Download - 07 - Antepartum Hemorrhage
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Antepartum Hemorrhage
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Peripartum Hemorrhage Causes of maternal death in US, 1987-90 (9.1/100,000)
– hemorrhage: 28.7% (*)– embolism: 19.7% (*)– pregnancy-induced hypertension: 17.6% (*)– infection: 13.1% (*)– cardiomyopathy: 5.6% (*)– anesthesia: 2.5% (*)
* compared with 1979-86
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Antepartum Hemorrhage
4% of women may develop antepartum hemorrhage.
Bleeding in pregnancy after 28 weeks gestation Causes:
– placenta previa (1/200)– placental abruption (1/100)– uterine rupture (<1% in scarred uterus)– vasa previa (1/2000-3000)
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Placenta Previa
Definitions:– Total: covers the cervical os– Partial: covers part of the os– Marginal: lies close to, but does not cover, the os
Risk factors:– multiparity– advanced maternal age– prior C/S or other uterine surgery– prior placenta previa
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Types of Placenta Previa
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Placenta Previa: Diagnosis
Painless vaginal bleeding in 2nd/3rd trimester Confirmed by ultrasound Vaginal exams are avoided Up to 10% may have simultaneous abruption Maternal shock is uncommon with 1st
presentation of bleeding
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Placenta Previa: Images
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Plcenta Previa: Images
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Placenta Previa: Obstetric Management
If possible, delay delivery until fetus is mature Indications for delivery:
– active labor– documented fetal lung maturity 37 weeks gestational age– excessive bleeding– development of another obstetric complication
mandating delivery
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Placenta Previa: Management Evaluation on arrival:
– airway– volume status– large bore IV access– type and cross– HCT
Patient has bleeding risk during surgery– OB may have to cut into placenta to remove baby– lower uterine implantation site does not contract as well as
normal fundal site risk of placenta accreta (esp. if prior C/S)
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Placental Abruption
Premature separation of placenta from endometrium
Diagnosis: vaginal bleeding, uterine tenderness, uterine tone
Risk factors:– HTN – multiparity– AMA – smoking– PROM – cocaine– trauma – h/o abruption
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Placental Abruption: Images
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Placental Abruption: Images
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Placental Abruption: Images
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Placental Abruption: Images
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Placental Abruption
Complications
– shock
– acute renal failure
– DIC (coagulopathy in 10% of these pts.)
– fetal distress/demise “Hidden” blood loss may approach 2500 cc
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Placental Abruption:Obstetric Management
Depends on fetal maturity, size of abruption, presence of fetal distress
– continuation of pregnancy
– induction/augmentation of labor
– Cesarean section
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Placental Abruption:Anesthetic Management
Be alert for possibility of coagulopathy and/or hypovolemia before considering regional anesthesia
For stat C/S, GA most appropriate if known or suspected hypovolemia or DIC– ketamine (or etomidate)– volume resuscitation invasive monitoring
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Uterine Rupture vs. Dehiscence Uterine scar dehiscence:
– fetal membranes remain intact, fetus is not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact
– usually no fetal distress / mat. hemorrhage Uterine rupture:
– separation of scar extension, rupture of fetal membranes with extrusion
– results in fetal distress / mat. hemorrhage– fetal mortality = 35%
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Uterine Rupture: Images
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Uterine Rupture
Diagnostic features:– vaginal bleeding– hypotension– cessation of labor– fetal distress– pain present in only 10%– postpartum hemorrhage may be a sign
Treatment: uterine repair, arterial ligation, hysterectomy (may be preferred)
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Comparison of Presentation of Abruption v. Previa v. Rupture
abruption previarupture
abd. pain present absent variable
vag. blood old fresh fresh
DIC common rare rare
acute fetal common rare common
distress
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Vasa Previa
“Umbilical vessels separate in the membranes at a distance from the placental margin and some of the vessels (fetal) cross the internal os and occupy a position ahead of the presenting part of the fetus.”
ROM may cause fetal exsanguination. High fetal mortality (50-75%) Risk factor: multiple gestation (esp., triplets)
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Vasa Previa: Images
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Vasa Previa: Images
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