Antepartum Hemorrhage

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

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)

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

Types of Placenta Previa

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

Placenta Previa: Images

Plcenta Previa: Images

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

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)

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

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption

Complications

– shock

– acute renal failure

– DIC (coagulopathy in 10% of these pts.)

– fetal distress/demise “Hidden” blood loss may approach 2500 cc

Placental Abruption:Obstetric Management

Depends on fetal maturity, size of abruption, presence of fetal distress

– continuation of pregnancy

– induction/augmentation of labor

– Cesarean section

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

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%

Uterine Rupture: Images

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)

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

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)

Vasa Previa: Images

Vasa Previa: Images

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