7/3/09

Hemorrhage
in
pregnancy


 Vaginal
bleeding
during
pregnancy

Hemorrhage
in
pregnancy
  a
cause
for
concern

 cause
maternal
morbidity
and
even
mortality

 decision
for
the
:me
of
op:mal
delivery


damar
prasmusinto



masdamar@yahoo.com

Early
pregnancy
bleeding
 Normal
pregnancy


 ~
80%
of
spontaneous
pregnancy
losses
occur
  can
be
visualized
with
transvaginal
ultrasound

in
the
first
trimester
of
pregnancy
 when

 Occured
in15‐20%
of
recognized
pregnancies
  the
sac
diameter
is
greater
than
4
mm


before
20
weeks’gesta:on

  the
HCG
level
is
more
than1025
mIU/L.


Normal
pregnancy


 The
embryonic
heart
starts
bea:ng
on

 the
22‐23
rd
day
of
fetal
life

 Ectopic
pregnancy

 can
be
detected
ultrasonically
at
5.5
weeks
(CRL

3.5
mm)


1
 7/3/09

Ectopic
pregnancy
 Clinical findings

 The
incidence
rate
is
approaching
2%
of
all

pregnancies
in
some
countries

Diagnosing
ectopic
pregnancy

Biochemical testings Ultrasound findings

Management
of
ectopic
pregnancy


 Expectant

  Up
to
50%
of
ectopic
pregnancies
will
eventually
resolve
spontaneously

  can
be
considered
in
women
whose
hCG
level
falls
over
48
h,
with
levels
of
less
than

2000
mIU/ml
~
indicate
resolu:on 

Miscarriage

 Medical

  Methotrexate
is
usually
the
agent
of
choice

  Methotrexate
can
be
considered
up
to
hCG
levels
of
3000
mIU/ml


 Surgical

  If
the
woman
is
in
a
significant
amount
of
pain

  If
there
is
any
indica:on
of
cardiovascular
compromise


Miscarriage
 Clinical findings

 the
spontaneous
loss
of
a
pregnancy
before

viability

 it
is
rarely
life‐threatening

Diagnosing
misscariage

Biochemical testings Ultrasound findings

2
 7/3/09

Management
of
miscarriage


 Expectant

 It
is
most
likely
to
be
successful
if
the
woman
is

symptoma:c
at
presenta:on

Management
of
miscarriage

 A
woman
who
is
completely
asymptoma:c,
and
whose
 For
 Against

gesta:on
sac
is
intact,
should
be
advised
that
expectant

management
might
take
weeks
 Non
interven:onist,
“natural”
 Very
unpredictable

Expectant
Management

Avoid
the
risk
of
surgery
 Likely
to
be
unsuccessful
if
the

Does
not
requires
an
inpa:ent
stay

 woman
is
asymptoma:c

The
woman
experiences
the

miscarriage


Management
of
miscarriage
 Management
of
miscarriage


 Medical
  Medical
management
of
miscarriage
in

 the
treatment
of
choice
for
second‐trimester
 pa:ent

miscarriages
 For
 Against

 a
combina:on
of
the
an:progesterone
mifepristone

Avoids
the
risks
of
general
 Requires
an
inpa:ent
stay

followed
35–48
h
later
by
a
prostaglandin

anaesthe:c
 Oben
an
early
resort
to
surgery

Avoids
the
risks
of
surgical
trauma
 The
woman
experiences
miscarriage

Support
is
available
from
the
nursing
 Reduced
chance
of
obtaining
a

staff
 karyotype

Takes
:me


Management
of
miscarriage
 Management
of
miscarriage


 Surgical
  Surgical
management
of
miscarriage

 when
interven:on
in
miscarriage
was
thought
to
be

necessary

 Surgery
has
associated
risks
 For
 Against

Rapid
 Requires
a
general
anaesthe:c

The
miscarriage
is
not
experienced
 Risk
of
cervical
trauma
and
resul:ng

Provides
the
best
chance
of
obtaining
a
 cervical
weakness

karyotype
of
the
pregnancy
 Risk
of
perfora:on
of
the
uterus

Requires
admission
to
hospital


3
 7/3/09

Late
Pregnancy
Bleeding
 Causes
of
bleeding
in
late

pregnancy


 The
most
common
causes
of
perinatal
  Abrup:o
placentae

mortality
in
developing
countries
  Placenta
praevia

 Hemorrhage
is
one
of
the
main
causes
of
  Carcinoma
of
the
cervix

maternal
death
  Other
local
causes

 Vasa
praevia
(fetal
origin)

 Haematuria

 Rectal
bleeding
(mistaken
as
vaginal
bleeding)

 Unknown
origin


Management
of
abrup:o

placentae

 Before
26‐28
weeks’gesta:on

Abrup:o
placentae
  The
fetus
is
usually
not
regarded
as
viable
at
this

gesta:onal
age,
first
concern
is
the
well‐being
of

the
mother

 Inducing
labour
and
limi:ng
Caesarean
sec:on

only
to
speci:c
obstetric
indica:ons


Management
of
abrup:o
 Management
of
abrup:o

placentae
 placentae

 Before
26‐28
weeks’gesta:on
  Aber
26‐28
weeks’
gesta:on

 Methods
  The
fetus
is
usually
regarded
as
viable

 Lower
amniotomy
  Delivery
by
the
quickest
route
is
essen:al

 Prostaglandin
  In
revealed
abrup:on
without
FHR
changes,
and
where

 Observa:ons
 the
mother
is
stable
and
the
blood
loss
is
not
of
concern,

induc:on
of
labour
by
amniotomy
may
lead
to
vaginal

 Urine
output

delivery
with
ligle
compromise
to
mother
or
fetus

 A
platelet
count
should
be
done
4
hourly


4
 7/3/09

Management
of
abrup:o
 Management
of
abrup:o

placentae
 placentae

 Aber
26‐28
weeks’
gesta:on

 Aber
26‐28
weeks’
gesta:on

 Caesarean
sec:on
is
the
choice
in
the
presence
of
FHR

abnormali:es,
irritable
uterus,
concealed
haemorrhage
  Referring
the
pa:ent
to
a
larger
hospital
with
beger

and
the
bleeding
is
of
concern
unless
the
pa:ent
is
fully
 facili:es
is
also
not
recommended,
as
severe
fetal
distress

dilated
and
vaginal
delivery
imminent
 may
occur
before
arrival

 As
neonatal
resuscita:on
may
be
required,
there
should

be
a
paediatrician
to
immediately
take
care
of
the
baby


Management
of
abrup:o
 Management
of
abrup:o

placentae
 placentae

 When
intrauterine
death
has
occurred

 implies
that

 •  When
intrauterine
death
has
occurred

 a
large
abrup:on
has
occurred
 » Immediate
fluid
replacement
of
at
least
l‐2
L
of
a

 the
dura:on
of
the
abrup:on
has
been
long
 crystalloid
solu:on

» Ruptured
the
membranes
to
s:mulate
contrac:ons
and
to

reduce
intrauterine
pressure
if
cervix
is
favourable


Poten:al
complica:ons
in
pa:ents
with
intrauterine
death

Management
of
abrup:o
 owing
to


placentae
 abrup:o
placentae


 When
intrauterine
death
has
occurred

 The
delivery
should
be
atrauma:c


 Beware
of
extensive
bleeding
in
the
pa:ent
with
a
coagula:on

defect

 Oxytocin
s:mula:on
to
prevent
postpartum
hemorrhage

 Caesarean
sec:on
should
not
be
done
when
clojng
factor

levels
are
unknown
or
when
fresh
blood
is
not
available


5
 7/3/09

placenta
previa


 Placenta
praevia
refers
to
the
loca:on
of
the

Placenta
previa
 placenta
over
or
very
near
the
internal
OS

 Affects
0.3‐0.5%
of
deliveries

 The
e:ology
is
uncertain


Placenta
previa’s
types
 placenta
previa’s
managements

 Low
lying
:
the
placenta
encroaches
the
lower

uterine
segment,
but
is
not
close
to
the
  Early
pregnancy(26‐34
weeks)

cervical
OS
  All
pa:ents
should
be
hospitalized,
unless
they
can

rapidly
be
transported
to
hospital
should
a
sudden

 Lateral
:
the
placenta
is
implanted
in
the
 haemorrhage
occur

lower
uterine
segment
coming
close
to
the
  Repeated
bleeds
is
also
an
indica:on
for

internal
OS
of
the
cervix
 hospitaliza:on

 Marginal
:
the
internal
OS
is
par:ally
covered
  Bed
rest
is
advocated

by
the
placenta

 Total:

the
internal
OS
is
completely
covered

by
the
placenta.


placenta
previa’s
managements
 placenta
previa’s
managements


 Early
pregnancy(26‐34
weeks)
  In
later
pregnancy
(34‐37
weeks)

 Suppressed
the
uterine
ac:vi:es
  Similar
management
except
no
longer
indica:on

 Check
fot
the
possibility
of
anemia
 for
steroid
medica:on

 Avoid
unnecessary
delivery
  Cesarean
sec:on
is
the
most
frequent
route
for

 Steroid
should
be
given
when
the
gesta:onal
age
is
 delivery

26‐28
weeks’
up
to
34
weeks
to
improve
fetal
lung

matura:on
in
case
an
immediate
delivery


6
 7/3/09

placenta
previa’s
managements


 In
later
pregnancy
(34‐37
weeks)

 Similar
management
except
no
longer
indica:on

for
steroid
medica:on

local
causes

 Cesarean
sec:on


 At
term

 Cesarean
sec:on
is
the
most
frequent
route
for

delivery


local
causes


 The
most
common
is
ectopy
of
the
cervix

 Carcinoma
of
the
cervix
 Antepartum
haemorrhage
of


 Vaginal
trauma
 unknown
origin


Antepartum
haemorrhage
of


unknown
origin

 It
should
be
followed
up
prospec:vely

 
OR
for
developing
abrup:o
placentae
is
3.8
 the
end

(95%
CI
1.5‐9.7;
P
<
0.005)
in
24
h

 Aber
24
h
the
OR
is
decreased
but
the
risk
for

preterm
labour
increase
 ReferenceS:

1.
Odendaal
HJ,
gebhardt
gs.
Bleeding
in
early
and
late
pregnancy.
Curr
Obstet

Gynaec,

1999:
9;
82‐87

2.
Moore
j.
Early
pregnancy
units
and
problems
in
early
pregnancy.
Curr
Obstet
Gynaec,
2006:
16;

327–332


 If
abrup:on
or
preterm
labour
does
not
occur

soon
aber
admission
and
within
the
first
24
h,

it
is
unlikely
to
occur
later