Port said University

Faculty of Medicine
Department of Obs & Gyne

BLEEDING in obstetrics

Dr: Ibrahim Arafa 2022-2023

A-EARLY PREGNANCY BLEEDING
Definition. Bleeding that occurs before 12 weeks ’ gestation.
The most common cause of early pregnancy loss is fetal in origin.
Etiology
• Cytogenetic etiology.
The majority of early pregnancy losses are caused by gross chromosomal
abnormalities of the embryo or fetus.
•Mendelian etiology. Other losses may becaused by autosomal or X-linked
dominant or recessive diseases.
• Antiphospholipid syndrome. An uncommon cause of early pregnancy loss
• Molar and ectopic pregnancy should be ruled out in all patients with early
pregnancy bleeding.
•Vaginal bleeding anduterinecramping leading to abortion
Management of abortion :
Scheduled suction D&C,
conservative management awaiting a spontaneous completed abortion, or
Induce contractions with misoprostol(Cytotec®)(PGE
.Threatened abortion
Sonogram finding of a viable pregnancy with vaginal bleeding but no cervical dilation.
Half of these pregnancies will continue to term successfully.
Management: Often the causeis implantation bleeding. Observation.No intervention is
generally indicated or effective.
Inevitable abortion
Vaginal bleeding and uterine cramping leading to cervical dilation, but no POC has yet
been passed. Management: Emergency suction D&C if bleeding is heavy to prevent further
blood loss and anemia.
Incomplete abortion
Vaginal bleeding and uterine cramping leading to cervical dilation, with some, but
notall, POC having been passed.
Management: Emergency suction D&C if bleeding is heavy to prevent further
blood loss and anemia.
Completed abortion
Vaginal bleeding and uterine cramping have led to all POC being passed.
This is confirme by a sonogram showing no intrauterine contents or debris.
Recurrent pregnancy loss
• The diagnosis of recurrent pregnancy loss (RPL) is ≥3failed clinical
pregnancies.
• Workup includes karyotype of products of conception(if available),
parental karyotypes, uterine study, an antiphospholipid antibodies (APAs).
• Women with RPL who are diagnosed with antiphospholipid syndrome
(APS) should be treated with low-dose aspirin and heparin in subsequent
pregnancies
. Women with unexplained RPL should not receive anti coagulantherapy.
• Women with RPL and uterine septum, synechiae, or submucous myomata
can consider hysteroscopic resection of these abnormalities.
Classification
Primary RPL: No intervening live births;
secondary RPL: Intervening live births. The prognosis is better with
secondary RPL .
Incidence
Approximately 15% of pregnant women experience loss of a clinically
recognized pregnancy
Etiology
Etiology of RPL is not established in at least 50% of cases after workup.
General categories include
genetic, anatomic, endocrine, immunologic, thrombophilic, and
environmental.
Risk factors/Associations
Advancing maternal age is associated with a higher rate of RPL.
The rate of clinically recognized miscarriage is 20% at age 35, 40% at age 40,
and up to 80% at age 45 .
Other risk factors include:
maternal medical diseases, especially poorly controlled, such as
hypertension and diabetes.
A previous pregnancy loss is a risk factor for recurrence .
Women with only an unsuccessful pregnancy history have a greater risk of
future miscarriage than primigravidas and women with a history of previous
successful pregnancy .
Management
Prevention Optimize preconception medical care of all maternal diseases.
Preconception care
In patients with RPL, workup should be performed prior to conception . If
workup is positive, patients should be counseled regarding specific
associations.
All women with RPL should be offered a support group.
UNITE offers services that provide emotional support through parent-to-
parent sharing on issues related to grieving.
Prenatal care
In cases of RPL, especially with current vaginal bleeding but even in the
absence of it, progesterone has shown benefit . Offer early and frequent
ultrasounds as needed given patient anxiety.
Abnormal uterine cavity
Septum, synechiae, and/or submucous myomata can be resected
hysteroscopically, but there are no trials regarding this intervention.
Medical condition
If a medical condition is identified (e.g. diabetes mellitus [DM], thyroid
disease), treat as indicated
ECTOPIC PREGNANCY
Definition.
This is a pregnancy in which implantation has occurred outside of the
uterine cavity.
The most common location of ectopic pregnancies is an oviduct.
The most common location within the oviduct is the distal ampulla.
Differential Diagnosis. With a positive pregnancy test, the differential
diagnosis consists of
A threatened abortion, incomplete abortion, ectopic pregnancy, and
hydatidiform mole.
In a reproductive age woman with abnormal vaginal bleeding, the
possibility of pregnancy or complication of pregnancy should always be
considered.
Risk Factors. The most common predisposing cause is previous
pelvic inflammatory disease (PID).
infectious(PID, IUD), postsurgical (tubal ligation, tubal surgery),or
congenital (diethylstilbestrol[DES] exposure).
Clinical Findings
• Symptoms. The classic triad with an un ruptured ectopic pregnancy is
amenorrhea, vaginal bleeding, and unilateral pelvic-abdominal pain.
•Signs. The classic findings with an un ruptured ectopic pregnancy are
unilateral adnexal and cervical motion tenderness.
Uterine enlargement and fever are usually absent
• Investigative findings. A b-hCG test will be positive.
Sonography may or may not reveal an adnexal mass, but most
significantly no intrauterine pregnancy (IUP) will be seen.

Management
• Ruptured ectopic
Immediate surgical intervention to stop the bleeding is vital, usually by
laparotomy.
• Un ruptured ectopic. Management can be medical with
methotrexate or surgical with laparoscopy. Medical treatment is preferable
because of thelower cost, with otherwise similar outcomes.
B-Late Pregnancy Bleeding
Definition. Vaginal bleeding occurring after 20 weeks’ gestation. Prevalence
is <5%, but when it does occur, prematurity and perinatal mortality
quadruple.
Etiology
• Cervical causes include erosion, polyps, and, rarely, carcinoma.
• Vaginal causes include varicosities and lacerations.
• Placental causes include abruption placenta, placenta Previa, and vasa
Previa.
ABRUPTIO PLACENTA
Etiology/Pathophysiology
• A normally implanted placenta (not in the lower uterine segment)
separates from the uterine wall before delivery of the fetus. Separation can
be partial or complete
• Most commonly bleeding is overt and external. In this situation
blood dissects between placental membranes exiting out the vagina.
• Less commonly, if bleeding remains concealed or internal, the retro
placental hematoma remains within the uterus, resulting in an increase in
fundal height overtime.
Risk Factors.
Abruptio placenta is seen more commonly with previous abruption,
hypertension, and maternal blunt trauma.
Other risk factors are smoking, maternal cocaine abuse and premature
membrane rupture.
Management. Management is variable
• Emergency cesarean delivery—
This is performed if maternal or fetal jeopardy is present as soon as the
mother is stabilized
• Vaginal delivery—This is performed if bleeding is heavy but controlled or
pregnancy is >36 weeks.
Perform amniotomy and induce labor.
Place external monitors to assess fetal heart rate pattern and contractions.
Avoid cesarean delivery if the fetus is dead.
• Conservative in-hospital observation—This is performed if mother and
fetus are stable and remote from term, bleeding is minimal or decreasing,
and contractions are subsiding. Confirm normal placental implantation with
sonogram and replace blood loss with crystalloid and blood products as
needed.
PLACENTA PREVIA
Etiology/Pathophysiology
• Placenta Previa is present when the placenta is implanted in the lower
uterine segment. This is common early in the pregnancy, but is most often
not associated with bleeding.
• Symptomatic placenta Previa occurs when painless vaginal
bleeding develops through avulsion of the anchoring villi of an abnormally
implanted placenta as lower uterine segment stretching occurs in the latter
part of pregnancy.
Diagnosis.
This is based on the presence of painless late-trimester vaginal bleeding
with an obstetric ultrasound showing placental implantation over the lower
uterine segment.
Management. Management is variable
• Emergency cesarean delivery—This is performed if maternal or fetal
jeopardy is present after stabilization of the mother
• Conservative in-hospital observation—Conservative management of bed
rest is performed in preterm gestations if mother and fetus are stable and
remote from term
PLACENTA ACCRETA/INCRETA/PERCRETA
• Placental villi normally in vade only the superficial layers of the
endometrial decidua basalis.
When the villi invade too deeply into the wall of the uterus, the condition is
known as placenta accreta, placenta increta, or placenta percreta, depending
the depth of the invasion.
Approximately 1 in 2,500 pregnancies experience placenta accreta, increta,
• Placenta accreta occurs when the villi invade the deeper layers of the
endometrial decidua basalis but do not penetrate the myometrium.
Placenta accreta is the most common, accounting for approximately 80% of
all cases
• Placenta increta occurs when the villi invade the myometrium but do not
reach the uterine serosal surface or the bladder. It accounts for
approximately 15% of all cases
• Placenta percreta occurs when the villi invade all the way to the uterine
serosa or into the bladder. Placenta percreta is the least common of the 3
conditions, accounting for approximately 5% of all cases
VASA PREVIA
Etiology/Pathophysiology.
Vasa Previa is present when fetal vessels traverse the fetal membranes over
the internal cervical os. These vessels may be from either a velamentous
insertion of the umbilical cord or may be joining an accessory (succenturiate)
placental lobe to the main disk of the placenta. If these fetal vessels rupture
the bleeding is from the feto placental circulation, and fetal exsanguination
will rapidly occur, leading to fetal death.
Diagnosis.
This is rarely confirmed before delivery but may be suspected when
antenatal sonogram with color-flow Doppler reveals a vessel crossing the
membranes over the internal cervical os. The diagnosis is usually confirmed
after delivery on examination of the placenta and fetal membranes.
Clinical Presentation. The classic triad is rupture of membranes and painless
vaginal bleeding, followed by fetal bradycardia.
Risk Factors. Vasa Previa is seen more commonly with velamentous insertion
of the umbilical cord, accessory placental lobes, and multiple gestation.
Management. Immediate cesarean delivery of the fetus is essential or the
fetus will die from hypovolemia.
Postpartum Hemorrhage
Any blood loss than has potential to produce or produces hemodynamic
instability
Incidence: About 5% of all deliveries
Etiology of Postpartum Hemorrhage
Tone Uterine atony 95%
Tissue Retained tissue/clots
Trauma laceration, rupture, inversion
Thrombin coagulopathy
Predisposing factors- Intrapartum
1-Operative delivery 2- Prolonged or rapid labor 3-
Induction or augmentation
4-Choriomnionitis 5- Shoulder dystocia 6-
Internal podalic version
7-Coagulopathy 8- Previous PPH or manual removal 9-
Abruption/Previa
10-Fetal demise 11- Gestational hypertension 12- Over
distended uterus
13-Bleeding disorders
Management
talk to and assess patient Get HELP! Large bore IV access
Crystalloid-lots! CBC/cross-match and type Foley catheter
Diagnosis ?
Assess in the fundus Inspect the lower genital tract
Explore the uterus
Retained placental fragments Uterine rupture Uterine inversion
Assess coagulation
Management1--Assess the fundus
Simultaneous with ABC’s
Atony is the leading case of PPH
Bimanual massage Rules out uterine inversion May feel lower tract
injury Evacuate clot from vagina and/ or cervix May consider manual
exploration at this time
Management-Manual exploration will: Rule out the uterine inversion
Palpate cervical injury Remove retained placenta or clot from uterus
Rule out uterine rupture or dehiscence
Management- Oxytocin 5 units IV bolus 20 units per L N/S IV wide open 10
units intramyometrial given trans abdominally
Management- Additional Uterotonics
Ergometrine (caution in hypertension).25 mg IM 0r .125 mg IV Maximum
dose 1.25 mg
Hemabate (asthma is a relative contraindication) 15 methyl-prostaglandin
F2 alfa O.25mg IM or intramyometrial Maximum dose 2 mg (Q 15 min- total
8 doses)
Cytotec (misoprostol) PG E1 800-1000 mcg
Management- Bleeding with Firm Uterus
Explore the lower genital tract
Requirements 1-Appropriate analgesia2- Good exposure and lighting
3-Appropriate surgical repair4- May temporize with packing
Management- Continued Uterine Bleeding
Consider coagulopathy Correct coagulopathy FFP, cryoprecipitate,
platelets
If coagulation is normal Consider embolization
Prepare for O.R.
Surgical Approaches 1- Uterine vessel ligation
2-Internal iliac vessel ligation
3-Hysterectomy