Third trimester Bleeding

Third Trimester Bleeding Placenta Previa Presenter:Dr.T.Kiak: Xianya 2 nd Hospital of Central South University, China

Content Definition Incidence Classification Etiology /Risk Factors Pathogenesis Presenting signs/symptoms Investigations Management Complications Remarks

Definition is the presence of placental tissue over or adjacent to the cervical os or the placenta is implanted in the lower segment within the zone of effacement and dilation of the cervix, thus constituting an obstruction to descent of the presenting part . Associated with significant maternal morbidity and perinatal mortality. The great majority of deaths are related to uterine bleeding and the complication of disseminated intravascular coagulopathy Perinatal morbididty rate range ranges form 2-3%. (See Table 1) Incidence Placenta Previa is encountered with appx 1 in 200 births Incidence as high as 1- 20 to 4/1000 deliveries Recent reported prevalence rates from 0.35% to 0,6% Data recorded from 1989-1997 indicated placenta previa occurs in 2.8 per 1000 live births in the United States .

1. Zlatnik MG, Cheng YW, Norton ME, Thiet MP, Caughey AB. Placenta previa and the risk of preterm delivery. J Matern Fetal Neonatal Med . Oct 2007;20(10):719-23 2. http://emedicine.medscape.com/article/262063-overview 6.6 Endometrosis 5 Thrombophletitis Aged > 40years=2% 5.5 Septicemia Aged 30-39years=1% 10 Blood Transfusion Aged 20-29years= 0.33% 33 Need for Hysterectomy Aged 12- 19years= 1% 10 Antepartum Hemorrhage Age Relative Risks Morbidities

Classification Total placenta previa occurs when the internal cervical os is completely covered by the placenta. Partial placenta previa occurs when the internal os is partially covered by the placenta. Marginal placenta previa occurs when the placenta is at the margin of the internal os. Low-lying placenta previa occurs when the placenta is implanted in the lower uterine segment. In this variation, the edge of the placenta is near the internal os but does not reach it. Figure 1. Of all placenta previas, the frequency of complete placenta previa ranges from 20-45%, partial placenta previa accounts for approximately 30%, and marginal placenta previa accounts for the remaining 25-50%. Note: A recent study concluded that more than two thirds of women with a distance of more than 10 mm from the placental edge to cervical os have vaginal delivery without an increased risk of hemorrhage Vergani P, Ornaghi S, Pozzi I, Beretta P, Russo FM, Follesa I, et al. Placenta previa: distance to internal os and mode of delivery. Am J Obstet Gynecol . Jul 23 2009; [Medline] . http://emedicine.medscape.com/article/796182-overview

Figure 1. Types of Placenta Previa ( http:// www.google.com /images )

Etiology Risk Factors Increase Parity Increase Maternal age > 35 years Cigarette smoking Residence in High altitude Multiple gestations Previous Placenta Previa Prior Currettage Erythroblastosis Prior uterine surgery Recurrent abortions Nonwhite ethnicity Low socioeconomic status Short interpregnancy interval Cocaine use Other causes include digital exam, abruption (pre-eclampsia, chronic hypertension, cocaine use, etc) and other causes of trauma (eg, postcoital trauma). http://emedicine.medscape.com/article/262063-overview

Pathophysiology Bleeding in placenta previa may be due to any of the following causes Mechanical separation of the placenta from its implantation site, either during the formation of LUS or during effacement and dilation of the cervix in labor, as a result of intravaginal manipulation Placentitis Rupture of poorly supported venous lakes in the decidua basalis that have become engored with venous blood.

Clinical History Placenta previa is one of the leading causes of vaginal bleeding. Vaginal bleeding is apt to occur suddenly during the third trimester. Bleeding is usually bright red and painless. Some degree of uterine irritability is present in about 20% of the cases. Initial bleeding is not usually profuse enough to cause death; it spontaneously ceases, only to recur later. The first bleed occurs (on average) at 27-32 weeks' gestation. Contractions may or may not occur simultaneously with the bleeding. http://emedicine.medscape.com/article/796182-overview

Physical Profuse hemorrhage Hypotension Tachycardia Soft and nontender uterus Normal fetal heart tones (usually) Vaginal and rectal examinations-Do not perform these examinations in the ED because they may provoke uncontrollable bleeding. Perform examinations in the operating room under double set-up conditions (ie, ready for emergent cesarean delivery).

Differential Diagnosis Abruptio Placentae Disseminated Intravascular Coagulation Pregnancy, Delivery Other problems to be considered Vasa previa Infection Vaginal Bleeding Lower genital tract Infections Bloody show

: Adult themes Are You 200% sure???. It’s not Placenta Previa Pelvic ,Vaginal and PR Examination Don’t Provoke Hemorrhage, both vaginal and Rectal should be avoided

Pelvic ,Vaginal and PR Examination ????????? Don’t provoke hemorrhage, both vaginal and Rectal should be avoided

Workup Laboratory Studies -The following studies are indicated in placenta previa: Beta-human chorionic gonadotropin (beta-hCG) subunit Rh compatibility Fibrin split products (FSP) and fibrinogen levels Prothrombin time (PT)/activated partial thromboplastin time (aPTT) Type and hold for at least 4 units CBC count Apt test to determine fetal origin of blood (as in the case of vasa previa) Wright stain applied to a slide smear of vaginal blood, looking for nucleated RBCs, not adult blood Lecithin/sphingomyelin (L/S) ratio for fetal maturity, if needed

Imaging Studies Sonography – to asses the placental location and fetal growth Transabdominal ultrasonography - A simple, precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 93-98%. Transvaginal Ultrasonography – safer and more accurate than TAUS.Probe is insert not more thab 3 cm to visualized the Placenta Previa..See Images Other imaging techniques include Transperineal ultrasonography MRI Other test Kleihauer-Betke test, if concerned about fetal-maternal transfusion Bedside clot test a double set-up bimanual examination under anesthesia (EUA) may be performed in the operating room.

Pathology- Macroscopic: Placenta Previa covering the entire cervical os Placenta previa partially separated from the LUS Placenta previa invading the lower uterine segment and covering the cervical os. http://emedicine.medscape.com/article/262063-media

Treatment Prehospital Care The key to prehospital care of placenta previa is to ensure hemodynamic stability of the patient and transfer to an appropriate facility. Types of treatment depends on: Amount of bleeding Duration of pregnancy and viability of the fetus Degree of placenta previa The presentation, position and station of the fetus Status of the cervix whether or not the labor has begun Patient MUST be admitted to the Hospital.. 2 or units of bank blood should be typed ,crossed-matched and ready for transfusion

A. Expectant Therapy Admitted to ward Establish Fetal Pulmonary Maturation If pt between 24-36 weeks ,single dose of betamethasone 12mg imi each, 24hrs Transfuse to replace blood loss Use of tocolytic agent to prevent premature of labor and prolong pregnancy(>36 weeks) Test for lung maturity Amniotic fluid surfactants Ultrasound growth measurements

medication Acts directly on beta2-receptors to relax uterine contractions. Terbutaline (Brethine) tocolytics to promote the time for expectant management of symptomatic placenta previa Loading dose: 6 g IV over 20 min; then 2-4 g/h continuous infusion; adjust to lessen contractions; not to exceed 4 g/h Tocolytics Magnesium sulfate Steroids may be administered after consultation with a gynecologist, if vaginal bleeding is mild and intermittent, if the patient is not in labor, and if gestation is less than 37 weeks. Corticosteroids Betamethasone (Celestone) Side Effect Dosage Drug

B. Delivery Cesarean section- the delivery method of choice with placenta previa Choice of operation technique is important If the placenta previa increta is found ,hemostasis may necessitate a Total hysterectomy Vagina Delivery – reserve for patients with a Marginal Implanation , cephalic presentation Cont monitor for possible fetal hypoxia,placental separation,cord accident thus require vaccum extraction

B. Delivery If B&C are not Possible ALWAYS refer to A. A. Cesarean section: METHOD OF CHOICE B. Vaginal Delivery C. Assisted Deliverly: Vacuum & Forceps REF: http:// www.google.com /images

Complications A. Maternal Maternal hemorrhage Hemorrhagic Shock Death- results from PPH, Operative trauma, infection or embolism B. Fetal Prematurity (Ga 36 weeks) IUFD, due intrauterine asphyxia Birth trauma Fetal Hemorrhage IUGR Fetal Anemia and Rh isoimmunization Congenital anomalies

Remarks Prevention/Deterrence Patients with placenta previa should decrease activity to avoid rebleeding. intercourse should be avoided Patients with complete placenta previa tend to have poorer pregnancy outcomes. They tend to deliver more prematurely and may require hysterectomies at the time of delivery.

Third trimester Bleeding

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Third trimester Bleeding