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A. First 20 Weeks of Gestationnavigator

  1. Blighted Ovum
  2. Cervical Lesion
  3. Threatened Abortion
    1. Most common cause of vaginal bleeding during first 20 weeks
    2. Need to rule this out in all cases of vaginal bleeding during this period
    3. No tissue is passed with the bleeding
  4. Incomplete abortion - heavy bleed, clots, some tissue still in uterus
  5. Missed abortion - dead fetus has not yet been expelled
  6. Gestational Trophoblastic Disease
  7. Pelvic ultrasound and quantitative ß-HCG levels are used for evaluation

B. Second 20 Weeks of Gestationnavigator

  1. Placenta previa
  2. Abruptio placentae
  3. Vasa previa
  4. Rupture of Marginal Sinus
    1. The marginal sinus is a vascular channel which rims placenta
    2. Functions to return blood to maternal circulation out through the umbilical veins

C. Placenta Previanavigator

  1. Placenta lies on or near internal cervical os in front of presenting part
  2. Painless vaginal bleeding
    1. Initial bleed usu self limited
    2. May herald serious second bleed
  3. Digital pelvic exam should NOT be done
  4. Diagnosis with ultrasound
  5. Determine L/S ratio for fetal maturity
  6. Cross-match 4 units blood
  7. Deliver when fetus is 37 weeks LMP with fetal maturity; C-section preferred
  8. Early Previas (Second Trimester)
    1. Early previas may "move" away from os as uterus increases in size and lower segment develops
    2. Repeat ultrasound if previa diagnosed early

D. Abruptio Placentanavigator

  1. Premature separation of placenta with hemorrhage into basal layers
  2. Painful bleed with major hypovolemia (out of proportion to apparent blood loss)
  3. Associated Disorders
    1. Hypertensive disorders of pregnancy
    2. Trauma
    3. Maternal use of cocaine
    4. Thrombophilic disorders [2]
  4. Diagnosis
    1. Clinical exam with Ultrasound confirming only if large abruption
    2. Complete blod count, PT/PTT and fibrinogen should be obtained and followed
    3. Cross match blood as well
  5. Blood transfusion essential if any evidence of circulatory failure is present
  6. Prompt delivery essential if fetal distress or maternal coagulopathy develops
  7. Cesarean-Section generally preferred if emergent

E. Vasa Previanavigator

  1. Presentation of fetal vessels across cervical os
  2. Bleed due to tearing of fetal vessels leading to fetal bleeding (rapid fetal death possible)
  3. Marked fetal bradycardia
  4. 60% Fetal Mortality
  5. Kleihauer test for vaginal blood to detect fetal RBC
  6. Immediate vaginal or cesarean delivery should be carried out

F. Post-Partum Hemorrhage (PPH) navigator

  1. Any post-partum bleeding >500cc within 24 hours of delivery (early PPH)
  2. Predisposing Conditions
    1. Multiple pregnancy, polyhydramnios, prolonged labor (increased uterine atony)
    2. Cesarean Section, difficult forceps delivery
    3. Third Trimester Hemorrhage: Placenta previa, Abruptio placentae
    4. Prior history, missed abortion
    5. Bleeding Diathesis: DIC is major problem, amniotic fluid embolism
  3. Complications include infection and death
  4. Active management of labor reduces risk of PPH [3]
  5. Late PPH: >24 hours after delivery; >500cc fluid loss
  6. Treatment can include fresh-frozen plasma, rFVIIa (NovoSeven®), platelets [4]

References navigator

  1. McKennett M and Fullerton JT. 1995. Am Fam Phys. 51(3):639 abstract
  2. Kupferminc MJ, Eldor A, Steinman N, et al. 1998. NEJM. 340(1):1
  3. Rogers J, Wood J, McCandlish R, et al. 1998. Lancet. 351(9104):693 abstract
  4. NovoSeven for Non-Hemophilia Hemostasis. 2004. Med Let. 46(1181):33 abstract