Case 18 A 39-year-old woman with painful vaginal bleeding at 37 weeks’ gestation

 Case 18 A 39-year-old woman with painful

vaginal bleeding at 37 weeks'

gestation

Mrs O'Neil, a 39-year-old woman, is brought into the

labour ward by ambulance at 37 weeks' gestation in her

fourth pregnancy. She gives a short history of sudden

onset worsening abdominal pain and bleeding per

vaginum.

What differential diagnoses would

you consider?

• Placental abruption

• Placenta praevia (see Case 17 )

• Early labour

• Other causes (e.g. cervical or vaginal polyps, cervical

ectopy)

• Unexplained

What history would you like to elicit

from this patient to help you formulate

a diagnosis?

Presenting complaints

• Nature and site of pain – is it constant or

intermittent?

• Amount and nature of bleeding – is it fresh and with

clots, exclude ‘ show ’ mixed with liquor?

• Fetal movements – are they present?

• History of problems in present pregnancy (e.g.

pre - eclampsia)

Past obstetric history

Details of previous pregnancies and labours including

complications such as placental abruption, placenta

praevia or intrauterine growth restriction.

Past medical, personal and social history

• Cervical smear history

• History of hypertension

• Smoking or cocaine use

Mrs O'Neil had been feeling somewhat off colour for the

past day or so, although prior to that her pregnancy had

been uneventful. Earlier today she experienced worsening

abdominal pain along with a small amount of dark red

vaginal bleeding. She feels this pain is different from her

previous labours as it was constant and did not feel like

uterine contractions. She had not felt her baby move since

the pain set in.

She has had three uneventful pregnancies all resulting in

vaginal deliveries at term. In her present pregnancy, she

booked at 18 weeks and has seen her midwife on two

occasions as documented in her handheld notes. She

smokes 25–30 cigarettes every day but denies substance

abuse and lives in a council house with her three children.

What key signs would you look for

during the physical examination?

General examination

Check for pallor. Take her pulse and blood pressure.

Abdominal examination

Check the symphysiofundal height, fetal lie and presentation. If uterine contractions are present, what is their

strength, duration and frequency. Is the uterus relaxing

well between contractions?

Check for tenderness on abdominal palpation. What

is the tone of the uterus between contractions (i.e. is it

soft, or hypertonic/hard/woody)?

Assess the fetal heart rate.

Mrs O'Neil is pale and in obvious pain. Her pulse is 132

beats/minute and her BP is 90/60mmHg. The uterine height

is appropriate for gestation, although it is difficult to

ascertain the fetal lie as her uterus feels woody hard and is

tender to touch. The midwife is unable to pick up the fetal

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.122 Part 2: Cases

PART 2: CASES

heart on Doppler ultrasound or cardiotocography (CTG).

There is minimal dark red blood loss per vaginum.

Now let us reconsider the diagnosis

on the basis of the information

available

Mrs O ' Neil ' s history and clinical examination are highly

suggestive of mixed type placental abruption leading to

Box 18.1 Placental abruption

This occurs in approximately 1 in 80 deliveries

Definition

The partial or complete premature separation of the

placenta prior to the birth of the baby

Risk factors

• Increasing maternal age and/or parity

• Low socioeconomic group

• Smoking or cocaine use

• Hypertensive disorders

• Sudden uterine decompression (e.g. rupture of

membranes with polyhydramnios)

• Severe external trauma

• Uterine abnormality, short cord

• Previous history of abruption. Recurrence rate is 7–9%

Symptoms

• Abdominal pain – usually constant and severe with

backache

• Vaginal bleeding – may be old or fresh blood

• Reduced or absent fetal movements

Signs

• Shock out of proportion to blood loss

• Spasm of uterus – described as ‘woody’ – from

hypertonic contractions

• Tender uterus

• Fetal parts difficult to feel

• Often no fetal heart

• Rarely may present as idiopathic preterm labour

Classification

• Concealed: blood trapped between the placenta and

uterine wall, no external bleeding

• Revealed: blood tracks between the membranes and

uterine wall with external bleeding from placenta edge

separation

• Mixed: combination of both types

Box 18.2 Pathophysiology of placental

abruption

• Placental abruption arises from haemorrhage into the

decidua basalis of the placenta

• Expanding haematoma leads to separation of adjacent

placenta with or without vaginal bleeding and fetal

distress or demise

• Bleeding may be concealed wholly or in part

• Bleeding into the amniotic sac leads to bloodstained

liquor

• Bleeding may infiltrate into the myometrium, tracking to

the serosa and resulting in the appearance of a

Couvelaire uterus

• Sustained uterine contraction is thought to be the result

of intramyometrial bleeding and the release of

prostaglandins

shock and intrauterine fetal death as the cause for her

antepartum haemorrhage (APH) (Boxes 18.1 & 18.2 ; Fig

18.1 ). The other common cause of APH, placenta praevia,

is usually associated with a painless APH in which the

shock is in proportion to the external bleeding. Also, as

the bleeding is maternal, the fetus is usually in good

condition. This is therefore an unlikely diagnosis in Mrs

Smith ' s case.

What are the complications associated

with placental abruption?

Placental abruption is a condition frequently associated

with serious maternal morbidity and high perinatal morbidity and mortality (Box 18.3 ).

What would be the next step in the

management of the mother?

Resuscitation of the mother

• Call for help from the senior obstetrician, anaesthetist

and midwifery staff

• Check airway, breathing and circulation (ABC) and

give oxygen. Insert two large - bore intravenous cannulae

and start fluid resuscitation by crystalloid or colloid (Box

18.4 )

• Determine the patient ' s rhesus status and cross - match

blood (4 – 6 units)

• Alert porters, laboratories and the blood bank

• Obtain blood for a full blood count, biochemistry

(urea and electrolytes, serum creatinine and urate, liver

function tests) and coagulation screenCase 18 123

PART 2: CASES

External abruption Relatively concealed abruption Concealed abruption

Figure 18.1 Concealed, revealed and mixed types of placental abruption.

Box 18.3 Complications of placental abruption

• Hypovolaemic shock

• Disseminated intravascular coagulation

• Postpartum haemorrhage

• Renal failure

Fetal complications

• Fetal distress

• Intrauterine fetal death

• Preterm delivery

• Perinatal mortality: 300/1000

KEY POINT

Treatment is aimed at treating the shock and preventing

disseminated intravascular coagulopathy (DIC).

Mrs O'Neil is managed as an obstetric emergency in the

high dependency area of the labour ward. Immediate help is

summoned and resuscitation commenced by giving facial

oxygen and inserting two 14-gauge cannulae for fluid

administration. Blood samples are obtained for urgent

cross-match and relevant investigations and a urinary

catheter inserted for output monitoring.

Intrauterine fetal death is confirmed by an onsite scan.

The scan also confirmed partial separation of an anteriorly

placed placenta by a large retroplacental clot.

Box 18.4 General management principles of

obstetric emergencies

• Manage airway, breathing and circulation

• Remember, there are two patients – the mother and the

fetus (although in this case there has been intrauterine

fetal death)

• The fetus is vulnerable to maternal hypoxia

• Consider invasive monitoring (e.g. central or arterial

line)

• Insert a urinary catheter for monitoring output and

check for proteinuria

• Replace blood and blood products as required

Assess fetal health

Assess by ultrasound and CTG if the fetus is alive. Check

fetal heart and lie and begin continuous fetal CTG. Also,

look for the presence of retroplacental clot, which is not

always evident on the scan, and confirm that the placenta

is not low lying.

Delivery of the fetus

If the fetus is alive, the decision regarding the mode of

delivery depends upon presence or absence of fetal

distress, and the amount of haemorrhage. A caesarean

section may be indicated for fetal or maternal reasons

(e.g. deterioration of maternal condition, fetal distress

as confirmed by CTG). If the fetus is not distressed,

induction or augmentation of labour with artificial

rupture of membranes with or without oxytocin infusion

may be attempted with the aim of a vaginal delivery;

however, the fetal condition must be closely and continuously monitored by CTG. If the fetus is dead, induction of labour may be performed if maternal condition

allows.

Women with severe abruption usually labour spontaneously and tend to have short labours.124 Part 2: Cases

PART 2: CASES

A vaginal examination is performed which reveals that

Mrs O'Neil is in labour and her cervix is 4cm dilated. An

amniotomy (artificial rupture of membranes) is performed

and an infusion of Syntocinon commenced to expedite

delivery. Liquor is noted to be bloodstained, consistent with

the diagnosis of placental abruption.

Mrs O'Neil's condition remains stable over the next 20

minutes and the uterine contractions become more regular.

Soon thereafter she delivers a fresh stillborn fetus weighing

3320g. The placental delivery was followed by the passage

of 950g of old clots, confirming the diagnosis of placental

abruption.

What would you watch out for

after delivery?

Abruption increases the risk of atonicity of the uterus and

postpartum haemorrhage (PPH). PPH can worsen or

cause DIC.

Following the completion of the third stage of labour, the

emergency buzzer is set off, as there is significant atonic

PPH. Help is summoned and the haemorrhage is controlled

by bimanual uterine compression and the administration of

oxytocics. While the resuscitation is being carried out the

anaesthetist notices that there is excessive oozing from the

venepuncture sites along with significant bruising of her arm

along the blood pressure cuff site, and haematuria. He

suspects that DIC has set in and alerts the resuscitation team

to the possibility. The on-call haematologist confirms the

diagnosis of DIC.

The International Society on Thrombosis and Haemostasis defines DIC as: ‘ An acquired syndrome characterized by the intravascular activation of coagulation with

loss of localization arising from different causes. ’

With placental abruption, decidual fragments containing activated coagulation factors enter the maternal circulation. DIC in abruption is caused by enhanced and

sustained abnormal generation of thrombin by intrinsic

pathways of coagulation.

What are the diagnostic tests for DIC?

DIC is primarily a clinical diagnosis; laboratory tests

are used to confirm the diagnosis and monitor replacement of blood components. No one test can diagnose

DIC.

Tests for DIC

• Platelet count ↓

• Prothrombin time ↑

• Thrombin time usually ↑

• Activated partial thromboplastin time ↑

• Fibrinogen ↓

• Fibrinogen degradation products

• Microangiopathic changes on peripheral smear

How will you manage Mrs O'Neil, who

has now developed DIC secondary to

placental abruption?

• Continue to manage ABC

• Mainstay of management is to treat the underlying

cause (e.g. if still undelivered, expedite delivery)

• Manage in consultation with a haematologist

• Laboratory tests dictate the need for blood, fresh

frozen plasma, clotting factors replacement and platelet

transfusion

Mrs O'Neil is managed by a multidisciplinary team

comprising a consultant obstetrician, consultant anaesthetist

and consultant haematologist along with supporting staff in

a high dependency setting. Fluid replacement is guided by

invasive monitoring, urine output and infusion of Syntocinon

is used to maintain uterine contractility.

Packed red cells, fresh frozen plasma and cryoprecipitate

are administered and over the next few hours her clinical

condition stabilizes and her coagulation profile improves.

She is monitored intensively for 24 hours with frequent

relevant investigations.

She is then transferred to a single room in the postnatal

ward caring for women with pregnancy loss. The following

day a debriefing session is undertaken to go through the

events and answer any questions. She is discharged home

on day 4 following delivery, with a date for postnatal

follow-up at the counselling clinic 6 weeks post delivery.Case 18 125

PART 2: CASES

CASE REVIEW

This 39 - year - old parous woman presented at 37 weeks '

gestation in shock with a history of painful APH and loss

of fetal movements. Her age, parity, smoking history and

socioeconomic status place her at risk for placental

abruption. Her history of constant abdominal pain,

vaginal bleeding and the findings of a tender woody

uterus along with fetal demise are highly suggestive of

the diagnosis of placental abruption.

The mainstay of management is adequate resuscitation

of the mother. The guidelines for managing major

obstetric haemorrhage recommend that two peripheral

lines should be set up using at least 14 - gauge cannulae

and blood cross - matched for 6 units. Plasma expansion

should be provided by colloids.

The next step is to expedite delivery of the fetus, the

mode of which depends upon gestation, fetal well - being

and maternal condition. If the mother ' s condition is

stable and the fetus is in good condition, induction of

labour is appropriate, as women with abruption usually

have a quick short labour.

Following delivery, PPH and DIC are the major

complications to watch out for.

• Multidisciplinary team involvement is strongly

recommended

• Resuscitation of the mother and early delivery of the

fetus are the mainstay of management

• PPH and DIC are serious complications to watch out for

KEY POINTS

• Placental abruption is an important cause of maternal

morbidity and perinatal morbidity and mortality

• Differential diagnosis is mainly from placenta praevia and

labour

• APH with sustained painful uterine contractions in the

presence of a tender uterus and fetal distress or demise

should alert one to the diagnosis

Further reading

Baskett TF , Arulkumaran S . Antepartum haemorrhage . Intrapartum Care for the MRCOG and Beyond. RCOG Press . 2002 ;

133 – 141 .

Hl - adky K , Yankowitz J , Hansen WF . Placental abruption . Obset

Gynecol Surv 2002 ; 57 : 299 – 305 .