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-bycase 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
THANK YOU