antepartum hemorraghe. first trimester bleeding vaginal bleeding is common in the first trimester,...
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Antepartum Hemorraghe
FIRST TRIMESTER BLEEDING
Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women
It may be any combination of light or heavy, intermittent or constant, painless or painful.
FIRST TRIMESTER BLEEDING
The four major sources of bleeding in early pregnancy are:
Ectopic pregnancy
Miscarriage (threatened, inevitable, incomplete, complete)
Implantation of the pregnancy
Cervical, vaginal, or uterine pathology (eg, polyps, inflammation/infection, trophoblastic disease
SECOND AND THIRD TRIMESTER BLEEDING
Vaginal bleeding is less common in the second and third trimesters. The major causes of bleeding at these times are:
Bloody show associated with cervical insufficiency or labor
Placenta previa
Abruptio placenta
Uterine rupture
Vasa previ
Abruptio Placenta
Definition
Placental abruption is defined as decidual hemorrhage leading to the premature separation of the placenta prior to delivery of the fetus.
Causes
The immediate cause of the premature placental separation is often the rupture of maternal vessels in the decidua basalis, where it interfaces with the anchoring villi in the placenta
Incidence
Placental abruption complicates about 1 in 100 births, and an abruption severe enough to result in stillbirth occurs in about 1 in 830 deliveries
COMPLICATIONS OF PLACENTAL ABRUPTION
Maternal
Hypovolemia related to blood loss
Need for blood transfusion
Disseminated intravascular coagulopathy
Renal failure
Adult Respiratory Distress Syndrome
Multisystem organ failure
Death
COMPLICATIONS OF PLACENTAL ABRUPTION
Fetal
Growth restriction (with chronic abruption) [1-6]
Fetal hypoxemia or asphyxia
Preterm birth [1,2]
Perinatal mortalit
INITIAL MANAGEMENT
Patients suspected to have a placental abruption should have a rapid initial evaluation
Subsequent management is determined on a case-by-case basis, and will depend upon the severity of the abruption, the gestational age, and maternal and fetal status
INITIAL MANAGEMENT
Continuous fetal monitoring should be initiated immediately, given the high likelihood of diminished placental perfusion
Most serious maternal risks are due to hypovolemia
It is important to immediately secure two wide-bore intravenous lines
INITIAL MANAGEMENT
The mother's hemodynamic status is closely monitored
In severe cases, a Foley catheter should be inserted to monitor maternal urine output hourly. The urine output should be maintained at above 30 ml/hour.
INITIAL MANAGEMENT
A complete blood count, blood type and Rh, and coagulation studies are obtained
A low fibrinogen level is the most sensitive indicator of coagulopathy related to abruption
Prolongation of the prothrombin time (PT) and partial thromboplastin time (PTT) does not occur with small degrees of placental separation
INITIAL MANAGEMENT
Blood loss should be evaluated carefully
It is frequently underestimated since the bleeding may be largely concealed, and the actual loss may be much more than observed
Blood and blood coagulation replacement products should be readily available
INITIAL MANAGEMENT
Ultra Sound should be performed in stable patients, if possible
While some studies have reported poor sensitivity of ultrasound in the diagnosis of placental abruption, others have found that ultrasound can be an accurate tool in diagnosis
The presence of sonographic features of abruption has a very high positive predictive value, and may influence management
Blood and Blood Product Replacement
Maintain the hematocrit above 30 percent
Each unit of 300 mL PRBC’s contains approximately 200 mL of red cells and will raise the hematocrit by roughly 3 to 4 percent
Give six units of platelets to patients with marked thrombocytopenia (<20) or moderate thrombocytopenia (< 50) with serious bleeding or planned cesarean deliver
Blood and Blood Product Replacement
Fresh frozen plasma or cryoprecipitate is indicated for fibrinogen level < 150 mg/dL, with the goal of raising he level to 150 to 200 mg/dL
Fresh frozen plasma provides more volume than cryoprecipitate depending on the patient's cardiovascular status
Blood and Blood Product Replacement
If multiple transfusions are given because of severe bleeding, the coagulation system should be frequently monitored with measurements of the PT, PTT and platelet count, preferably after each five units of blood are replaced
If the PT and PTT exceed 1.5 times the control value, the patient should be transfused with two units of fresh frozen plasma
If the platelet count falls below 50,000/microL, six units of platelets should be given
SUBSEQUENT MANAGEMENT
Subsequent management of pregnancies complicated by abruption depends primarily on:
The fetus (alive or dead)
Maternal status
Live fetus at or near term
The fetus should be delivered by the quickest, safest method if it is alive, the pregnancy is at least 34 weeks of gestation, and abruption is suspected
Live fetus at or near term
Vaginal delivery requirements:
Maternal status is stable
Fetal heart tracing is reassuring with continuous monitoring
Preparating for emergency cesarean section
Live fetus at or near term
Cesarean delivery indications:
Fetal heart tracing is nonreassuring
There is ongoing major blood loss or other serious maternal complications
Fetal Demise
The mode of delivery should be one that minimizes the risk of maternal morbidity or mortality
Vaginal delivery is preferable unless urgent delivery is needed to enable stabilization of the mother or there are obstetrical contraindications to vaginal birth
Since the patient is often contracting vigorously, amniotomy may be all that is required to expedite delivery
Oxytocin can be given, if needed to augment labor
Fetal Demise
The frequency of coagulopathy is much higher in abruptions in which fetal death has occurred
Blood pressure, pulse, urine output and blood loss should be monitored closely
Blood, fresh frozen plasma, platelets, and cryoprecipitate should be readily available and given liberally.
Placenta Previa
INTRODUCTION
The management of pregnancies complicated by placenta previa is best considered in terms of the clinical setting:
Asymptomatic women
Women who are actively bleeding
Women who are stable after one or more episodes of active bleeding
ASYMPTOMATIC PLACENTA PREVIA
Sonographic reassessment to determine placental position (serial transvaginal ultrasound evaluations at four-week intervals beginning at 28 weeks of gestation)
Development of the lower uterine segment over time often relocates the stationary lower edge of a marginal or low-lying placenta away from the internal os
ASYMPTOMATIC PLACENTA PREVIA
Sonographic measurement of cervical length
It provides useful information about the risk of hemorrhage
Studis found that a short cervix was associated with a significantly increased frequency of delivery because of hemorrhage
64 percent of women with a cervical length greater than 3 cm had no bleeding episodes and progressed to term
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
An actively bleeding placenta previa is anobstetrical emergency
These women should be admitted to the Labor and Delivery Unit for maternal and fetal monitoring
Intravenous access should be established (two large bore IV lines)
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Blood Bank and Laboratory Monitoring :
A blood type and antibody screen should be performed
If bleeding is heavy or increasing, or difficulty in procuring compatible blood is anticipated, then we advise cross-matching two to four units of packed red blood cells
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Fetal monitoring
The fetal heart rate is continuously monitored
Loss of reactivity, persistent minimal variability, or fetal tachycardia, recurrent late decelerations are nonreassuring signs suggesting the potential presence of fetal hypoxia or anemia
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Maternal monitoring
Use a cardiac monitor and automated blood pressure cuff to follow maternal heart rate and blood pressure
Urine output is evaluated hourly with a Foley catheter attached to a urimeter
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Maternal monitoring
Vaginal blood loss can be estimated by weighing or counting perineal pads
Visual estimations of blood loss in obstetrics have historically been inaccurate
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Tocolysis
Generally tocolysis is not used with actively bleeding patients
Tocolysis may be considered if contractions are present, bleeding is diminishing or has ceased, and delivery is not otherwise mandated by the maternal or fetal condition
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Indications for delivery
A nonreassuring fetal heart rate tracing unresponsive to maternal oxygen therapy, left-sided positioning, and intravascular volume replacement
Life-threatening refractory maternal hemorrhage
Significant vaginal bleeding after 34 weeks of gestation
ACUTE CARE OF SYMPTOMATIC PLACENTA PREVIA
Anesthesia
General anesthesia is typically administered for emergency cesarean delivery, especially in hemodynamically unstable women or if the fetal status is nonreassuring
However, regional anesthesia is an acceptable choice in hemodynamically stable women with reassuring fetal heart rate tracings
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Most women who initially present with symptomatic placenta previa respond to supportive therapy and do not require immediate delivery
Fifty percent of women with a symptomatic previa (any amount of bleeding) are not delivered for at least four
A large bleed does not preclude conservative management
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Symptomatic women often remain hospitalized from their significant bleeding episode until delivery
Since recurrent bleeding episodes are unpredictable, keeping close to the hospital minimizes the risk of complications by enabling fast access to transfusion therapy and emergency cesarean delivery when needed
Select women with placenta previa may be discharged if bleeding has stopped for a minimum of 48 hours and there are no other pregnancy complications
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Candidates for outpatient care should:
Be able to return to the hospital within 20 minutes
Have an adult companion available 24 hours a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding
Be reliable and able to maintain bed rest at home
Understand the risks entailed by outpatient managemen
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Correction of anemia
Iron supplementation may be needed for optimal correction of anemia
Stool softeners and a high-fiber diet help to minimize constipation and avoid excess straining that might precipitate bleeding
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Autologous blood donation
Autologous blood donation is acceptable in stable women who meet usual criteria (hemoglobin ≥11.0 g/dL)
A program of autologous blood collection and transfusion can result in a decrease in homologous blood transfusion
Most women who have bled from a placenta previa, however, will not meet standard criteria for autologous donation
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Antenatal corticosteroids
A course of antenatal corticosteroid therapy should be administered to symptomatic women between 24 and 34 weeks to improve fetal pulmonary maturity
Do not administer steroids to asymptomatic women or those whose first bleed is after 34 weeks of gestation
CONSERVATIVE MANAGEMENT AFTER AN ACUTE BLEED
Fetal assessment
There is value of nonstress testing or BPP in the asymptomatic placenta previa patient who has no evidence of uteroplacental insufficiency or other signs of distress
Active vaginal bleeding is an indication for fetal assessment
DELIVERY
Timing
Severe persistent hemorrhage is an indication for delivery, regardless of gestational age
The delivery of a pregnancy with uncomplicated placenta previa should be accomplished at 36 to 37 weeks, without documentation of fetal lung maturity by amniocentesis
The rationale behind this is that the risks of continuing the pregnancy were greater than the risks of complications from prematurity
DELIVERY
Women with increasing frequency or volume of bleeding or with signs of imminent labor are delivered at ≤36 weeks if they have received a steroid course
However, women whose first bleed occurred after 34 weeks may not have received a course of betamethasone
If a course of antenatal steroids has not been given, an amniocentesis is performed and deliver the baby at ≤36 weeks if pulmonary indices are mature
Route of Delivery
Complete previa
A cesarean delivery is always indicated when there is sonographic evidence of a complete placenta previa and a viable fetus
Vaginal delivery may be considered in rare circumstances, such as in the presence of a fetal demise or a previable fetus, as long as the mother remains hemodynamically stable
Route of Delivery
Low-lying placenta
Rates of cesarean delivery and antepartum bleeding decrease as the distance between the placental edge and internal os increases.
There is a reasonable possibility of vaginal delivery when the placenta is more than 2 cm from the internal os, so a trial of labor is appropriate
When this distance is between 1 and 20 mm, the rate of cesarean delivery ranges from 40 to 90 percent
Route of Delivery
Marginal previa
Historically, it was believed that vaginal delivery could occasionally be performed safely in women with marginal previa because the fetal head tamponades the adjacent placenta
However most women with marginal previa will end up with a cesarean delivery
Scheduled cesarean delivery is done for these pregnancies to minimize the risk of emergent delivery and hemorrhage
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