Placental Abnormalities and Hemorrhagic Complications

Normal Placenta• The placenta is a new organ formed in the

uterus during pregnancy, and connect the fetus to the uterus.

• The baby's umbilical cord arises from the placenta.

• This structure provides oxygen and nutrients to the growing baby and removes waste products from baby's blood via umbilical cord.

Normal Placenta• Is blue-red in color and

discoid in shape.• Is about 22 cm in diameter

and 2.5 cm thick in the center.

• Normally; attaches at the top or side of the uterus.

• The normal umbilical cord is 51-60 cm long, contains two arteries and one vein.

Placental Abnormalities and Hemorrhagic Complications

• Blood loss during pregnancy is a first cause of both mother and fetal morbidity and mortality (Death & defect).

• Up to 1,000 mL/min of maternal blood flows through the placenta at term.

• Hemorrhage is a MEDICAL EMERGENCY• All placental problems can detected and

observed by ultrasound.

Placental Abnormalities and Hemorrhagic Complications

1. Antepartum Hemorrhage (APH)2. Postpartum Hemorrhage (PPH)3. Abortion 4. Ectopic Pregnancy

1 .Antepartum Hemorrhage (APH)• Antepartum hemorrhage (APH) is a bleeding from

the birth canal (Vagina) after the 24th week (some said after the 20th week) of pregnancy.

• It can occur at any time until the second stage of labor is complete.

• It called also; the third-trimester bleeding complicates about 4% of all pregnancies and considered as medical emergency.

• Bleeding before the week 24 of pregnancy is miscarriage.

APH Common Causes

a. Placental Previa b. Placental Abruptionc. Uterine Ruptured. Vasa Previa

e. Reproductive system injuriesf. Neoplasia

Life threatening

• The condition in which the placenta partially or totally covers the cervix (the lower part of uterus).

• It may cause anemia and death due to severe blood loss.

• The most common symptom of placenta previa is painless vaginal bleeding (bright red blood).

a. Placental Previa

Risk factors:• Previous Caesarean section • Old mother (>35 years)• Previous placenta previa• Diabetes or hypertension• Cigarette smoking• Uterine problems and anomalies• Multiple fetuses

a. Placental Previa

Classification:1. Total: The placenta completely covers the

cervix.2. Partial: The placenta is partially covers the

cervix.3. Marginal: The placenta is near the edge of the

cervix.

a. Placental Previa

Management:• Treatment depends on gestational age, severity and type

of the pervia, blood loss, and the health of the mom and the baby.

• Reducing activities and bed rest.• Medicines to prevent early labor.• Blood transfusion for the mother as necessary.• After 36 weeks, a caesarean section is usually

performed. • If the bleeding can't be controlled; an emergency C-

section is important even if the baby is premature.

a. Placental Previa

• We called also abruptio placentae.• Placental abruption is the separation of a

placenta from the wall of the uterus before the delivery.

• This condition can occur any time after the 20th week of pregnancy.

• When the placenta separate from the uterus, the vessels within the placenta detached and start to bleed.

b. Placental Abruption

b. Placental AbruptionRisk factors:• Old mother (>35 years)• Previous placental abruption • High blood pressure• Cigarette smoking• Uterine problems and anomalies• Multiple fetuses• Abdominal trauma

b. Placental AbruptionEffects & Complications:• Shock due to blood loss• The need for a blood transfusion• A serious blood clotting complication • Poor blood flow and damage to kidneys or brain of

the mother• Premature birth• Fetus heart rates problems• Fetal death

b. Placental AbruptionSymptoms and signs:• Vaginal bleeding (dark red blood)• Abdominal pain• Uterine contractions that doesn't relax.• Blood in amniotic fluid• Nausea• Faint feeling• Decreased fetal movements

b. Placental AbruptionClassification:• Revealed (Visible – External bleeding):

Causes vaginal bleeding that helps with early detection.

• Concealed (Internal): The blood gets trapped, pooling and clotting behind the placenta. It can only be detected only through an ultrasound.

b. Placental AbruptionManagement:• The treatment depends on depends on the amount

of bleeding, the gestational age, and condition of the fetus.

• Before week 34 the mom should rest. • After week 34:

− If the fetus is normal, and the bleeding is mild; vaginal labor is possible

− If not; C-Section is necessary

b. Placental Abruption• There is no treatment to stop placental

abruption or reattach the placenta.

• After the baby is born, bleeding from the site of the placental attachment is likely.

• If the bleeding can't be controlled, emergency removal of the uterus (hysterectomy) might be needed.

• A uterine rupture is a tear in the wall of the uterus.

c. Uterine Rupture

Risk factors:• Previous C-Section• Previous uterine surgery• Abdominal trauma

Uterine Rupture

c. Uterine RuptureSymptoms and signs:• Excessive vaginal bleeding • Sharp pain between contractions • Contractions that slow down and relax• Unusual abdominal pain or tenderness • Baby’s head moving back up not down • Rapid heart rate and abnormally low blood

pressure in the mother

c. Uterine RuptureManagement:• Immediate C-section is necessary in uterine

rupture.• Followed by repair of the uterus. • Antibiotics is important to prevent infection.• If the damage to the woman's uterus is

extensive and the bleeding can't be controlled, she'll need a hysterectomy.

d. Vasa PreviaA condition in which blood vessels within the placenta or the umbilical cord are trapped between the fetus and the cervix causing hemorrhage and lack of oxygen.

d. Vasa PreviaSymptoms:• Painless vaginal bleeding

Risk factors:• Previous C-Section• Low-lying placentas (Inferior placenta)• Multiple fetuses

Management:• Steroid treatment to develop fetal lung maturity.• The C-section should be done early to avoid an emergency

Vasa Previa baby

2 .Postpartum Hemorrhage (PPH)• Postpartum Hemorrhage (PPH) is a

blood loss after delivery greater than: - 500 mL for vaginal delivery, and - 1,000 mL for cesarean delivery, - with 10% drop in hematocrit

• PPH is responsible for around 25% of maternal mortality.

PPH Classification

• PPH is classified into: − Primary (early) occurs within

the first 24 hours after delivery − Secondary (late) occurs after 24

hours post-birth

PPH Common CausesThe causes of PPH have been described as the "four T"1. Tone: uterine atony (“70%” failure of the uterus

to contract properly after delivery).2. Trauma: lacerations of the uterus, cervix, or

vagina, and uterus inversion.3. Tissue: retained placenta.4. Thrombin: Coagulation abnormalities.

PPH Risk factors• Antepartum hemorrhage in this pregnancy.• Multiple fetuses. • Macrosomia (over 4 kg baby).• Pre-eclampsia.• Previous PPH. • Maternal obesity. • Uterine abnormalities.• Maternal age (35 years or older).• Maternal anemia.• Operative vaginal delivery.• Induction of labor.• Prolonged first and second stage of labor (over 12 hours

labor).

PPH Prevention• Detect any abnormality (anemia, diabetes…) before the

delivery and try to control it.• Ensure that the bladder of the mother is empty since a full

bladder makes it more difficult for the uterus to contract.• We should know the mother’s blood type.• IV access should be maintained.• Slow IV infusion.• Oxytocin medication (A drug used to stimulate uterine

contractions and control bleeding).• Oxytocin should be routinely used in the third stage of labor.

• Massage the mother’s uterus to help it contract.

PPH ManagementTone

• Massage• Drugs (Oxytocin)

Thrombin• Drugs (according to

the cause)• Platelet and blood

transfusion

Tissue• Manual removal of

retained placenta

Trauma• Manual fixation of

uterus inversion• Repair the rupture

and laceration

Uterus inversion and how to fix it back

Uterine massage Manual Removal of the Placenta

PPH Management• Large-bore intravenous access, and increase

oxytocin.• A blood clotting medication.• Transfuse blood. • Laparotomy: Surgery to open the abdomen to

find the cause of bleeding. • If the blood does not stop; we need to do

Hysterectomy (This is always a last resort in all condition).

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3 .Abortion • Abortion is the spontaneous or

elective ending of pregnancy before the fetus is able to survive on its own in the first 24 weeks of pregnancy.

• Losing of the fetus after the 24 week called Stillbirth.

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3 .Abortion • There are two type:1. Elective abortion (Induced): Ending

of pregnancy at the request of the mother. it may done medically or surgically.

2. Spontaneous abortion (Miscarriage): Is the end of the pregnancy on its own.

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Miscarriage• A miscarriage refers to naturally

death of the embryo/fetus, not to medical abortions or surgical abortions.

• 80% of miscarriage happen in the first 12 weeks (1st trimester).

• 20% happen in the second 12 weeks (13th – 24th week).

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Miscarriage Symptoms • Low back pain.• Abdominal pain and cramps.• Tissue or clot-like material that

passes from the vagina.• Vaginal bleeding.• Fever.

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Miscarriage Causes • The major cause is baby’s chromosomes abnormality, that

prevent the baby from developing well. Other cause:• Infection such as HIV• Exposure to radiation or other toxins• Uterine abnormalities• Smoking, drinking alcohol, and drugs• Disorders of the immune system• Kidney, heart, and thyroid disease• Diabetes that is not controlled• Severe malnutrition • Trauma to the uterus• Old mother

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Miscarriage Types 1. Threatened abortion: • Miscarriage has started but

recovery is possible.• Or woman with miscarriage

signs but loss of the pregnancy has not yet occurred.

• Management:− Rest − Good nutrition (folic acid

should be taken)− Fetus and uterus monitoring

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Miscarriage Types 2. Complete abortion: • This is the most common

type of miscarriage, when all of the contents of the uterus leave the body.

• Management:− Control bleeding− Ultrasound to observe the

uterus

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Miscarriage Types 3. Incomplete abortion: • Only some of the products of

uterus leave the body.• Treatment:− Dilatation and Curettage (D&C): is

a procedure to remove tissue from inside the uterus, by opening (dilate) the cervix and using a surgical instrument called a curette to remove any remaining pregnancy tissue.

− Antibiotics− Complete uterine evacuation

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Dilatation and

Curettage (D&C)

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Miscarriage Types 4. Missed abortion: • The pregnancy is ended

without any symptoms and the products of uterus do not leave the body. In this type the death will be discovered at a routine scan.

• Treatment:− Oxytocin− Antibiotics− Complete uterine evacuation− D&C

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Miscarriage Types 5. Septic infected abortion: • The lining of the uterus and any remaining

products of pregnancy become infected after miscarriage.

• Treatment:− Hospitalization IV antibiotics− Complete uterine evacuation− D&C

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General Management• Medical management depends on

type and signs and symptoms.• The main goal of treatment during or

after a miscarriage is to prevent hemorrhage and/or infection.

• We should support the mother psychologically.

504-5 Weeks miscarriage 6 Weeks miscarriage

517-8 Weeks miscarriage 10 Weeks miscarriage

5212 Weeks miscarriage 16 Weeks miscarriage

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4 .Ectopic Pregnancy • An ectopic pregnancy is the implanting

of the zygote somewhere other than the inner endometrial lining of the uterus (pregnancy that occurs outside the uterus).

• It occurs in 1%-2% of all pregnancies.• It is life-threatening to the mother.

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4 .Ectopic Pregnancy • The vast majority of ectopic

pregnancies occur in the fallopian tube “tubal pregnancy’’ (95%), but the fertilized ovum can also implant in the ovary, cervix, or abdominal cavity (5%).

• Doctors usually discover it between week 5 and week 14 of pregnancy .

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Sites of ectopic pregnancy

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Ectopic Pregnancy symptoms • Abnormal vaginal bleeding.• Abdominal pain, typically just in one side, which

can range from mild to severe.• An absent of menstruation (amenorrhea), and

other symptoms of pregnancy.• Shoulder pain (unknown why).• If the fallopian tube ruptures, the pain and

bleeding could be severe enough to cause fainting.

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Ectopic Pregnancy Causes • The most common cause is damaged fallopian tube.• Zygote abnormality.• Previous ectopic pregnancy. • Sexual diseases (typically chlamydia).• Reproductive organs infections and inflammations.• Smoking.• Endometriosis (abnormal uterus lining).• Using fertility drugs.• Getting pregnant while having an intrauterine device

(IUD).

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Intrauterine device (IUD)

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Ectopic Pregnancy Complications • The major health risk of ectopic

pregnancy is rupture leading to internal bleeding.

• Decreased fertility related to removal of fallopian tube.

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Ectopic Pregnancy Management • In early stage; a medication used to stop

the egg developing. The pregnancy tissue is then absorbed into the woman’s body.

• In more advanced stage; a surgery is required to remove the egg.

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Ectopic Pregnancy Management • If the fallopian tube has ruptured,

emergency surgery is necessary to stop the bleeding and fix the tube.

• In some cases, the fallopian tube and ovary may be damaged and will have to be removed.

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Ectopic Pregnancy Management • The hCG level will need to be rechecked

on a regular basis until it reaches zero if the entire fallopian tube did not removed.

• An hCG level that remains high could indicate that the ectopic tissue was not entirely removed, which would require another surgery or medical management.