Antepartum hemorrhage

Antepartum hemorrhage is a serious complication of pregnancy occurring within the third trimester. It is associated with significant maternal and fetal morbidity and mortality. Common causes of antepartum hemorrhage are bloody show associated with labor, placental previa, and placental abruption. Rare causes include vasa previa and uterine rupture. Symptoms of placental abruption typically include lower abdominal pain, vaginal bleeding, and rigid uterus. Placenta previa and vasa previa on the other hand typically manifest prior to rupture of membranes or after rupture of membranes respectively, with painless vaginal bleeding and fetal distress. Uterine rupture, which occurs during labor, is discussed in a separate article. In cases of severe hemorrhage, patients may present with signs of hypovolemic shock. Fetal symptoms include signs of fetal stress, such as decelerations on heart monitoring and decreased fetal movements. The diagnosis is primarily clinical and is confirmed via transabdominal or transvaginal ultrasound. The treatment approach depends on maternal symptoms and fetal vitality. A conservative approach with continuous monitoring is advised for asymptomatic patients carrying a healthy fetus, while an emergency cesarean delivery is indicated in patients with acute symptoms and a live, distressed fetus.

Definition

• The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.

Epidemiology

• Incidence: ∼ 0.2–1% of pregnancies ^[1]
• Occurs most often in the third trimester
• The recurrence rate in subsequent pregnancies is 3–15%.

Etiology

• Predisposing factors
  • Vascular changes
    • Hypertension (most common cause)
    • Preeclampsia/eclampsia
  • (Abdominal) trauma; (up to 10% of cases): car accidents, falls, iatrogenic (e.g., postamniocentesis)
  • Sudden decrease in intrauterine pressure
  • Previous abruption, chorioamnionitis, prolonged rupture of membranes, short umbilical cord
  • Maternal age: < 20 years and > 35 years
  • Alcohol and cigarette consumption, cocaine use

Clinical features

Following placental separation of more than 30%, there is a sudden onset of the following symptoms:

• Continuous vaginal bleeding (revealed abruptio placentae)
• In ∼ 20% of cases, the hemorrhage is mainly retroplacental; vaginal bleeding does not occur (concealed abruptio placentae)
• Sudden-onset abdominal pain or back pain , uterine tenderness
• Hypertonic contractions (rigid uterus), premature labor
• Fetal distress (60% of cases)
  • Possible diminished or absent fetal movement
  • Decelerations seen on fetal heart monitor
• Vaginal exam contraindicated: may worsen bleeding!

In cases of retroplacental hemorrhage, patients may present with signs of hypovolemic shock without evident vaginal bleeding!

Diagnostics

Placental abruption is a clinical diagnosis.

• Ultrasound (transabdominal, transvaginal): only 25% sensitivity!
  • Presentation of the placental position and a possible retroplacental hematoma
  • Monitoring vital signs of the fetus (heartbeat, fetal movement)
  • To rule out placenta previa in unclear cases
• Fetal heart rate monitoring (see “Clinical features” above)
• Laboratory tests: CBC, coagulation factors

Rapid diagnosis and immediate treatment are vital for the survival of both mother and child!

Treatment

General approach

• Hemodynamic control: monitor vital signs, maintain airways, volume resuscitation, type and crossmatch blood
• Correct coagulopathy if necessary
• RhD prophylaxis in RhD negative mothers
• See also peripartum hemorrhage.

Specific approach according to severity

• Normal fetal findings and a hemodynamically stable mother
  • Observation, bed rest, regular control
  • Up to the 34^th week of pregnancy
    • Fetal lung maturity induction with corticosteroids (e.g., betamethasone)
    • If necessary, tocolysis (e.g., nifedipine, β2-adrenergic agonist)
    • Aim for a normal delivery
  • 34^th to 36^th week
    • Active uterine contractions present: vaginal delivery
    • No contractions + no signs of fetal distress + bleeding has stopped: expectant management and observation
  • All pregnancies are delivered if acute abruption occurs after 36^th weeks.
• In acute symptoms and a live fetus
  • Emergency cesarean delivery independent of gestational age unless vaginal delivery is impending
• In acute symptoms and intrauterine fetal death
  • Induction of vaginal delivery through pharmacologic uterine contraction inducers and opening of the amniotic sac
  • An emergency cesarean delivery must be performed if there is a maternal risk; due to severe bleeding or slow progression of the birthing process, even in cases of intrauterine fetal death.

Complications

• Intrauterine fetal death
• Maternal DIC and hypovolemic shock: occurs as a result of blood loss and massive coagulation; the placenta is rich in tissue thromboplastin, which is released as a result of the placental abruption.
• Couvelaire uterus
  • Retroplacental hemorrhage may extend through the uterus into the peritoneum.
  • The myometrium is weakened, with possible subsequent uterine rupture during contractions.

Abruptio placentae is characterized by the “abrupt” onset of painful bleeding.

References:^[2][3][4]

Definition

• Presence of the placenta in the lower uterine segment; ; can lead to partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications

Epidemiology

• ∼ 0.5% of all pregnancies ^[5]

Risk factors ^[6]

• Maternal age > 35 years, multiparity, short intervals between pregnancies
• Previous curettage or cesarean delivery
• Previous placenta previa, previous/recurrent abortion

Classification ^[7]

• Placenta previa: placenta that covers the internal os either partially or completely
  • Previously, this category included marginal previa (placenta reaching the internal os), partial previa (placenta partially covering the internal os), and complete previa (placenta completely covering the internal os); these terms have been excluded from the new classification.
• Low-lying placenta: : lower edge of the placenta lies less than 2 cm from the internal cervical os

Clinical features

• Sudden, painless, bright red vaginal bleeding
• Usually occurs during the 3^rd trimester (before rupture of the membranes), stops spontaneously after 1–2 hours, and recurs during birth
• Often causes preterm delivery (∼ 45% of cases)
• Soft, nontender uterus
• Usually no fetal distress

In contrast to placental abruption, bleeding in patients with placenta previa is painless.

Diagnostics

• Transvaginal ultrasound to assess the position of the placenta
• Digital vaginal examinations are contraindicated in cases of hemorrhage of unknown cause

Treatment ^[8]

Approach

• Asymptomatic patients (with early detection of placenta previa on transvaginal ultrasound (gestational age ∼18–20 weeks'): Monitor placental placement.
  • Follow up transvaginal ultrasound at 32 weeks: Determine if the placental edge is < 2 cm from or covers the internal os.
    • If low-lying placenta or placenta previa without placenta accreta is diagnosed: repeat transvaginal ultrasound at 36 weeks gestation.
    • If low-lying placenta or placenta previa with placenta accreta is diagnosed: schedule lower segment cesarean delivery, ideally between 36–37 weeks' gestation.
  • In most patients diagnosed with placenta previa on early transvaginal ultrasound, the placenta returns to a normal position with progressive lengthening of the lower uterine segment.
• Gestational age < 37 weeks
  • No active bleeding AND no evidence of fetal distress: expectant management
  • Severe, active bleeding OR evidence of fetal distress: stabilization and emergency cesarian delivery
• Gestational age > 37 weeks: immediate delivery

Expectant management

• Hospitalization and observation for 48 hours
• If gestational age is < 34 weeks: fetal lung maturity induction with corticosteroids (e.g., betamethasone)
• If gestational age is between 34 and 37 weeks and delivery is likely within 7 days: fetal lung maturity induction with corticosteroids
• If mild uterine contractions are present: tocolysis with magnesium sulfate may be performed (especially if the fetus is extremely premature)

Management of hemorrhage

• Prepare blood transfusion for possible massive hemorrhage.
• Bilateral uterine artery ligation, internal iliac artery ligation; packing with gauze or tamponade
• If severe, perform emergency cesarean hysterectomy.

Route of delivery

• Lower segment cesarean delivery; is almost always preferred; ideally scheduled at 36–37 weeks gestation
• Induction of labor and/or vaginal delivery may be performed in the operating room if the mother is hemodynamically stable, fetal cardiac status is reassuring, and the placenta lies > 2 cm away from the internal os on ultrasonography

Vaginal delivery should never be attempted outside the operating room in a patient with placenta previa.

In placenta previa, we receive a “preview” of the placenta through the cervical os.

References:^{[9][10][11][12][13][14]}

Definition

• Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture

Epidemiology

• 1/2500 births

Etiology

In most cases, at least one of the following risk factors is present.

• Placental anomalies, such as:
  • Velamentous umbilical cord insertion
  • Bilobate or succenturiate placenta
    • Variation of the placental morphology with one or more accessory lobes developing separately from the main placental body
    • Fetal vessels connecting the lobes are only supported by the chorioamniotic membranes.
    • Risk factors: advanced maternal age, in vitro fertilization
    • Can lead to vasa previa, placenta previa, and retained placental tissue
• Placenta previa
• Low-lying placenta
• Multiparity
• In vitro fertilization

Clinical features

• Painless vaginal bleeding (fetal blood) that occurs suddenly after rupture of membranes
• Fetal distress (e.g., fetal bradycardia; decelerations or sinusoidal pattern on fetal heart tracings)
• Fetal death can occur quickly through exsanguination or asphyxiation if fetal vessels are compressed during labor.

Diagnostics

• Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels.

Treatment

• Emergency cesarean delivery if there are signs of fetal distress

References:^[15]

1. Ananth CV, Keyes KM, Hamilton A, et al. An international contrast of rates of placental abruption: an age-period-cohort analysis.. PLoS ONE. 2015; 10 (5): p.e0125246. doi: 10.1371/journal.pone.0125246 . | Open in Read by QxMD
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3. Oyelese Y, Ananth CV. Placental abruption: Management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/placental-abruption-management.Last updated: March 2, 2016. Accessed: April 25, 2017.
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5. Jauniaux E, Grønbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019; 9 (11): p.e031193. doi: 10.1136/bmjopen-2019-031193 . | Open in Read by QxMD
6. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. The Journal of Maternal-Fetal & Neonatal Medicine. 2003; 13 (3): p.175-190. doi: 10.1080/jmf.13.3.175.190 . | Open in Read by QxMD
7. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging. Journal of Ultrasound in Medicine. 2014; 33 (5): p.745-757. doi: 10.7863/ultra.33.5.745 . | Open in Read by QxMD
8. Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. Am J Obstet Gynecol. 2018; 218 (1): p.B2-B8. doi: 10.1016/j.ajog.2017.10.019 . | Open in Read by QxMD
9. Lockwood CJ, Russo-Stieglitz K. Clinical features, diagnosis, and course of placenta previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/clinical-features-diagnosis-and-course-of-placenta-previa?source=see_link.Last updated: November 30, 2016. Accessed: February 17, 2017.
10. Gibbs RS. Danforth's Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2008
11. Beckmann CRB. Obstetrics and Gynecology. Lippincott Williams & Wilkins ; 2010
12. Hacker NF, Gambone JC, Hobel CJ. Hacker & Moore's Essentials of Obstetrics and Gynecology E-Book. Elsevier Health Sciences ; 2015
13. Sakornbut E, Leeman L, Fontaine P. Late Pregnancy Bleeding. Am Fam Physician. 2007; 75 (8): p.1199-1206.
14. Lockwood CJ, Russo-Stieglitz K. Management of placenta previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-placenta-previa.Last updated: March 3, 2017. Accessed: June 24, 2017.
15. Lockwood CJ, Russo-Stieglitz K. Velamentous umbilical cord insertion and vasa previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/velamentous-umbilical-cord-insertion-and-vasa-previa.Last updated: November 22, 2016. Accessed: April 25, 2017.