractions
THOUGH MANY HAVE FEW OR NO SYMPTOMS and are id’d after seeing the placenta after delivery
Classic sign of placental abruption that can only be seen during c/s?
Couvelaire uterus- LIFE THREATENING.
When the myometrium turns bluish due to having so much bleeding
Diagnosis of placental abruption?
Mostly clinical. Negative u/s DOES NOT exclude placental abruption.
Retroplacental clot with overlying placental destruction confirms.
Additional findings with placental abruption?
- Hypovolemic shock (with oliguria which can be corrected with rigorous IV infusion)
- Consumptive coagulopathy (elevated D-dimer aka fibrin degradation products). MORE LIKELY WITH A CONCEALED ABRUPTION. Plasminogen–> plasmin.
Treatment of placental abruption?
Vaginal or c/s?
1) Stabilize patient
2) Prepare for future hemorrhage (Large bore IVs, infusion of lactated Ringer’s, 2 units packed RBCs: 1 unit fresh frozen plasma)
3) Prepare for preterm delivery
4) Deliver if bleeding is life threatening or fetal testing is nonreassuring
VAGINAL DELIVERY PREFERRED AS LONG AS BLEEDING IS CONTROLLED AND THERE ARE NO SIGNS OF FETAL DISTRESS.
Uterine rupture risk?
More than 90% are associated with prior uterine scar from either c/s or other uterine surgery
For example, TRAUMA, L&D issues like improper oxytocin use or excessive fundal pressure
Spontaneous causes: placenta percreta, multpile gestation, grand multiparity, invasive mole, choriocarcinoma, large fetus, external version
Presentation of uterine rupture?
HIGHLY VARIABLE
Regression of the presenting fetal part Nonreassuring fetal testing Abnormal abdominal contour Cessation of contractions Disappearance of fetal heart tones
How do you treat uterine rupture?
- Immediate laparotomy
- Delivery of fetus
Discouraged to attempt future pregnancies given high risk of recurrence or told they would need a c/s.
Fetal vessel rupture cause? Incidence? Clinical manifestations?
Velamentous cord insertion- cords inserting between amnion and chorion instead of directly into the chorionic plate
Only 0.1-0.8% of pregnancies
Singletons 1%, Twins 4-12%
Vaginal bleeding assoc with sinusoidal FHR (fetal anemia).
DELIVER THE FETUS IMMEDIATELY
Diagnosis of fetal vessel rupture?
Apt test- examines blood for nucleated (FETAL) RBCs.
Pink is fetal meaning positive test, yellow-brown is maternal and negative.
Nonobstetric causes of antepartum hemorrhage? Outcomes following treatment?
Cervical and vaginal lacerations, hemorrhoids, infections, neoplasms
Simple treatment and good outcomes.
