zareh.f.md. all bleeding during pregnancy should be investigated by examination and imaging studies

Zareh.F.MD

All bleeding during

pregnancy should be

investigated by examination

and imaging studies

• 1/4 of women who bleed at 14-26 w had pp or ap.

• 1/3 of pregnancy with vag bleeding after 26 w had

poor outcome. Unexplained vag.bleeding

at term must be considered for

delivery.

etiologies

• Placenta previa• Placenta abruption• Vasa previa• Cervical lesions (carcinoma,polyps)• Vaginal laceration

(trauma,carcinoma)• Uterine rupture or dehiscence

Placenta previaincidece

• 0.5-1% of all pregnancies

• Fatal 0.03% of cases

• Incidence in multipar :1/20

• Incidence in nulipar : 1/1500

difinition• Dillated cervix:

complete previa partial previa

marginal previa low lying

• Closed cervix:complete

partial / marginal<1 cm from int.os1-2 cm from int.os>2 cm from int.os

pathophysiology

• Abnormal endometrial tissue less favorable location for implantation: poor vascularization thinner myometrium

• Uterine trauma from c/s (6 fold)

Risk factors• Perior c/s

• Black , minority

• Older women >35 y

• High gravidity & parity

• Cigarette smoking 2.6-4.4 fold

• Previous abortion

diagnosis

• Abdominal sonographymisdiagnosis :

full distended bladderlower ut segment contraction

pp in 2nd trimester 90-95% resolved by the 3rd trimester (but no central)

• 3 dimensional scanning• transvaginal scan• Transperineal scan• Double set up examination • MSAFP>2 MoM

Clinical features

• Asymptomatic

• Vaginal bleedingvariableintermittentred to brownish

maternal origin

• the fetus usually not in jeopardy

complication

• Hospital stay• c/s• Abruptio placenta• Malpresentation• Post partum hemorrhage• Growth restriction• Placenta accreta

pp+previous c/s10-35% +multiple c/s 60-65%

• Coagulation defect

Other complications

• A.T.N• Sheehan syndrome• Maternal mortality<1% • Perinatal mortality <5%

outcome• IUGR ?

• Preterm birth

• Congenital anomaly

• Respiratory distress syndrome

• Anemia

• Recurrence rate 2-3%(6-8 fold)

management

no bleeding• 2nd trimester

intercourse avoidusual activityrepeat sonography

• 3rd trimester decrease physical activity travel away from home

prolonged bed rest

management with Bleeding• Evaluation of the patient• Fetal status• IV fluid• Blood cross match• RHoGam if necessary• Steroid if 24-34 W• Delivery after 34-36W

management

Severe hemorrhage• Medical team for immediate

delivery• 2 large bore IV line• Blood cross match• Foley catheter• Coagulation panel• Continuous Fetal monitoring• delivery

Premature separation of placenta.

• 0.5-1% of deliveries

• Perinatal mortality is 20-25%

• Preterm birth is 40%

• Cause of 15% of stillbirth

Definition

Preplacental or subamniotic

retroplacental

Risk factors

Socioeconomic:• High parity

• low education

• infertility

Risk factors

Uterine:• ut.malformation

• ut.septum

• Myoma

Risk factors

Medical:• Diabete pregestational

• Hypertension _chronic&gestational

• PROM with chorioamnionitis

Risk factorsThrombophilias

• Antiphospholipid syndrome

• Prothrombin 20210A mutation

• Hyperhomocysteinemia

• Factor V leiden mutation

• Activated protein C resistance

• Protein C and S deficiency

• dysfibrinogenemia

Risk factor iatrogenic• Sudden decompression(amniocentesis)

• External cephalic version

• Cigarette smoking

• Cocaine abuse

• Blant trauma

• Heavy physical activity

pathophysiology• Blunt trauma : forceful shearing effort • Majority of other case : cell death

(apoptosis) induced through ischemia ,hypoxia.

• Thrombophilia : thrombose in decidua basalis

• Chorioamnionitis: infectious agents (lipopolysacharids & endotoxins) cytokines,superoxide ischemia and hypoixia

Pathophysiologycont.

• Nicotine(cigarete) and cocaine vasoconstriction ischemia placental lesions(infarction,oxidative stress,appoptosis and necrosis)

• Circumvalate placenta(chorion leave don’t insert at the edge of placenta) A.P,IUGR,PROM,preterm labor

diagnosis Clinically• vaginal bleeding

• Uterine pain• tetanic contraction

• fetal heart abnormality

sinusoidal pattern

diagnosis Paraclinic• Ultrasound • MRI• Doppler • Biochemical testUnexplained elevated of MSAFP AP>10

foldPreterm labor+AFP>2MoM = AP (67%)Preterm labor+AFP>2MoM+bleeding= AP

(100%) HCG Inhibin A Fetal Hb

management• Marginal Abruptio

hospitalize a patient with any bleeding after fetal viability

• Large retroplacentalusually require acute &

aggressive management

Large bleeding

• Continues fetal monitoring

• Foley catheter

• Frequent maternal v/s

• Steroid therapy (24-34w , membrane intact)

• Folic acid 1mg ,vit B12 ,vit B6

discharge• Mild bleeding : 2-5 days without any further bleeding

• Large bleeding :decision is difficult

with any bleeding , pain , contraction no discharge

Tocolytic use• Now become acceptable to consider a

short course of tocolytic therapy for: stable patient , limited abruptio ,

established fetal well being, preterm G.age

Which tocolytic

• B mimetics (terbut,ritod): mask cardiovascular response to volume depletion

• Ca channel blockers (nifidipine): reduce BP

• Mgso4 : most acceptable agents

delivery

Vaginal or c/s Depending on the: Degree of bleeding Presence or absence of: Active labor Fetal distress

complications

• c/s 50% of case

• Shock

• DIC

• Renal failure

• Couvelaire uterus

• Recurrence : 10 fold

Fetal outcome

• Mortality: term babies 25 fold

• Prematurity: 40%

Thrombophilia defects• Anticardiolipin antibodies

• Lupus anticoagulant

• Pr c, Pr s and antithrombin 3 deficiencies

• Factor v leiden “activated pr c resistance”

• Metilentetrahydrofulate reductase gene mutation • Prothrombin 20210A gene mutation

• Congenital dysfibrinogenemia

Factor V leiden• Activated protein C resistance

• Most common genetic factor predisposing to thrombosis

• Most common identifiable causes

• Substitution of adenine for guanine

• “ Amino acid arginine for glutamine

• Increased tendency to form clots

hyperhomocysteinemia

Methionine metabolise

homocysteine damage

vascular Remethylate MTHFR endothelium

folate vit.B12 , vit. B6

Methionine