Ghadeer Al-Shaikh

Ghadeer Al-Shaikh, MD, FRCSC
Assistant Professor & Consultant

Obstetrics & Gynecology
Urogynecology & Pelvic Reconstructive Surgery
Department of Obstetrics & Gynecology
College of Medicine
King Saud University
Obstetrics is "bloody business."
Death from hemorrhage still remains a

leading cause of maternal mortality.
Causes of 763 Pregnancy-related Deaths Due to Hemorrhage

Causes of Hemorrhage
Number (%)
Abruptio placentae
141 (19)
Laceration/uterine rupture
125 (16)
Uterine atony
115 (15)
Coagulopathies
108 (14)
Placenta previa
50 (7)
Placenta accreta / increta / percreta
44 (6)
Uterine bleeding
47 (6)
Retained placenta
32 (4)
APH is blood loss Per vagina after 20

weeks gestation.
Complicates close to 4% of all

pregnancies and is a MEDICAL
EMERGENCY!
Is one of the leading causes of

antepartum hospitalization, maternal
morbidity, and operative intervention.
Placental Abruption
Placenta Previa
Uterine Rupture
Vasa Previa
Bloody Show
Coagulation Disorder
Hemorrhoids
Vaginal Lesion/Injury
Cervical Lesion/Injury
Neoplasia
The pregnancy in which such bleeding

occurs remains at increased risk for a
poor outcome even though the bleeding
soon stops and placenta previa appears
to have been excluded by sonography.
Defined as a placenta implanted in the lower

segment of the uterus, presenting ahead of the
leading pole of the fetus.
1.
Total placenta previa. The internal cervical os is covered

completely by placenta.
2.
Partial placenta previa. The internal os is partially

covered by placenta.
3.
Marginal placenta previa. The edge of the placenta is at

the margin of the internal os.
4.
Low-lying placenta. The placenta is implanted in the

lower uterine segment such that the placenta edge
actually does not reach the internal os but is in close
proximity to it.
Bleeding results from small

disruptions in the placental
attachment during normal
development and thinning of
the lower uterine segment
Incidence about 1 in 300
Perinatal morbidity and mortality are

primarily related to the complications of
prematurity, because the hemorrhage is
maternal.
Etiology:
Advancing maternal age
Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa
The most characteristic event in placenta

previa is painless hemorrhage.
This usually occurs near the end of or

after the second trimester.
The initial bleeding is rarely so profuse as

to prove fatal.
It usually ceases spontaneously, only to

recur.
Placenta previa may be associated with

placenta accreta, placenta increta or
percreta.
Coagulopathy is rare with placenta

previa.
The simplest and safest method of placental

localization is provided by transabdominal
sonography.
Transvaginal ultrasonography has substantively

improved diagnostic accuracy of placenta previa.
MRI
At 18 weeks, 5-10% of placentas are low lying.

Most migrate with development of the lower
uterine segment.
Admit to hospital
NO VAGINAL EXAMINATION
IV access
Placental localization
Severe
bleeding
Moderate
bleeding
Resuscitate
>34/52
Gestation
<34/52
Resuscitate
Steroids
Mild
bleeding
Caesarean
section
Gestation
<36/52
>36/52
Unstable
Stable
Conservative
care
Delivery is by Caesarean section
Occasionally Caesarean hysterectomy

necessary.
Defined as the premature separation of

the normally implanted placenta.
Occurs in 1-2% of all pregnancies
Perinatal mortality rate associated with

placental abruption was 119 per 1000
births compared with 8.2 per 1000 for all
others.
external hemorrhage
concealed hemorrhage
Total
Partial
What are the risk factors for placental

abruption?
The primary cause of placental abruption is unknown, but

there are several associated conditions.
Increased age and

parity
Cigarette smoking
Thrombophilias
Preeclampsia
Cocaine use
Chronic hypertension
Prior abruption
Preterm ruptured
membranes
Uterine leiomyoma
External trauma
Multifetal gestation
Hydramnios
Pathology
Placental abruption is initiated by hemorrhage

into the decidua basalis.
The decidua then splits, leaving a thin layer

adherent to the myometrium.
development of a decidual hematoma that leads

to separation, compression, and the ultimate
destruction of the placenta adjacent to it.
Bleeding with placental abruption is

almost always maternal.
Significant fetal bleeding is more likely to

be seen with traumatic abruption.
In this circumstance, fetal bleeding

results from a tear or fracture in the
placenta rather than from the placental
separation itself.
The hallmark symptom of placental abruption is pain

which can vary from mild cramping to severe pain.
A firm, tender uterus and a possible sudden increase

in fundal height on exam.
The amount of external bleeding may not accurately

reflect the amount of blood loss.
Importantly, negative findings with ultrasound

examination do not exclude placental
abruption. Ultrasound only shows 25% of
abruptions.
Shock
Consumptive Coagulopathy
Renal Failure
Fetal Death
Couvelaire Uterus
Management: Treatment for placental

abruption varies depending on gestational age
and the status of the mother and fetus.
Admit
History & examination
Assess blood loss
Nearly always more than revealed
IV access, X match, DIC screen

Assess fetal well-being
Delivery
Reported in 0.03-0.08% of all delivering

women, but 0.3-1.7% among women with a
history of a uterine scar (from a C/S for
example)
13% of all uterine ruptures occur outside the

hospital
The most common maternal morbidity is

hemorrhage
Fetal morbidity is more common with extrusion
Classic presentation includes vaginal

bleeding, pain, cessation of contractions,
absence/ deterioration of fetal heart rate,
loss of station of the fetal head from the
birth canal, easily palpable fetal parts, and
profound maternal tachycardia and
hypotension.
Patients with a prior uterine scar should

be advised to come to the hospital for
evaluation of new onset contractions,
abdominal pain, or vaginal bleeding.
What are the risk factors

associated with uterine
rupture?
Excessive uterine
stimulation
Multiparity
Non-vertex fetal
presentation
Hx of previous C/S
Trauma
Shoulder dystocia
Prior rupture
Forceps delivery
Previous uterine
surgery
Management: Emergent laparotomy
Rarely reported condition in which the

fetal vessels from the placenta cross the
entrance to the birth canal.
Incidence varies, but most resources note

occurrence in 1:3000 pregnancies.
Associated with a high fetal mortality rate

(50-95%) which can be attributed to rapid
fetal exsanguination resulting from the
vessels tearing during labor
There are three causes typically noted for

vasa previa:
1. Bi-lobed placenta
2. Velamentous insertion of the umbilical cord
3. Succenturiate (Accessory) lobe
Risk Factors:
Bilobed and succenturiate placentas
Velamentous insertion of the cord
Low-lying placenta
Multiple gestation
Pregnancies resulting from in vitro fertilization
Palpable vessel on vaginal exam
Management:
When vasa previa is detected prior to labor, the

baby has a much greater chance of surviving.
It can be detected during pregnancy with use of

transvaginal sonography.
When vasa previa is diagnosed prior to labor,

elective caesarian is the delivery method of
choice.
Is a blood test used to measure the

amount of fetal hemoglobin transferred
from a fetus to the mother's bloodstream.
Used to determine the required dose of

Rh immune globulin.
Used for detecting fetal-maternal

hemorrhage.
The test allows the clinician to determine

whether the blood originates from the infant or
from the mother.
Place 5 mL water in each of 2 test tubes
To 1 test tube add 5 drops of vaginal blood
To other add 5 drops of maternal (adult) blood
Add 6 drops 10% NaOH to each tube
Observe for 2 minutes
Maternal (adult) blood turns yellow-green-brown; fetal

blood stays pink.
If fetal blood, deliver STAT.
Admit
History
Examination
NO PV
Nurse on side
IV access/
resuscitate
Clotting screen
Cross match
Kleihauer-Betke test
Apt test
CTG
Observation
Speculum
examination when
placenta previa
excluded
Anti-D if Rh-negative

Ghadeer Al-Shaikh

Uploaded by

Copyright:

Available Formats

Ghadeer Al-Shaikh

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ghadeer Al-Shaikh

Uploaded by

Copyright:

Available Formats

Ghadeer Al-Shaikh, MD, FRCSC

Assistant Professor & Consultant

Obstetrics is "bloody business."

Death from hemorrhage still remains a

Causes of 763 Pregnancy-related Deaths Due to Hemorrhage

Placenta accreta / increta / percreta

APH is blood loss Per vagina after 20

Complicates close to 4% of all

Is one of the leading causes of

The pregnancy in which such bleeding

Defined as a placenta implanted in the lower

Total placenta previa. The internal cervical os is covered

Partial placenta previa. The internal os is partially

Marginal placenta previa. The edge of the placenta is at

Low-lying placenta. The placenta is implanted in the

Bleeding results from small

Incidence about 1 in 300

Perinatal morbidity and mortality are

The most characteristic event in placenta

This usually occurs near the end of or

The initial bleeding is rarely so profuse as

It usually ceases spontaneously, only to

Placenta previa may be associated with

Coagulopathy is rare with placenta

The simplest and safest method of placental

Transvaginal ultrasonography has substantively

At 18 weeks, 5-10% of placentas are low lying.

Delivery is by Caesarean section

Occasionally Caesarean hysterectomy

Defined as the premature separation of

Occurs in 1-2% of all pregnancies

Perinatal mortality rate associated with

What are the risk factors for placental

The primary cause of placental abruption is unknown, but

Increased age and

Placental abruption is initiated by hemorrhage

The decidua then splits, leaving a thin layer

development of a decidual hematoma that leads

Bleeding with placental abruption is

Significant fetal bleeding is more likely to

In this circumstance, fetal bleeding

The hallmark symptom of placental abruption is pain

A firm, tender uterus and a possible sudden increase

The amount of external bleeding may not accurately

Importantly, negative findings with ultrasound

Management: Treatment for placental

IV access, X match, DIC screen

Reported in 0.03-0.08% of all delivering

13% of all uterine ruptures occur outside the

The most common maternal morbidity is

Fetal morbidity is more common with extrusion

Classic presentation includes vaginal

Patients with a prior uterine scar should

What are the risk factors

Management: Emergent laparotomy

Rarely reported condition in which the

Incidence varies, but most resources note

Associated with a high fetal mortality rate