Obstetric Hemorrhage

Dr mukhamad Nooryanto,SpOG

Placental Abruption
Risk Factors

Trauma (usually shearing, such as a car accident),

preeclampsia (and maternal HTN), smoking, cocaine
abuse, high parity, previous history of abruption

Vaginal

Clinical Presentation

bleeding (maternal and fetal blood present)

Constant and severe back pain or uterine tenderness
Irritable, tender, and typically hypertonic uterus
Evidence of fetal distress
Maternal shock

Figure 9-3. Placental abruption

Diagnosis

Ultrasound will show retroplacental hematoma

only part of the time
Clinical and pathological findings

Management

Correct shock (packed RBCs, fresh frozen

plasma, cryoprecipitate, platelets)
Expectant management: Close observation of
mother and fetus with ability to intervene
immediately
If there is fetal distress, perform C-section

Placenta Previa

1.

2.

3.

A condition in which the placenta is implanted

in the immediate vicinity of the cervical canal.
It can be classified into three types:
Complete placenta previa: The placenta covers
the entire internal cervical os
Partial placenta previa: The placenta partially
covers the internal cervical os
Marginal placenta previa: One edge of the
placenta extends to the edge of the internal
cervical os

Figure 9-4.

Incidence
0,5 to 1 %

Etiology

Unknown, but associated with:

Increased parity
Older mothers
Previous abortions
Previous history of placenta previa
Fetal anomalies

Clinical Presentation

Painless, profuse bleeding in T3

Postcoital bleeding
Spotting during T1 and T2
Cramping (10% of cases)

Diagnosis

Transabdominal ultrasound (95% accurate)

Double set-up exam: Take the patient to the
operating room and prep for a C-section. Do
speculum exam: If there is local bleeding, do a
C-section; if not, palpate fornices to determine if
placenta is covering the os. The double set-up
exam is performed only on the rare occasion
that the ultrasound is inconclusive

Management
Cesarean section is always the delivery method of choice for placenta previa. The
specific management is geared toward different situations
For Preterm

If there is no pressing need for delivery, monitor in hospital or send home after
bleeding has ceased

Transfusions to replace blood loss, and tocolytics to prolong labor to 36 weeks if

necessary
Even after the bleeding has stopped, repeated small hemorrhages may cause IUGR
For Mature Fetus

C-section
For a Patient in Labor

C-section
If Severe Hemorrhage

C-section regardless of fetal maturity

Fetal Vessel Rupture

Two conditions caused third-trimester
bleeding resulting from fetal vessel
rupture:
1. Vasa previa
2. Velamentous cord insertion
These two conditions often occur together

Vasa Previa

A condition in which the fetal cord vessels unprotectedly pass over

the internal os, making them susceptible to rupture and bleeding

Incidence
0.03 to 0.05%
Presentation
Rapid vaginal bleeding and fetal distress (sinusoidal variation of fetal
heart rate)

Management
Correction of shock and immediate C-section

Velamentous Cord Insertion

The velamentous insertion of the umbilical cord into the fetal
membrane other words, the fetal vessels insert between amnion
and chorion. This cause them susceptible to ripping when the
amniotic sac ruptures
Epidemiology
1% of single pregnancies
10% of twins
50% of triplets

Clinical Presentation
Vaginal bleeding with fetal distress
Management
Correction of shock and immediate C-section

Uterine Rupture
The ripping of the uterine musculature through all of its
layers, usually part of the fetus protruding through the
opening
Incidence
0,5%
Risk Factors
Prior uterine scar is associated with 40% of cases:
Vertical scar:5% risk
Transverse scar:0,5% risk

Presentation and Diagnosis

Sudden cessation of uterine contractions with a tearing

Recession of the fetal presenting part
Increased suprapubic pain and tenderness with labor
Vaginal bleeding (or bloody urine)
Sudden, severe fetal heart rate decelerations
Sudden disappearance of fetal heart tones
Maternal hypovolemia from concealed hemorrhage

Management

Total abdominal hysterectomy is treatment of choice

If childbearing is important to the patient, rupture repair
is risky

Other obstetric causes of ThirdTrimester bleeding

Circumvillate placenta: The chorionic plate
(on fetal side of placenta)is smaller than
the basal plate