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    Antepartum Hemorrhage

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    1. A 27-year-old pregnant woman presented with vaginal bleeding at 33 weeks of gestation. Her care requires stabilizing her vitals, monitoring the fetus, performing tests to diagnose the cause of bleeding, and preparing for potential early delivery. 2. The differential diagnosis includes placenta previa, placental abruption, vasa previa, and uterine rupture. Placenta previa and abruption are the most common causes and present a risk of excessive bleeding. 3. Management depends on the diagnosis and gestational age. It may involve expectant monitoring, early delivery by cesarean section, or hysterectomy in severe cases. The risks include maternal shock, complications of early birth

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    Antepartum Hemorrhage

    Uploaded by

    code-24
    182 views5 pages
    1. A 27-year-old pregnant woman presented with vaginal bleeding at 33 weeks of gestation. Her care requires stabilizing her vitals, monitoring the fetus, performing tests to diagnose the cause of bleeding, and preparing for potential early delivery. 2. The differential diagnosis includes placenta previa, placental abruption, vasa previa, and uterine rupture. Placenta previa and abruption are the most common causes and present a risk of excessive bleeding. 3. Management depends on the diagnosis and gestational age. It may involve expectant monitoring, early delivery by cesarean section, or hysterectomy in severe cases. The risks include maternal shock, complications of early birth

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    Antepartum Hemorrhage summary for OSCE

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    1. A 27-year-old pregnant woman presented with vaginal bleeding at 33 weeks of gestation. Her care requires stabilizing her vitals, monitoring the fetus, performing tests to diagnose the cause of bleeding, and preparing for potential early delivery. 2. The differential diagnosis includes placenta previa, placental abruption, vasa previa, and uterine rupture. Placenta previa and abruption are the most common causes and present a risk of excessive bleeding. 3. Management depends on the diagnosis and gestational age. It may involve expectant monitoring, early delivery by cesarean section, or hysterectomy in severe cases. The risks include maternal shock, complications of early birth

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    182 views5 pages

    Antepartum Hemorrhage

    Uploaded by

    code-24
    1. A 27-year-old pregnant woman presented with vaginal bleeding at 33 weeks of gestation. Her care requires stabilizing her vitals, monitoring the fetus, performing tests to diagnose the cause of bleeding, and preparing for potential early delivery. 2. The differential diagnosis includes placenta previa, placental abruption, vasa previa, and uterine rupture. Placenta previa and abruption are the most common causes and present a risk of excessive bleeding. 3. Management depends on the diagnosis and gestational age. It may involve expectant monitoring, early delivery by cesarean section, or hysterectomy in severe cases. The risks include maternal shock, complications of early birth

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    © All Rights Reserved
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    of 5

    ANTEPARTUM HEMORRHAGE

    Definition: Vaginal bleeding after 24 weeks of gestation


    A 27 years old female, pregnant at 33 weeks of gestation presented to the ER with vaginal bleeding. How to
    manage her?
    NO PELVIC/RECTAL until previa ruled out
    ABC's first: continuous fetal monitoring, intravenous access, Keep maternal oxygen saturation >95 percent,
    Draw blood for a complete blood count, blood type and Rh, and coagulation studies, Notify the anesthesia
    team
    DDx:

    Vasa previa

    Placenta previa

    Abruptio placenta

    Uterine rupture

    Bloody show

    Cervical (cervicitis, polyp, cancer)

    Vaginal (post-coital)

    Non-gyne (hematuria, BRBPR)

    Abruptio Placenta

    Classification: concealed vs apparent

    Presentation: pain with bleeding, pain is sudden/constant, localized to back and uterus, and Uterine
    Contractions are usually high frequency and low amplitude, but a contraction pattern typical of labor
    is also possible and labor may proceed rapidly

    Risk Factors:

    HTN, Preeclampsia/Pregnancy induced hypertension, Eclampsia.

    Previous abruption

    Large uterus (macrosomia, polyhydramnios, multiple gest)

    EtOH, smoking, cocaine

    Uterine anomaly

    Trauma

    Multiparity

    Premature rupture of membranes

    Chorioamnionitis

    Consequences:

    Maternal:

    Excessive blood loss and DIC generally necessitate blood transfusion and can lead to
    hypovolemic shock, renal failure, adult respiratory distress syndrome, multiorgan
    failure, peripartum hysterectomy and, rarely, death.

    Emergency cesarean delivery for fetal or maternal indications

    Fetal and neonatal:

    Perinatal morbidity and mortality related to hypoxemia, asphyxia, low birth weight,
    and/or preterm delivery.

    Fetal growth restriction (with chronic abruption).

    DIAGNOSIS: The diagnosis is primarily clinical, but findings from imaging (retroplacental
    hematoma).

    Management:

    Maternal stabilization

    Severe abruption at any gestational age and nonsevere abruption at >36 weeks: Deliver.

    Nonsevere abruption at 34 to 36 weeks (fetal status reassuring, maternal vital signs normal,
    laboratory tests normal or mildly abnormal, mild to moderate bleeding): Deliver. Since these
    patients remain at risk of developing a sudden severe abruption.

    Minor abruption at 34 to 36 weeks: They should be monitored closely and delivered if they
    have recurrent bleeding.

    Nonsevere abruption at <34 weeks: Expectant management of abruption in pregnancies.


    Corticosteroids to promote fetal lung maturation should be administered to pregnancies at 23
    to 34 weeks of gestation, given the increased risk of need for preterm delivery

    Recurrence risk: several-fold higher risk of abruption in a subsequent pregnancy

    Placenta previa

    Classification: partial vs complete vs marginal vs low-lying placenta


    2

    Presentation: In the second half of pregnancy, the characteristic clinical presentation is painless
    vaginal bleeding.

    Risk Factors:

    Previous placenta previa

    Previous cesarean delivery

    Multiple gestation

    Multiparity

    Advanced maternal age

    Infertility treatment

    Previous abortion

    Previous intrauterine surgical procedure

    Maternal smoking, cocaine use.

    Associated conditions:

    Placenta accreta

    Preterm labor and rupture of the membranes

    Malpresentation

    Intrauterine growth restriction

    Vasa previa and velamentous umbilical cord

    Congenital anomalies

    Amniotic fluid embolism

    DIAGNOSIS:

    Sonographic determination of placental location before digital vaginal examination is


    performed because palpation of the placenta can cause severe hemorrhage.

    Echogenic homogeneous placental tissue covering or proximate to the internal cervical os (a


    distance greater than 2 cm from the os excludes the diagnosis of previa).

    Management:

    ACUTE CARE:

    Assessment:

    Maternal: BP, HR, Urine output, estimation of vaginal blood loss (Soaked
    pads)

    Fetal: fetal heart rate

    Intravenous access and crystalloid One or two large bore intravenous lines are
    inserted and crystalloid is infused to achieve/maintain hemodynamic stability and
    adequate urine output (at least 30 mL/hour).

    Transfusion: begin red cell transfusions in hypotensive patients whose blood pressure
    fails to improve after two liters of crystalloid have been rapidly infused.

    Tocolysis: reduce or eliminate uterine contractions, which may promote placental


    separation and bleeding. Prolong pregnancy and result in an increase in birthweight

    Magnesium sulfate neuroprotection in patients with preterm (24 to 32 weeks) placenta


    previa in whom a decision has been made to deliver within 24 hours, but not
    emergently.

    Antenatal corticosteroids A course of antenatal corticosteroid therapy should be


    administered to symptomatic women between 23 and 34 weeks of gestation to
    enhance fetal pulmonary maturity.

    Admit and observe if: minimal bleeding, <36wks, fetus stable, no contractions

    Indications for delivery Cesarean delivery is indicated if any of the following occur:

    A nonreassuring fetal heart rate tracing unresponsive resuscitative measures

    Life-threatening refractory maternal hemorrhage

    Significant vaginal bleeding after 34 weeks of gestation

    C/S if: previa unstable, fetal distress, >36wks

    RECURRENCE: Placenta previa recurs in 4 to 8 percent of subsequent pregnancies

    Vasa previa
    Definition: fetal blood vessels are present in the membranes covering the internal cervical os. The
    membranous vessels may be associated with a velamentous umbilical cord (membranous umbilical vessels at
    the placental insertion site, no Wharton's jelly)

    Presentation: painless bleeding, tachycardia, bradycardia, severe variables

    Risk Factors:

    Velamentous insertion of cord on low lying cervix

    Diagnosis:

    Ultrasonographic evidence of vasa previa

    Painless vaginal bleeding upon rupture of membranes


    4

    Fetal heart rate abnormalities

    Positive Apt, Ogita, or Loendersloot tests

    Management:

    Recommend inpatient observation starting at 32 weeks. Inpatient observation allows for emergent
    caesarean in event of nonreassuring fetal testing, preterm labor, or preterm premature ruptured
    membranes. Empiric delivery at approximately 35 weeks of gestation without confirmation of lung
    maturity via amniocentesis is also recommended

    Uterine rupture

    Presentation: painful bleeding, during labour: suprapubic pain, contractions stop, vaginal bleeding,
    hemoperitoneum

    Risk Factors:

    Prior uterine surgery

    Trauma

    Uterine distension (macrosomia, polyhydramnios, multiple gest)

    Uterine anomolies

    Choriocarcinoma, difficult labor (forceps, vag breech, shoulder


    dystocia

    Diagnosis: clinical

    Management: two options: repair of the rupture site and hysterectomy

    Complications of Antepartum Hemorrhage


    Maternal
    Shock
    DIC
    Anemia
    C-section
    Uterine atony > PPH
    Hysterectomy
    Death
    Fetal
    HR abnormalities
    Hypoxia > Cerebral Palsy
    Prematurity
    Death
    References:

    CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e


    Placental abruption: Clinical features and diagnosis (UPTODATE)
    Placental abruption: Management (UPTODATE)
    Clinical features, diagnosis, and course of placenta previa (UPTODATE)
    Management of placenta previa (UPTODATE)
    Velamentous umbilical cord insertion and vasa previa (UPTODATE)

    Good Luck Dalal AlEesa


    5

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