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Antepartum Hemorrhage

Peripartum Hemorrhage

of maternal death in US, 1987-90


hemorrhage: 28.7% (*) embolism: 19.7% (*) pregnancy-induced hypertension: 17.6% (*) infection: 13.1% (*) cardiomyopathy: 5.6% (*) anesthesia: 2.5% (*)
* compared with 1979-86

Antepartum Hemorrhage

of women may develop antepartum hemorrhage. Bleeding in pregnancy after 28 weeks gestation Causes: placenta previa (1/200) placental abruption (1/100) uterine rupture (<1% in scarred uterus) vasa previa (1/2000-3000)

Placenta Previa

Total: covers the cervical os Partial: covers part of the os Marginal: lies close to, but does not cover, the os Risk factors: multiparity advanced maternal age prior C/S or other uterine surgery prior placenta previa

Types of Placenta Previa

Placenta Previa: Diagnosis


vaginal bleeding in 2nd/3rd trimester Confirmed by ultrasound Vaginal exams are avoided Up to 10% may have simultaneous abruption Maternal shock is uncommon with 1st presentation of bleeding

Placenta Previa: Images

Plcenta Previa: Images

Placenta Previa: Obstetric Management


possible, delay delivery until fetus is mature Indications for delivery: active labor documented fetal lung maturity 37 weeks gestational age excessive bleeding development of another obstetric complication mandating delivery

Placenta Previa: Management


on arrival:

airway volume status large bore IV access type and cross HCT

has bleeding risk during surgery

OB may have to cut into placenta to remove baby lower uterine implantation site does not contract as well as normal fundal site risk of placenta accreta (esp. if prior C/S)

Placental Abruption

separation of placenta from endometrium Diagnosis: vaginal bleeding, uterine tenderness, uterine tone Risk factors: HTN multiparity AMA smoking PROM cocaine trauma h/o abruption

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption: Images

Placental Abruption

shock acute renal failure DIC (coagulopathy in 10% of these pts.) fetal distress/demise Hidden blood loss may approach 2500 cc

Placental Abruption: Obstetric Management


on fetal maturity, size of abruption, presence of fetal distress continuation of pregnancy induction/augmentation of labor Cesarean section

Placental Abruption: Anesthetic Management


alert for possibility of coagulopathy and/or hypovolemia before considering regional anesthesia For stat C/S, GA most appropriate if known or suspected hypovolemia or DIC ketamine (or etomidate) volume resuscitation invasive monitoring

Uterine Rupture vs. Dehiscence


scar dehiscence: fetal membranes remain intact, fetus is not extruded intraperitoneally, separation limited to old scar, peritoneum overlying is intact usually no fetal distress / mat. hemorrhage Uterine rupture: separation of scar extension, rupture of fetal membranes with extrusion results in fetal distress / mat. hemorrhage fetal mortality = 35%

Uterine Rupture: Images

Uterine Rupture

features: vaginal bleeding hypotension cessation of labor fetal distress pain present in only 10% postpartum hemorrhage may be a sign Treatment: uterine repair, arterial ligation, hysterectomy (may be preferred)

Comparison of Presentation of Abruption v. Previa v. Rupture

abruption abd. pain vag. blood DIC acute fetal distress present old common common previa absent fresh rare rare rupture variable fresh rare common

Vasa Previa

vessels separate in the membranes at a distance from the placental margin and some of the vessels (fetal) cross the internal os and occupy a position ahead of the presenting part of the fetus. ROM may cause fetal exsanguination. High fetal mortality (50-75%) Risk factor: multiple gestation (esp., triplets)

Vasa Previa: Images

Vasa Previa: Images