Dangerous Bleeds in Late Pregnancy

by Valeria Chew

* OB CONSULT ASAP IF YOU SUSPECT THESE: *

Placental Abruption

- separation of placenta from uterus

- clinical diagnosis

- painful! + contractions

- can use ultrasound to visualize hemorrhage from placenta (often hard to see), might not have vaginal bleeding if hemorrhage is encased behind fetus

- may have unstable vitals

Uterine Rupture

- full thickness tear of uterine wall after C-section

- clinical presentation:

- painful

- can lose contractions/uterine tone

- hypotension

Placenta Previa

-placenta covering cervical os (hopefully, patient will know she has this on an outpatient OB work up)

- * AVOID pelvic examination with patient where you suspect this *

- clinical presentation: 

- classically painless, but can be associated with contractions

Vasa Previa

- fetal vessels running over/near the cervical os unprotected by cord/placenta, (hopefully, patient will know she has this on an outpatient OB work up)

- clinical presentation:

- painless

Labs to obtain/consider for all: H&H, platelet count, fibrinogen level, coagulation studies, blood type, and antibody screen 

Management considerations for all:  resuscitate (fluids, blood), tocolysis, continuous fetal monitoring, might need to prepare for urgent delivery (consider the medications for preterm delivery like steroids), preop prep as patient might need to C-section, consider kleihauer-betke test (for placental abruption)

Complications for all: fetal/maternal mortality, hemorrhage, preterm delivery, DIC (placental abruption)

References

Chauhan SP, Martin JN Jr, Henrichs CE, Morrison JC, Magann EF. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol. 2003;189(2):408-417. doi:10.1067/s0002-9378(03)00675-6

Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005-1016. doi:10.1097/01.AOG.0000239439.04364.9a

Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol. 2015;126(3):654-668. doi:10.1097/AOG.0000000000001005