PV bleeding in late pregnancy - abruption, placenta praevia, etc

see also:

• Obstetrics
• the shocked hypotensive patient
• post-partum haemorrhage (PPH)

• bleeding in the 2nd or 3rd trimesters of pregnancy requires:
  • resuscitation of the mother
  • assessment of fetal wellbeing
  • correction of coagulopathy if present
  • determination of cause of the bleeding
  • 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
  • Rh immunisation if Rh negative
• nearly all patients after 20 weeks gestation require admission for observation
• some patients need expeditious delivery or cesarian section

• 2x large bore iv access
• bloods for FBE, U&E, cross match, coagulation studies
  • consider bedside clotting test
  • if disseminated intravascular coagulation (DIC) is suspected, activate the hospital’s massive transfusion protocol
• assess extent of bleeding and resuscitate accordingly with blood transfusions if needed
  • do not perform VE is placenta praevia is a possibility
• notify obstetrics team +/- anaesthetics ASAP
• CTG to assess fetal well being
• keep warm
• aim for SaO2 > 95%
• consider need for expeditious delivery (not if placenta praevia) or cesarian section
  • see below for placenta praevia indications for emergent cesarian section
  • if abruption:
    • severe abruption at any gestational age
    • non-severe abruption at gestation > 36wks
  • if possible, delay cesarian section if severe coagulopathy until it can be corrected

• occurs in ~1% of pregnancies
• usually painful bleeding with contractions
• 14% occur before 32wks
• 40-60% occur before 37wks

• smoking 2.5x risk
• hypertension 5x risk
• pre-eclampsia
• severe trauma 6x risk
• premature ROM - risk increases from time of ROM
• chronic placental disease
• uterine abnormailities
• PH abruption 10x risk if one abruption, 20x risk if PH of two pregnancies with abruptions
• cocaine use

• occurs in 1 in 250 births
• bleeding is generally painless although 10-20% also develop contractions
• 10% reach term without bleeding
• only significant after 20 weeks gestation as the lower uterine segment has not formed prior to this
• most resolve prior to delivery due to extension of the lower uterine segment
• only 12% of low lying placentae on USS at 15-19wks are present at delivery as placenta praevia, compared to ~50% on scans at 24-27wks
• do NOT perform VE is this is a possibility
• the distance the placenta extends over the internal cervical os is the best predictor of placenta previa at delivery.
• those who present < 30wks gestation with bleeding have higher risk of:
  • needing blood transfusions
  • preterm delivery
  • perinatal mortality
• transabdominal USS gives a 25% false positive rate so careful TV scan should be done to confirm it

• PH placenta praevia
• PH LUSCS
• multiple gestation
• multiparity
• advanced maternal age

• premature ROM
• preterm labour
• malpresentation
• IUGR
• vasa praevia
• amniotic fluid embolism

• actively bleeding placenta previa is a potential obstetrical emergency
• resuscitate the mother
  • 2x large bore iv access
  • cross match blood
  • if massive blood loss, check coagulation
• monitor FHR
• avoid tocolytics if actively bleeding
• consider corticosteroids for fetal lung maturation if delivery can be delayed and fetus is premature
• consider neuroprotective magnesium sulphate if 24-32wks gestation and delivery within 24hrs
• cesarian section if either:
  • non-reassuring FH trace
  • life threatening refractory bleeding
  • significant bleeding after 34 weeks gestation

• rare cause of bleeding