Perdarahan Ante Partum

Pembimbing: dr. Cut Meurah Yeni, Sp.OG

Oleh:

Andi Marwansyah Rizky Fajri Teuku Rizka Saputra

Introduction
Definition:

Vaginal bleeding which occurs after fetal viability.

Incidence:

2 6 %.

Causes
Placental: Abruptio placenta. Placenta previa. Non-placental: Vasa previa. Bloody show. Trauma. Uterine rupture. Cervicitis. Carcinoma. Idiopathic.

Abruptio Placenta

Introduction
Definition:

It is the separation of the placenta from its site of implantation before delivery of the fetus.
Incidence:

1 in 200 deliveries.

Risk Factors
Increased age & parity. Smoking.

Hypertensive

Thrombophilia.
Cocaine use. Prior abruption.

disorders. Preterm ruptured membranes. Multiple gestation. Polyhydramnios.

Uterine fibroid.
Trauma.

Types
Total or partial. Concealed or reveiled.

Presentation
Vaginal bleeding.

Uterine tenderness or back pain.

Fetal distress. High frequency contractions. Uterine hypertonus. Idiopathic PTL. IUFD.

Diagnosis
The diagnosis is primarily clinical, but may be

supported by radiologic, laboratory, or pathologic findings.

It is generally obvious in severe cases.
In milder forms the diagnosis is often made

by exclusion.

Diagnosis
The echogenic appearance depends upon the onset of symptoms:
Acute hemorrhage is hyperechoic to

isoechoic compared with the placenta.

Resolving hematomas is hypoechoic within

one week and sonolucent within two weeks.

Diagnosis
Laboratory testing is not useful in making the diagnosis: Kleihauer-Betke test: sensitivity 17%. CA-125: elevated. D-dimer: sensitivity 67, specificity 93% Thrombomodulin: sensitivity 88, specificity 77%. Hypofibrinogenemia < 200 mg/dL. Thrombocytopenia < 100,000/microL.

Diagnosis
Gross examination of the placenta often

reveals a clot and/or depression in the maternal surface.

It may be absent with acute abruption.

Initial Management
Stabilization of the maternal cardiopulmonary

status. Blood work: - CBC. - Coagulation profile. - Fibrinogen. - Blood type and Rh.

Initial Management
Large-bore intravenous lines and continuous

fetal monitoring Correction of the intravascular fluid deficit via crystalloid +/- PRBC. If the PT and PTT > 1.5x control 2u FFP. If the platelet count is < 50,000/microL 6u plt.

Initial Management
Heparin or other anticoagulants ? Tocolysis is generally contraindicated. Delivery is the optimal treatment. DIC &

hemorrhage will resolve over 12 hours when the placenta is removed.

Initial Management
Medical treatment of coagulopathy for: Marked thrombocytopenia (< 20,000/microL) Moderate thrombocytopenia(<50,000/microL) &serious bleeding or planned cesarean delivery. FFP or cryoprecipitate if fibrinogen is <100 mg/dL

Mild Abruption
Expectant management with short term

hospitalization.
Corticosteroid. Tocolysis may be of value in mild cases.

Delivery
The mode and timing of delivery depend upon: GA. The condition of the fetus. The condition of the mother (eg, hypotension, coagulopathy, hemorrhage). The status of the cervix.

Delivery
The term or near term fetus should be

expeditiously delivered.
Amniotomy with placement of a fetal scalp

electrode.
Oxytocin may be used to augment uterine

activity.

Delivery
C/S is performed in the presence of a

nonreassuring fetal heart rate pattern & when delay in delivery will endanger the mother or fetus.
It should be done after rapid maternal

hemodynamic and clotting factor stabilization.

Complications

1.
2. 3.

4.

Maternal: Hypovolemia. DIC. Renal failure. Death.

Fetal:

1. PTL.
2. PNM. 3. IUGR.

4. IUFD.

Placenta Previa

Introduction
Definition:

The presence of placental tissue overlying or proximate to the internal cervical os after viability.
Incidence:

Complicates approximately 1 in 300 pregnancies.

Risk Factors
Increasing parity: incidence 0.2 percent in nulliparas

versus up to 5 percent in grand multiparas. Maternal age: incidence 0.03 percent in nulliparous women aged 20 to 29 versus 0.25 percent in nulliparous women 40 years of age. Number of prior cesarean deliveries incidence 10 percent after four or more. Number of curettages for spontaneous or induced abortions.

Independent Risk Factors

Maternal smoking

Residence at higher altitudes

Male fetus Multiple gestation: 3.9 and 2.8 previas per

1000 live twin and singleton births, respectively Gestational age: the prevalence of placenta previa is much higher early in pregnancy than at term

Classification
Complete placenta previa: The placenta

completely covers the internal os. Partial placenta previa: The placental edge does not completely cover the internal cervical os but partially covers it. Marginal placenta previa: The placenta is proximate to the internal os. Low-lying placenta: in which placental edge lies within 2 to 3 cm of the internal os. (reference)

Clinical Manifestations
Painless vaginal bleeding occurs in 70 to 80

percent of patients.
10 to 20 percent present with uterine

contractions associated with bleeding.

Fewer than 10 percent are incidentally

detected by ultrasound.

Associated Conditions
Malpresentation.

PPROM.
Congenital anomalies. IUGR.

Diagnosis
The diagnosis is based upon results of

ultrasound examination.
Clinical findings are used to support the

sonographic diagnosis.
Placenta previa should be suspected in any

woman beyond 24 weeks of gestation who presents with painless vaginal bleeding.

Transabdominal US
It has a diagnostic accuracy as high as 95%

in detecting placenta previa, with a false negative rate of 7%.

Sagittal, parasagittal and transverse

sonographic views should be obtained.

Transabdominal US
It requires the identification of echogenic

placental tissue overlying or proximate to the internal cervical os (a distance >2 cm).

Transvaginal US
It has become the gold standard for the

diagnosis of placenta previa.

It is a safe and effective technique, with

diagnostic accuracy greater than 99 percent.

The probe does not need to come into

contact with the cervix to provide a clear image.

Ultrasound
Both the transabdominal and transvaginal US

should be used as complementary studies.

Initial transabdominal examination, with

transvaginal sonography if there is any ambiguity in the placental position.

Translabial ultrasound imaging is an

alternative technique.

Antepartum Management
Avoidance of coitus and digital cervical

examination. Counseling to seek immediate medical attention if there is any vaginal bleeding. Women are also encouraged to avoid exercise, decrease their activity, and notify the physician of uterine contractions. Serial ultrasound evaluations every two to four weeks to assess placental location and fetal growth.

Acute Care of Symptomatic Placenta Previa

Large bore IV access & administration of

crystalloid. Type and cross-match for four units of PRBC. Transfuse to maintain a Hct of 30% if the patient is actively bleeding. Maternal pulse and blood pressure every 15 minutes to 1 hour depending upon the degree of blood loss.

Acute Care of Symptomatic Placenta Previa

The fetal heart rate is continuously monitored.

Quantitative monitoring of vaginal blood loss.

The source of the vaginal blood (maternal

versus fetal) is intermittently assessed by either an Apt test or Kleihauer-Betke analysis. Urine output is evaluated hourly with a Foley catheter & should be at least 30 mL/hour.

Acute Care of Symptomatic Placenta Previa

Hb & Hct. Serum electrolytes and indices of renal

function.
Coagulation profile (fibrinogen, Plt, PT & PTT)

are checked especially if there is a suspicion of coexistent abruption.

Delivery
Tocolysis is not administered to actively

bleeding patients.
Delivery is indicated if:

(1) there is a nonreassuring fetal heart

rate. (2) life threatening refractory maternal hemorrhage.

Mode of Delivery

Cesarean delivery is the delivery route of choice.

Vaginal delivery may be considered in the presence of: 1. a fetal demise 2. previable fetus 3. some cases of marginal previa, as long as the mother remains hemodynamically stable.

Conservative Management of Stable Preterm Patients

The patient is hospitalized at bedrest with bathroom

privileges.
Stool softeners and a high-fiber diet help to minimize

constipation and avoid excess straining.

Periodic assessment of the maternal hematocrit. Ferrous gluconate supplements (300 mg orally three

or four times per day) are given with vitamin C to improve intestinal iron absorption.

Conservative Management of Stable Preterm Patients

Cross match to provide two to four units of

packed red blood cells.

Prophylactic transfusions to maintain the

maternal hematocrit above 30 percent in stable asymptomatic patients in anticipation of future blood loss.

Conservative Management of Stable Preterm Patients

A single course of corticosteroid between 24

and 34 w.
Rh(D)-negative women should receive Rh(D)-

immune globulin if they bled.

Readministration is not necessary if delivery

or rebleeding occurs within three weeks, unless a large fetomaternal hemorrhage is detected by KBT.

Conservative Management of Stable Preterm Patients

Fetal growth, amniotic fluid volume, and

placental location are evaluated sonographically every two to four weeks.

Tocolysis may be safely utilized if

contractions are present and delivery is not otherwise mandated by the maternal or fetal condition.

Conservative Management of Stable Preterm Patients

Amniocentesis can be done at 36 weeks to

assess pulmonary maturity.

Scheduled abdominal delivery is suggested

@ 37w or upon confirmation of pulmonary maturity.

Delivery
Abdominal delivery. Two to four units of PRBC should be

available for the delivery.

Appropriate surgical instruments for

performance of a cesarean hysterectomy should also be available since there is a 5 to 10 percent risk of placenta accreta.

C/S
The surgeon should try to avoid disrupting the

placenta when entering the uterus.

If the placenta is encountered upon opening

the uterus then it is necessery to cut through the placental tissue to deliver the fetus.

Outpatient Managaement
Women who have never bled. Women with placenta previa if bleeding has

stopped for more than one week.

There are no other pregnancy complications,

such as fetal growth restriction.

Outpatient Management
Live within 15 minutes of the hospital.

Have an adult companion available 24 hours

a day who can immediately transport the woman to the hospital if there is light bleeding or call an ambulance for severe bleeding. Be reliable and able to maintain bed rest at home. Understand the risks entailed by outpatient management.

Outcome
The maternal and perinatal mortality rates in pregnancies complicated by placenta previa have been reduced over the past few decades because of: The introduction of conservative obstetrical management. The liberal use of cesarean rather than vaginal delivery. Improved neonatal care.

Vasa Previa

Introduction
Vasa previa refers to vessels that traverse the

membranes in the lower uterine segment in advance of the fetal head.

Rupture of these vessels can occur with or

without rupture of the membranes and result in fetal exsanguination.

The incidence is 1 in 2000 3000 deliveries.

Associated Conditions
Low-lying placenta.

Bilobed placenta.
Multi-lobed placenta. Succenturiate-lobed placenta. Multiple pregnancies. Pregnancies resulting from IVF.

Diagnosis
The diagnosis of vasa previa is considered if

vaginal bleeding occurs upon rupture of the membranes.

Concomitant fetal heart rate abnormalities,

particularly a sinusoidal pattern.

Ideally, vasa previa is diagnosed antenatally

by US with color flow Doppler.

Antenatal Management
Consider hospitalization in the third trimester

to provide proximity to facilities for emergency cesarean delivery. Fetal surveillance to detect compression of vessels. Antenatal corticosteroids to promote lung maturity. Elective cesarean delivery at 35 to 36 weeks of gestation.

Antepartum Management
Immediate C/S. Avoid amniotomy as the risk of fetal mortality

is 60-70% with rupture of the membranes.

Uterine Rupture

Risk Factors
The most common risk factor is a previous

uterine incision.
The rate is higher with classical & T-shape

uterine incision in comparison to low vertical & transverse incisions.

The rate increases with the number of

previous uterine incisions.

Risk Factors

High parity. Labor complications: 1. CPD. 2. Abnormal presentation. 3. Unusual fetal enlargement (hydrocephalus).

Trauma.

Delivery complications:
1. Difficult forceps. 2. Breech extraction.

3. Internal podalic version.

Presentation
Sudden severe fetal heart decelerations. Abdominal pain & PV bleeding ( <10%).

Diaphragmatic irritation.
Loss of fetal station. Cessation of uterine contractions.

Prognosis
Fetal death 50-75%. Maternal mortality is high if not diagnosed &

managed promptly.
Maternal morbidity: hemorrhage & infection.

Management
stabilization of maternal hemodynamics. Prompt C/S with either repair of the uterine

defect or hysterectomy.
Antibiotics.

MCQs

A 23-y-o PG, @ 29w comes to A&E for evaluation following a RTA in which a restrained passenger in the back seat. She denies any symptoms & examination is normal with fetal heart rate of 150bpm. Before discharging the patient your recommendation regarding electronic fetal monitoring: 1. Do none. 2. Monitor for 2-6h. 3. Monitor for 6-12h. 4. Monitor for 12-18h. 5. Monitor for 18-24h.

 In counseling a woman with a prior C/S

1. 2. 3. 4.

regarding IOL, you tell her that the highest risk of uterine rupture is associated with: Osmotic cervical dilator. Transcervical Foley balloon placement. Prostaglandins. Oxytocin.

 A 34-y-o woman G3P2, present @38w in

1. 2. 3.

4.
5.

early labor. V/E: 3cm with a firm ridge in the membranes by palpation. U/S: placenta located both anteriorly & posteriorly in the lower uterine segment. There is no placenta previa. A tocolytic is administered. What should be the next step in management? Allow continued labor. Speculum examination. Amniocentesis. Color flow Doppler U/S. Amniotomy.

 A 19y-o PG admitted @ 34w with heavy

1.

2.
3. 4.

5.

vaginal bleeding & regular contractions. She reports no leakage of fluid. BP:156/98. F Ht 35cm. CTG is reactive. U/S: anterior placenta & no retroplacental sonolucency. V/E: 4cm. The most likely Dx is: Vasa previa. Placental abruption. Chorioangioma. Placenta accreta. Placental succenturiate lob.

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