Pain & Bleeding During Pregnancyjeffline.jefferson.edu/jurei/conference/pdfs/obgyn/May 16/7 - 215...

4/4/2019

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Mani Montazemi, RDMS

Acute Pelvic Pain

Director of Ultrasound Education & Quality Assurance

Baylor College of Medicine

Department of Obstetrics & Gynecology

Division of Maternal-Fetal Medicine

Houston Texas

Mani Montazemi RDMS

Pain & Bleeding

During Pregnancy


Acute Pelvic Pain

The initial goal is to identify patients

who have a serious or even life-

threatening etiology for their symptoms

and require urgent intervention…

Pain & Bleeding During Pregnancy


Acute Pelvic Pain

Sonograms Performed

For Emergency Indications

Patient present with acute symptoms

Sonograms Demonstrating

Emergency Findings

Scans are being done for non-emergent reasons

Emergency Obstetric Ultrasound


Acute Pelvic Pain

Two key signs of a potentially

serious obstetric etiology

of abdominal pain are

vaginal bleeding & hypertension


Acute Pelvic Pain

Vaginal bleeding

is a common event at all

stages of pregnancy

The source is virtually always maternal, rather than fetal


Acute Pelvic Pain

Vaginal Bleeding

• The clinician typically makes a provisional

clinical diagnosis based upon

– Patient's gestational age

– Character of her bleeding (light or heavy, associated

with pain or painless, intermittent or constant)

• Laboratory and imaging tests are then used to

confirm or revise the initial diagnosis

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Acute Pelvic Pain

4 major sources of non-traumatic bleeding in early pregnancy

• Ectopic pregnancy

• Miscarriage (threatened, inevitable,

incomplete, complete)

• Implantation of the pregnancy

• Cervical, vaginal, or uterine pathology (i.e.

polyps, inflammation/infection, trophoblastic

disease)

First Trimester Bleeding


Acute Pelvic Pain

Antepartum bleeding (after 20 weeks of gestation)

complicates 4 to 5% of pregnancies

• Placenta previa

• Abruptio placenta

• Uterine rupture (rare)

• Vasa previa (rare)

• Bloody show associated with labor (by definition,

labor occurs after 20 weeks) or, less commonly,

cervical insufficiency

2nd & 3rd Trimester Bleeding


Acute Pelvic Pain

Placenta Previa – Risk Factors

• Previous placenta previa

• Prior cesarean deliveries

• Multiple gestation

• Increasing parity – incidence 0.2 % in nulliparas versus up to 5 % in grand multiparas

• Maternal age – higher in older nulliparous females

• Number of curettages for spontaneous or induced abortions

• Smoking

• Cocaine use


Acute Pelvic Pain

Risk of Previa

• 0.26% If no prior C-section

• 0.65% If 1 prior C-section



• 10.0% If 4 or more prior C-section

Clark 1985


Acute Pelvic Pain

Definitions

• The terms “partial” & “marginal” have been

eliminated from the nomenclature

• All placentas overlying the os (to any degree) are

termed previas

• Those near to but not overlying the os are termed

low-lying

– The distance between the internal cervical os and

the placenta edge is 1-20mm

Silver R. Obstet Gynecol 2006; 107:107:927-41

Vintileos A, Ananth C, Smulian J Am J Obstet Gynecol 2015; 213(4 suppl):S70-7

Reddy U, Abuhamad A, Levine D, Saade G Obstet Gynecol 2014; 123:1072-82Mani Montazemi, RDMS

Acute Pelvic Pain

Placenta Previa

Inferior edge of placenta within 2cm of IO

Often resolves with advancing pregnancy

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Acute Pelvic Pain

Placenta Previa

Edge of placenta partially covers IO

Often resolves with advancing pregnancy


Acute Pelvic Pain

PL

BL


Acute Pelvic Pain

Placenta Previa – Complete

Asymmetric complete previa

Small part of placenta crosses IO

May resolve with advancing pregnancy

If > 1.5 cm crosses IO then less likely to resolve Mani Montazemi, RDMS

Acute Pelvic PainMani Montazemi, RDMS

Placenta

Placenta Previa – Complete

Symmetric complete previa

Placenta centrally implanted on cervix

Will not resolve with advancing pregnancy


Acute Pelvic Pain

Use TVUS to R/O placenta

previa in all patients

with bleeding in

2nd & 3rd trimester

Remember


Acute Pelvic Pain

27 weeks

Hospitalized with bleeding

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Acute Pelvic Pain

3 weeks later


Acute Pelvic Pain

• It is recognized that apparent placental position early in pregnancy may not correlate well with its location at the time of delivery

• “Trophotropism”

– The ability or the desire of the placenta to seek a blood supply

– Proliferation of placental villi in areas of better blood supply (corpus , fundus)

Kurt Benirschke, MD


Acute Pelvic Pain

• It is recognized that apparent placental position early in pregnancy may not correlate well with its location at the time of delivery

• “Trophotropism”

– The ability or the desire of the placenta to seek a blood supply

– Proliferation of placental villi in areas of better blood supply (corpus , fundus)

Kurt Benirschke, MD


Acute Pelvic Pain


Acute Pelvic Pain


Acute Pelvic Pain

Trophotropism

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Acute Pelvic Pain

Trophotropism


Acute Pelvic Pain

Placenta Previa: False Positives

• Overfilling of the bladder

• Uterine contraction

• Fibroid low in the uterus


Acute Pelvic Pain

Placenta Previa: False Positives



Emergency OB US

“Contractions”

Round myometrium



Emergency OB US

“Contractions”Thick & asymmetric LUS



Emergency OB US


Myometrial Thickness ≤ 1.5 cm

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Emergency OB US



Cervical length > 5 – 5.5cm



Emergency OB US




“S” shaped cervical canal



Emergency OB US







Emergency OB US



Internal os cephalad to

bladder reflection




Acute Pelvic Pain

• The placenta’s relationship to the IO should be

assessed in every scan. Failure to see the inferior

edge of the placenta should lead to TV scanning to

R/0 previa if not previously done in the 2nd trimester


Acute Pelvic Pain

Diagnostic Challenge

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Acute Pelvic Pain

• Placenta previa

• Vasa previa


• Uterine rupture



Acute Pelvic Pain

Vasa Previa

• Partial or complete obstruction of the internal

cervical os by blood vessels


Acute Pelvic Pain

Vasa Previa – Risk Factors

• Low lying placentas

• Succenturiate lobed placentas

• Velamentous cord insertion

• Multiple pregnancies

• Pregnancies resulting from IVF


Acute Pelvic Pain

Low Lying PlacentaVasa Previa – Risk Factors


Acute Pelvic Pain

Low Lying PlacentaVasa Previa – Risk Factors


Acute Pelvic Pain

Succenturiate Lobe of the PlacentaVasa Previa – Risk Factors

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Acute Pelvic Pain

Succenturiate Lobe of the Placenta

• One or more extra lobes of the placenta separated

from the body of the placenta



Acute Pelvic Pain

Succenturiate Lobe of the Placenta







Acute Pelvic Pain



Acute Pelvic Pain

Identify Communicating VesselsVasa Previa – Risk Factors


Acute Pelvic Pain



Acute Pelvic Pain


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Acute Pelvic Pain

Velamentous Cord Insertion

Insertion of cord into membranes before

entering the placenta



Acute Pelvic Pain

“ Cord appears to insert directly on uterine wall ”

Velamentous Cord InsertionVasa Previa – Risk Factors


Acute Pelvic Pain

Velamentous Cord Insertion

The velamentous vessels are surrounded only by fetal

membranes, with no Wharton's jelly, thus they are

prone to compression or disruption



Acute Pelvic Pain

Velamentous Cord InsertionVasa Previa – Risk Factors


Acute Pelvic Pain



Acute Pelvic Pain

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Acute Pelvic Pain

Umbilical Cord Prolapse

• Cord slips ahead of the presenting part of the

fetus and protrudes into the cervical canal or

vagina



Ultrasound of the Cervix

Funic Presentation Overt Prolapse


Acute Pelvic Pain


• It is an obstetrical emergency because the prolapsed

cord is vulnerable to compression, umbilical vein

occlusion, and umbilical artery vasospasm, which can

compromise fetal oxygenation


Acute Pelvic Pain


• The diagnosis is based on the abrupt onset of

severe, prolonged fetal bradycardia or

moderate to severe variable decelerations in a

patient with a previously normal tracing

• The diagnosis is supported by the presence of

risk factors for prolapse


Acute Pelvic Pain


Fetal and maternal risk factors • Malpresentation (breech, transverse, oblique)

• Prematurity

• Low birth weight

• Second twin

• Low lying placentation

• Pelvic deformities

• Uterine malformations/tumors

• External fetal anomalies

• Multiparity

• Polyhydramnios

• Long umbilical cord


Acute Pelvic Pain

• Placenta previa

• Vasa previa


• Uterine rupture


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Acute Pelvic Pain

Placental Abruption

• Placental abruption causes a wide spectrum of

sonographic findings that may be overlooked

or misdiagnosed

• Look for placenta abruption in all gestations

>20 wks with vaginal bleeding or tender uterus

• Poor outcome when fetal bradycardia present



Placenta

Abruptio Placenta

• Acute hemorrhage

occasionally difficult to

distinguish from the

adjacent placenta


Acute Pelvic Pain

Sonographic Features of Abruptio Placenta


Acute Pelvic Pain

Placental Abruption – False Positives


Acute Pelvic Pain

Subchorionic Hemorrhage

• Spontaneous abortion rates by size

– Small 7.7%

– Moderate 9.2%

– Large 18.8%

Bennett, Radiology 1996; Dickey, Obstet Gynecol 1992Mani Montazemi, RDMS

Acute Pelvic Pain

Perigestational Hemorrhage

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Acute Pelvic Pain

Perigestational Hemorrhage


Acute Pelvic Pain


Acute Pelvic Pain


Acute Pelvic Pain


Acute Pelvic Pain

Subchorionic Hemorrhage


Acute Pelvic Pain“Color Doppler” is essential for making diagnosis

Chorioangioma

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Acute Pelvic Pain

Chorioangioma

• Benign non-trophoblastic vascular tumor of the placenta

Chorioangioma with multiple small vascular channels


Acute Pelvic Pain

Chorioangioma

• Amount of flow in mass is quite variable

• Vascularity may either increase or decrease as

gestation progresses

Greater arterial flow risk of developing high-output cardiac failure & hydrops


Acute Pelvic Pain

Chorioangioma


Acute Pelvic Pain

Chorioangioma

• Well-defined

• Usually solitary but may be multiple (Chorioangiomatosis)

• Near cord insertion

• Generally hypoechoic

– Heterogeneous

• Hemorrhage

• Infarction

• Degeneration

• Size usually stable throughout pregnancy


Acute Pelvic Pain

Chorioangioma

• In chorangiomas larger than 4 cm, there can be

significant effects on the hemodynamic and

circulatory processes of the fetus, leading to grave

clinical consequences, such as polyhydramnios and

fetal heart failure.


Acute Pelvic Pain

Chorioangioma “complications”

• Chorangiomatosis has been associated with

– Hydrops • From arteriovenous shunting or fetal anemia

– Dilated cardiomyopathy from progressive cardiac

decompensation

– IUGR • May result from chronic hypoxia from unoxygenated blood that

bypasses maternal circulation through the chorangioma

– Fetal hemolytic anemia

– Polyhydramnios• Common with large or multiple masses

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Acute Pelvic Pain

Chorioangioma

• Fetal tachcardia and fetal distress may develop

if there is great vascularity acting as an AVM


Acute Pelvic Pain

• Placenta previa

• Vasa previa


• Uterine rupture


Acute Pelvic Pain



Acute Pelvic Pain

26yrs – Vaginal Bleeding – 14wks

G4 P3 – h/o previa & C-section

1st scan


Acute Pelvic Pain

1st scan


Acute Pelvic Pain

1st scan

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Acute Pelvic Pain

2nd scan – 1 wk later


Acute Pelvic Pain



Acute Pelvic Pain



Acute Pelvic Pain

Vaginal Bleeding

Sudden Onset of Severe RLQ Pain

3rd scan – 5 days later


Acute Pelvic Pain


Acute Pelvic Pain

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Emergency OB US



Emergency OB US

Emergency Hysterectomy

Male fetus – 17 weeks GA

Fragmented 1st trimester placenta

Gravid uterus with horizontal wall rupture



Emergency OB US

Sonograms Performed

For Emergency Indications

Vasa previa, Placenta previa,

Placenta accreta, Placental

hemorrhage/abruption

Sonograms Demonstrating

Emergency Findings

Cervical insufficiencyMani Montazemi, RDMS

Acute Pelvic Pain

Definitions…

• Cervical Insufficiency

– Clinical diagnosis

– Inability of the cervix to retain a pregnancy in the

absence of contraction

• Short Cervix

– Sonographic diagnosis

– Is a marker of increased risk for PTB but NOT a

specific marker for cervical insufficiency

Mani Montazemi,

RDMS

Ultrasound of the

Cervix


Acute Pelvic Pain

Definitions…





• Short Cervix




Mani Montazemi,

RDMS

Ultrasound of the

Cervix


Acute Pelvic Pain

Definitions…





• Short Cervix




Mani Montazemi,

RDMS

Ultrasound of the

Cervix

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Acute Pelvic Pain

Cervical Length

• A short cervix is a consistent and reliable risk factor for PTB

• Cervical length <10th % for gestational age is considered “short”

• At 18 to 24 weeks (a short cervix is < 25mm)

• The rate of CL change is an important predictor of PTB– For each additional 1mm of CL change between 24 and 28 weeks gestation

the risk of PTB increases 3%

• The cervix undergoes physiologic shortening at 28 to 30 weeks– At 32 weeks the 50th % is 25mm

Moroz, Am J Obstet Gynecol 2012; 206:234

Iams, Am J Obstet Gynecol 2011; 205:130

Fox, Am J Obstet Gynecol 2010; 202:155

…Therefore there is limited clinical utility in cervical measurement beyond 28 weeks

Mani Montazemi,

RDMS

Ultrasound of the

Cervix


Acute Pelvic Pain

“Remember”

• After 28 to 32 weeks of gestation, a gradual

decline in cervical length is normal

• The median cervical length after 32 weeks is

30 mm versus 35 mm at 22 to 32 weeks and 40

mm before 22 weeks

Mani Montazemi,

RDMS

Ultrasound of the

Cervix


Acute Pelvic PainMani Montazemi,

RDMS

Ultrasound of the

Cervix

Cervical Length



RDMS

Ultrasound of the

Cervix

Cervical Beaking – V Shape



RDMS

Ultrasound of the

Cervix

Cervical Funneling – U Shape



RDMS

Ultrasound of the

Cervix

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RDMS

Ultrasound of the

Cervix

Blood clot, meconium, vernix, or cellular material related to

infection / inflammation

“Increased Risk of Preterm Delivery”


Acute Pelvic Pain

Acute Pain During Pregnancy

1st half of pregnancy

• Life-threatening causes

– Ectopic pregnancy

• Common causes

– Miscarriage

– Stretching of round ligament

2nd half of pregnancy

• Life-threatening causes

– Placenta abruption

– Uterine rupture

– Pregnancy-related liver dz.

• Preeclampsia

• HELLP syndrome

• Acute fatty liver

• Common causes

– Labor

– Intra-amniotic infection

– Fetal position


Acute Pelvic Pain


• Common causes

– Leiomyoma

– Rupture of an ovarian cyst

– Bleeding into an ovarian cyst

– Constipation

• Uncommon causes

– Ovarian torsion

– Fallopian tube torsion

– PID

Anytime in pregnancy


Acute Pelvic Pain


• Common causes

– Leiomyoma

– Rupture of an ovarian cyst

– Bleeding into an ovarian cyst

– Constipation

• Uncommon causes

– Ovarian torsion

– Fallopian tube torsion

– PID

• Urologic

– Lower urinary infection

– Ureteral calculi

• Gastrointestinal

– Acute appendicitis

– Acute sigmoid diverticulitis

– Crohn’s disease

– Abdominal wall hernia

Anytime in pregnancy


Acute Pelvic Pain

• An abnormal fetal heart rate may be the direct

consequence of a pregnancy-related cause

of abdominal/pelvic pain (placental abruption)

OR

• It may be an indirect consequence of maternal

compromise (hypotension, infection)

Fetal Heart Rate Monitoring


Acute Pelvic Pain

Thank You

Pain & Bleeding During Pregnancyjeffline.jefferson.edu/jurei/conference/pdfs/obgyn/May 16/7 - 215...

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Transcript of Pain & Bleeding During Pregnancyjeffline.jefferson.edu/jurei/conference/pdfs/obgyn/May 16/7 - 215...