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