Vaginal Bleeding in Late Pregnancy

Objectives

• Identify major causes of vaginal bleeding in the second half of pregnancy

• Describe a systematic approach to identifying the cause of bleeding

• Describe specific treatment options based on diagnosis

Causes of Late Pregnancy Bleeding

• Placenta Praevia• Abruption• Ruptured vasa praevia• Uterine scar disruption• Cervical polyp• Bloody show• Cervicitis or cervical ectropion• Vaginal trauma• Cervical cancer

Life-threatening

Prevalence of Placenta Praevia

• Occurs in 1/200 pregnancies that reach 3rd trimester

• Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks– 90% will have normal implantation

when scan repeated at > 30 weeks– No proven benefit to routine screening

ultrasound for this diagnosis

Risk Factors for Placenta Praevia

• Previous caesarean delivery• Previous uterine instrumentation• High parity• Advance maternal age• Smoking• Multiple gestation

Morbidity and Placenta Praevia

• Maternal haemorrhage• Operative delivery complications• Transfusion• Placenta accreta, increta or

percreta• Prematurity

Patient History – Placenta Praevia

• Painless bleeding– 2nd or 3rd trimester, or at term– Often following intercourse– May have preterm contractions

• “Sentinel bleed”

Physical Exam – Placenta Praevia

• Vital signs• Assess fundal height• Fetal lie• Estimated fetal weight (Leopold)• Presence of fetal heart tones• Gentle speculum exam• No digital vaginal exam unless

placental location known

Laboratory – Placenta Praevia

• Haematocrit or complete blood count

• Blood type and Rh• Coagulation tests

Ultrasound – Placenta Praevia

• Can confirm diagnosis• Full bladder can create false

appearance of anterior praevia• Presenting part may overshadow

posterior praevia• Transvaginal scan can locate

placental edge and internal os

Treatment – Placenta Praevia

• With no active bleeding– Expectant management– No intercourse, digital exams

• With late pregnancy bleeding– Assess overall status, circulatory stability– Full dose Rhogam if Rh-– Consider maternal transfer if premature– May need corticosteroids, tocolysis,

amniocentesis

Double Set-Up Exam• Appropriate only in marginal praevia

with vertex presentation• Palpation of placental edge and fetal

head with set up for immediate surgery

• Caesarean delivery under regional anaesthesia if:– complete praevia– fetal head no engaged– non-reassuring tracing– brisk or persistent bleeding– mature foetus

Placental Abruption

• Premature separation of placenta from uterine wall– Partial or complete

• “Marginal sinus separation” or “marginal sinus rupture”– Bleeding, but abnormal implantation

or abruption never established

Epidemiology of Abruption

• Occurs in 1-2% of pregnancies• Risk factors

– hypertensive diseases of pregnancy– smoking or substance abuse (e.g.

cocaine)– trauma– overdistension of the uterus– history of previous abruption– unexplained elevation of MSAFP– placental insufficiency– maternal thrombophilia/metabolic

abnormalities

Abruption and Trauma

• Can occur with blunt abdominal trauma and rapid deceleration without direct trauma

• Complications inculde prematurity, growth restriction, stillbirth

• Fetal evaluation after trauma– Increased use of FHR monitoring may

decrease mortality

Bleeding from Abruption

• Externalized hemorrhage• Bloody amniotic fluid• Retroplacental clot

– 20% occult– “Couverlaire” uterus

• Look for consumptive coagulopathy

Patient History - Abruption• Pain = hallmark symptom

– Varies from mild cramping to severe pain– Back pain – think posterior abruption

• Bleeding– May not reflect amount of blood loss– Differentiate from exuberant blood show

• Trauma• Other risk factors (e.g. hypertension)• Membrane rupture

Physical Exam - Abruption

• Signs of circulatory instability– Mild tachycardia normal– Signs and symptoms of shock

represent > 30% blood test

• Maternal abdomen– Fundal height– Leopold’s estimated fetal weight, fetal

lie– Location of tenderness– Tetanic contractions

Ultrasound - Abruption

• Abruption is a clinical diagnosis!• Placental location and appearance

– Retroplacental echolucency– Abnormal thickening of placenta– “Torn” edge of placenta

• Fetal lie• Estimated fetal weight

Laboratory - Abruption

• Complete blood count• Type and Rh• Coagulation tests • Kleihauer-Betke not diagnostic, but

useful to determine Rhogam dose• Preeclampsia labs, if indicated• Consider using drug screen

Sher’s Classification - Abruption

Grade I mild, often retroplacental clot identified at delivery

Grade II tense, tender abdomen and live fetus

Grade IIIIII AIII B

with fetal demise- without coagulopathy (2/3)- with coagulopathy (1/3)

Treatment – Grade II Abruption

• Assess fetal and maternal stability• Amniotomy• IUPC to detect elevated uterine tone• Expeditious operative or vaginal

delivery• Maintain urine output > 30cc/hr and

haematocrit > 30%• Prepare for neonatal resuscitation

Treatment – Grade III Abruption

• Assess mother for hemodynamic and coagulation status

• Vigorous replacement of fluid and blood products

• Vaginal delivery preferred, unless severe haemorrhage

Coagulopathy with Abruption

• Occurs in 1/3 of Grade III abruption• Usually not seen if live fetus• Etiologies: consumption, DIC• Administer platelets, FFP• Give factor VIII if severe

Epidemiology of Uterine Rupture

• Occult dehiscence vs. symptomatic rupture

• 0.03-0.08% of all women• 0.3-1.7% of women with uterine scar• Previous caesarean incision most

common reason for scar disruption• Other causes: previous uterine

curettage or perforation, inappropriate oxytocin usage, trauma

Risk Factors – Uterine Rupture

• pervious uterine surgery

• congenital uterine anomaly

• uterine overdistension

• gestational trophoblastic neoplasia

• adenomyosis• fetal anomaly• vigorous uterine

pressure• difficult placental

removal• placenta increta

or percreta

Morbidity with Uterine Rupture

• Maternal– haemorrhage with anaemia– bladder rupture– hysterectomy– maternal death

• Fetal– respiratory distress– hypoxia– acidaemia– neonatal death

Patient History – Uterine Rupture

• Vaginal bleeding• Pain• Cessation of contractions• Absence of FHR• Loss of station• Palpable fetal parts through

maternal abdomen• Profound maternal tachycardia and

hypotension

Uterine Rupture• Sudden deterioration of FHR pattern is

most frequent finding• Placenta may play a role in uterine rupture

– Transvaginal ultrasound to elevate uterine wall– MRI to confirm possible placenta accreta

• Treatment– Asymptomatic scar disruption – expectant

management– Symptomatic rupture – emergent caesarean

delivery

Vasa Praevia• Rarest cause of haemorrhage• Onset with membrane rupture• Blood loss is fetal, with 50% mortality• Seen with low lying placenta,

velamentous insertion of the cord or succenturiate lobe

• Antepartum diagnosis– amnioscopy– colour doppler ultrasound– palpate vessels during vaginal

examination

Diagnostic Tests – Vasa Praevia

• Apt test – based on colorimetric response of fetal haemoglobin

• Wright stain of vaginal bleed – for nucleated RBCs

• Kleihauer-Betke test – 2 hour delay prohibits its use

Management – Vasa Praevia

• Immediate caesarean delivery if fetal hear rate non-assuring

• Administer normal saline 10-20 cc/kg bolus to newborn, if found to be in shock after delivery

Summary

• Late pregnancy bleeding may herald diagnoses with significant morbidity/ mortality

• Determining diagnosis important, as treatment dependent on cause

• Avoid vaginal exam when placental location not known