Third Trimester Bleeding

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Third Trimester Bleeding

• Ahmad Behrooz, M.D.
• Ahwaz University of Medical Sciences

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Occurring in 5 of all pregnancies , obstetric
hemorrhage is a major cause of maternal
mortality morbidity.
Hemorrhage most commonly occurs in the third
trimester or immediately postpartum.
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Causes of T.T.Bleeding

• Bloody show
• Cervical neoplam
• Cervicitis
• Circumvallate placenta
• Genital tract trauma

• Placenta previa
• Placental abruption
• Vaginal neoplasm
• Vasaprevia

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Which one is better ?
Abruption
Previa
Previa
Previa
Abruption
Abruption
Previa
Previa
Abruption
Previa
Abruption
Previa
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Placenta previa

• Complete
• Partial
• Marginal
• Low-lying

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Placenta previa Risk factors

• Multiparity
• Maternal age
• Previous C/Section
• Smoking
• Cocaine
• Erythroblastosis fetalis
• Multiple fetuses

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Placenta previa Diagnosis

• Painless vaginal bleeding
• Blood is bright red with or without clots
• Incidence peaks at the 30th to 34th weeks
• Malpresentation
• Ultrasonography

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Placenta previa Management

• Double set-up
• Trial labor
• Vaginal delivery
• Cesarean Section
• Expectant management

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Placenta previa Expectant
Management

• The mother is stable
• Vaginal bleeding has stopped
• The fetus has normal heart rate
• Cesarean can be performed immediately at any time

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Indication for discontinuing expectant
management
Placenta previa

• Fetal indications
  Anomalies incompatible with
  life Distress
  
  Death
  
  Pulmonary maturity
• Maternal indications
  Labor that fails
  tocolysis
  Excessive bleeding
  Other obstetric
  Indication(e.g.,preeclampsia)

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Placenta previa in a pregnancy of viable
gestational age
Management
-

Bleeding
-
Expectant management
Torrential and/or Fetal distress


C/Section
Fetal lung maturity
-
-
Sono assessment q 3-4 weeks
-

Placental migration
Bleeding
Trial of labor
-

Complete resolution

Trial of labor (low-lying only)
Double set-up
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Abruptio placenta
Among all episodes of third trimester
hemorrhage, approximately 30 are due to
placental abruption .
Incidence 0.5 - 2.5 pregnancies
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Abruptio placenta Risk factors

• Maternal hypertension
• Maternal age, Multiparity
• Previous abruption
• Illicit drugs, especially Cocaine
• Trauma
• Cocaine, Cigarette, Ethanol
• Uterine leiomyoma

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Abruptio placenta Diagnosis

• History Physical examination
• Painful uterine contraction
• Bloody amniotic fluid
• Sonography

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Abruptio Placenta Management

• Hospitalized
• Type Cross-match blood
• Large-bore IVs
• Bed rest
• Tocolysis as needed
• Hb, HCT monitoring
• Clotting studies
• Urine output

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Management
Abruption in a pregnancy of viable gestational
age
-

Unstable patient
-

Stabilize and deliver
Fetal distress
C/Section

Expectant management
Fetal lung maturity
Deliver
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Differentiating Placental abruption from
Placenta previa
Abruption
Previa
Risks
Hypertension,Trauma prior abruption,Smoking Advanc
e maternal age, Fibroids
High parity Prior Cesarean delivery
Diagnosis
Clinical
Sonographic
Pain
Yes
No
Cont...
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Differentiating Placental abruption from
Placenta previa
...Cont
Abruption
Previa
Bleeding
Dark, nonclotting (may be occult)
Bright Red , Clotting
Sequelae
DIC, Postpartum hemorrhage
Placenta accreta P.P.Hemorrhage
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Which one is better ?
Abruption
Previa
Previa
Previa
Abruption
Abruption
Previa
Previa
Abruption
Previa
Abruption
Previa
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Thank you

Goodbye