Bleeding in pregnancy


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Bleeding in pregnancy

  1. 1. BLEEDING IN PREGNANCY Early Pregnancy Bleeding – Antepartum Haemorrhage
  2. 2.  Spontaneous Abortion • Threatened Miscarriage • Inevitable Miscarriage  Implantation Bleeding  Decidual Bleeding  Ectopic Pregnancy EARLYPREGNANCYBLEEDING
  3. 3.  Spontaneous Abortion • Threatened Miscarriage • Inevitable Miscarriage EARLYPREGNANCYBLEEDING
  4. 4. SpontaneousAbortion  Defined as the involuntary loss of the products of conception prior to 24 weeks gestation  It is thought that 15% of conceptions result in miscarriage  Majority occur within first trimester
  5. 5. Spontaneous Abortion Threatened Pregnancy Progresses Birth of Viable Infant Missed Carneous Mole Inevitable Incomplete Septic Complete
  6. 6. SpontaneousAbortion Causes  Maldevelopment of the conceptus  Most common cause  Chromosomal abnormalities account for 70% of defective conceptions  Spontaneous mutations may still arise  Defective Implantation  Hydatidiform Mole  Fibroids
  7. 7. SpontaneousAbortion Causes  Maternal Infection  Due to high temperature relating to general metabolic effect of fever  Result of transplacental passage of viruses, e.g.  Influenza  Rubella  Pneumonia  Toxoplasmosis  Cytomegalovirus  Listeriosis  Syphilis  Brucellosis  Appendicitis
  8. 8. SpontaneousAbortion Causes  GenitalTract Infections  Bacterial vaginosis  Vaginal mycoplasma infection  Medical Disorders  Diabetes  Thyroid disease  Hypertensive disorders  Renal disease
  9. 9. SpontaneousAbortion Causes  Endocrine Abnormalities  Poor development of the corpus luteum  Inadequate secretory endometrium  Low serum progesterone levels  UterineAbnormalities  Structural abnormalities implicated in 15% of early pregnancy losses e.g.  Double uterus  Unicornuate, bicornuate, septate or subseptate uterus  Failure of uterus to develop to adult size, remaining infantile
  10. 10. SpontaneousAbortion Causes  Retroversion of the Uterus  Does not itself cause abortion  As uterus fails to enlarge into abdomen, vaginal and abdominal manipulation to correct the retroversion causes abortion  CervicalWeakness  Caused by laceration of cervix or undue stretching of internal os as a result of previous medical abortion or childbirth  Membranes bulge through cervical canal and rupture  Characterised by recurrent late pregnancy losses
  11. 11. SpontaneousAbortion Causes  Environmental Factors  Environment teratogens such as lead and radiation  Ingested teratogenetic substances such as drugs (namely cocaine) and alcohol  Smoking  Maternal Age  Women in late 30’s and older at higher risk, irrespective of previous obstetric history
  12. 12. SpontaneousAbortion Causes  Stress and Anxiety  Severe emotional upset may disrupt hypothalmic and pituitary functions  Paternal Factors  Poor sperm quality  Source of chromosomal abnormalities  Immunologocial Factors  Maternal lymphocytes with natural killer cell activity may affect trophoblast development  Autoimmune diseases such as antiphospholipid syndrome
  13. 13. SpontaneousAbortion Causes Despite detailed investigations, no cause can be found for the majority of cases of spontaneous abortion
  14. 14. SpontaneousAbortion ThreatenedMiscarriage  Signs and Symptoms  Pain: Variable, possibly slight lower abdominal pain or backache  Bleeding: Scant, during first 3 months  Cervical Os: Closed, no dilation  Uterus: If palpable, soft and not tender
  15. 15. SpontaneousAbortion ThreatenedMiscarriage  No vaginal assessment as may provoke uterine activity  No evidence that bedrest is effective  Woman should be referred for medical attention straight away  A pregnancy test is carried out and ultrasound performed to assess viability  Heavy or increased amount of bleeding in an ominous sign and may precede inevitable abortion
  16. 16. SpontaneousAbortion InevitableMiscarriage  Signs and Symptoms  Pain: Severe, rhythmical  Bleeding: Heavy, clots  Cervical Os: Open with dilation  Uterus: If palpable, smaller than expected
  17. 17. SpontaneousAbortion InevitableMiscarriage  As name indicates, it is unavoidable pregnancy loss  Gestational sac separates from uterine wall and uterus contracts to expel the contents of conception  Midwife should attend at once when called as woman may collapse from blood loss  Speculum examination in hospital, input from obstetrician or gynaecologist  Oxytocic drug may be given after products expelled
  18. 18. SpontaneousAbortion IncompleteMiscarriage  Signs and Symptoms  Pain: Severe  Bleeding: Heavy, profuse  Cervical Os: Open with dilation  Uterus: Tender and painful  Other: Tissue present in cervix Shock
  19. 19. SpontaneousAbortion IncompleteMiscarriage  Gestational sac is incompletely expelled, with usually the placental tissue retained  Static or slowly falling HCG levels  Evacuation of retained products of conception from the uterus carried out  Medical management possible using prostaglandin analogues such as misoprostol  If surgical evacuation required, woman should be screened for chlamydial infection  Transfusion may be given if blood loss excessive
  20. 20. SpontaneousAbortion CompleteMiscarriage  Signs and Symptoms  Pain: Diminishing or absent  Bleeding: Minimal or absent  Cervical Os: Closed  Uterus: If palpable, firm and contracted
  21. 21. SpontaneousAbortion CompleteMiscarriage  Gestational sac completely expelled  History of abdominal pain, bleeding with passing of clots and tissue  Once miscarriage is complete, pain and bleeding subside, cervix closes  Ultrasound shows empty uterus coupled with falling HCG levels
  22. 22. SpontaneousAbortion MissedMiscarriage  Signs and Symptoms  Pain: Absent  Bleeding: Some spotting possible, brown loss  Cervical Os: Closed  Uterus: If palpable, smaller than expected
  23. 23. SpontaneousAbortion MissedMiscarriage  Also known as delayed or silent abortion  Usually follows threatened abortion  Bleeding occurs between uterine wall and gestational sac and embryo dies  Layers of blood clots form and later become organised  Retainment of fetus inhibits menses  Other signs of pregnancy diminish  Confirmed by ultrasound  Surgical evacuation or expectant management possible
  24. 24. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  GTD general term that covers  Hydatidiform mole (benign)  Choriocarcinoma (malignant)
  25. 25. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  Clinical presentation of Hydatidiform Mole  Exaggerated signs of pregnancy, appearing by 6-8 weeks due to high levels of HCG  Bleeding or a blood stained vaginal discharge after period of amenorrhoea  Ruptured vesicles, resulting in light pink or brown vaginal discharge, or detached vesicles, which may be passed vaginally  Anaemia as a result of the gradual loss of blood  Early-onset pre-eclampsia  On examination, uterine size exceeding that expected for gestation  On palpation, a uterus that feels ‘doughy’ or elastic
  26. 26. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  Hydatidiform Mole  Gross malformation of trophoblast  Chorionic villi proliferate and become avascular  Found in cavity of uterus and rarely within uterine tube  Can lead to development of cancer, therefore accurate and rapid diagnosis, treatment and follow- up paramount  Two forms of mole  Complete hydatidiform mole (risk of choriocarcinoma)  Partial mole
  27. 27. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  Treatment of Hydatidiform Mole  Treatment is to remove all trophoblastic tissue  In some cases, mole will abort spontaneously  If this does not occur, vacuum aspiration or D and C necessary  Spontaneous abortion carries less risk of malignant change  Pregnancy to be avoided in follow up period  IUCDs contraindicated and hormonal methods of contraception to be avoided until HCG levels normal
  28. 28. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  Choriocarcinoma  Malignant disease of trophoblastic tissue  HCG levels will rise and test will become strongly positive again  May occur in next pregnancy following evacuation of mole  Condition rapidly fatal unless treated  Disease spreads by local invasion and via bloodstream  Metastases my occur in lungs, liver or brain
  29. 29. SpontaneousAbortion MissedMiscarriage–GestationalTrophoblasticDisease  Treatment of Choriocarcinoma  Responds extremely well to chemotherapy  Cytotoxic drugs are used singly or in combination with other therapy  Nearly always completely successful  Pregnancy should be avoided for at least one year on completion of treatment  Subsequent pregnancy will require close HCG monitoring as there is a risk of recurrance
  30. 30. SpontaneousAbortion SepticMiscarriage  Signs and Symptoms  Pain: Severe or variable  Bleeding: Variable, may be offensive  Cervical Os: Open  Uterus: Bulky, tender and painful on examination
  31. 31. SpontaneousAbortion SepticMiscarriage  May occur after spontaneous or induced abortion, more likely after incomplete miscarriage  Causitive organisms include Staphyloccus aureus, Clostridium welchii, Escherichia coli, Klebsiella, Serratia and Bacteroides species, and group B haemolytic streptococci  Woman will feel acutely ill with fever, tachycardia, headache, nausea and general malaise  High vaginal swab and blood cultures should be taken  Antibiotics before any surgical intervention  Risks include septicaemia, endotoxic shock, DIC, liver and renal damage, salpingitis and infertility
  32. 32. SpontaneousAbortion MidwiferyAssessments  Blood loss  Amount?  Nature?  When did it start?  What were you doing at the time?  Pain  Menstrual History  Confirm LMP  Symptoms of Pregnancy  Still present?  Have they changed?  Obstetric History  Gynaecological History  Cervical infections  Cervical operations  Contraceptive History  Blood Group and Rhesus Status
  33. 33. SpontaneousAbortion MidwiferyResponsibilities  Referral  Support groups  Recurrent miscarriage clinic  GP/gynaecologist-obstetrician  Advice  Expect a grief reaction  Dependent on gestation, lactation may occur  Understand it takes weeks – months to recover from a miscarriage physically and even longer emotionally  Menstruation may return four to six weeks later  Await the next normal period before trying to conceive  Expect bleeding for up to two weeks  No intercourse, swimming, tampons for two weeks or duration of bleeding  Support  Remember the partner too
  34. 34.  Implantation Bleeding EARLYPREGNANCYBLEEDING
  35. 35. ImplantationBleeding  As the trophoblast erodes the endometrial endothelium and the blastocyst implants, a small vaginal loss may be apparent  Occurs at approximately 10-12 days post conception, around the same time as expected menses and may be mistaken for a woman’s period, although abnormal (usually bright red and lighter)  It is significant when calculating LMP for estimation of due date
  36. 36.  Decidual Bleeding EARLYPREGNANCYBLEEDING
  37. 37. Decidual Bleeding  Occasionally there is bleeding from the decidua during the first 10 weeks, usually at around the time menses is expected  Caused by menstrual hormones  Especially common in the early stages of pregnancy, before the lining has completely attached to the placenta  Not thought to be a health threat to mother or fetus  May affect calculation of EDD
  38. 38.  Ectopic Pregnancy EARLYPREGNANCYBLEEDING
  39. 39. EctopicPregnancy  Occurs when a fertilised ovum implants itself outside the uterine cavity  Sites can include the uterine tube, an ovary, the cervix or the abdomen  95% implant in the uterine tube (tubal pregnancy), of which 64% are implanted in the ampulla of the fallopian tube (where fertilisation takes place) 
  40. 40. EctopicPregnancy RiskFactors  Any alterations of the normal function of the uterine tube in transporting gametes contributes to the risk of ectopic pregnancy:  Previous ectopic pregnancy  Previous surgery on the uterine tube, pelvic or abdominal surgery which may cause adhesions  Exposure to diethylstillboestrol in utero (postcoital contraception)  Congenital abnormalities of the tube  Endometriosis  Previous infection including chlamydia, gonorrhoea and pelvic inflammatory disease  Use of intrauterine contraceptive devices  Assisted reproductive technology  Delayed childbearing (>35 years)
  41. 41. EctopicPregnancy SignsofEctopicPregnancy  Tubal pregnancy very rarely remains asymptomatic beyond 8 weeks gestation  Typical Signs:  Localised/abdominal pain  Amenorrhoea  Vaginal bleeding or spotting  Atypical Signs:  Shoulder pain  Abdominal distension  Nausea, vomiting  Dizziness, fainting
  42. 42. EctopicPregnancy ClinicalPresentation  Pelvic pain can be very severe  Acute symptoms are the result of tubal rupture (more likely to occur between 5-7 weeks gestation) and relate to the degree of haemorrhage there has been  Ultrasound enables an accurate diagnosis of tubal pregnancy, making management more proactive  Vaginal ultrasound, combined with the use of sensitive blood and urine tests which detect the presence of HCG, helps to ensure diagnosis is made earlier  If the tube ruptures, shock may ensue; therefore resuscitation, followed by laparotomy, is needed  The mother should be offered follow-up support and information regarding subsequent pregnancies
  43. 43. EctopicPregnancy Diagnosis  The woman will give a history of early pregnancy signs  The uterus will have enlarged and feel soft  Abdominal pain may occur as the tube distends and uterine bleeding may be present  Abdomen may be tender and distended  Shoulder tip pain due to referred pain  Woman may appear pale, complain of nausea and collapse  Severe pain felt during pelvic exam  A mass may be felt on one side of the uterus  Hormonal assay will find progesterone levels low and hCG levels falling  USS may show fluid or and mass in pelvic cavity and absence of intrauterine pregnancy
  44. 44. EctopicPregnancy Diagnosis Nowadays occurrence of an extra-uterine pregnancy is diagnosed with a combination of serum hCG levels and ultrasound scan
  45. 45. EctopicPregnancy Treatment  Common perception is that everyone with an ectopic needs an operation to deal with it  However, a number of treatment options are available including expectant management if no bleeding, pain or shock  If there is evidence of pain and bleeding producing shock, immediate treatment is essential, as it is a life-threatening condition  This is a surgical emergency and in most cases a laparotomy is performed
  46. 46. EctopicPregnancy SurgicalTreatment  Salpingectomy  Salpingectomy (tubal removal) is the principle treatment especially where there is tubal rupture  Salpingotomy  Conservative surgical management may be employed when the ectopic has not ruptured and where the tube appears normal  This is called salpingotomy, where the ectopic is removed and the tube allowed to heal
  47. 47. EctopicPregnancy ExpectantTreatment  Used when pain is less and indicators are that the ectopic is a small one or it is not bleeding too much  Expectant approach involves close follow up with hCG tests every 2-7 days until levels have returned to normal  Is successful in 90% of selected patients  Methotrexate – a drug that destroys actively growing tissues such as the placental tissues that support the pregnancy is used as an injection in selected cases to avoid surgery (in non ruptured ectopic)  Side effects include abdominal pain for 3 – 7 days in 50% of cases and mild symptoms of nausea, mouth dryness and soreness and diarrhoea
  48. 48.  Placental Abruption  Placenta Praevia ANTEPARTUMHAEMORRHAGE
  49. 49. AntepartumHaemorrhage  Defined as bleeding from the genital tract after the 24th week of gestation and before the onset of labour  Bleeding during labour is referred to as Intrapartum Haemorrhage  Bleeding usually due to placental separation, but can also be due to incidental causes from extraplacental sites in the birth canal, such as cervical polyps or some other local lesion
  50. 50. AntepartumHaemorrhage EffectsontheFetus  Mortality and Morbidity increased as a result of severe vaginal bleeding in pregnancy  Stillbirth or neonatal death may occur  Premature separation of the placenta and subsequent hypoxia may result in severe neurological damage in the baby
  51. 51. AntepartumHaemorrhage EffectsontheMother  If bleeding is severe, it may be accompanied by shock and disseminated intravascular coagulation (DIC)  The mother may die or be left with permanent ill health  APH is unpredictable and the woman’s condition can deteriorate rapidly at any time  Rapid decisions about the urgency of need for medical or paramedic presence, or both, must be made often at the same time as observing and talking to the woman and her partner
  52. 52. AntepartumHaemorrhage CausesofBleedinginLatePregnancy Placenta Praevia Incidence = 31.0% Placental Abruption Incidence = 22.0% ‘Unclassified Bleeding”, e.g. Incidence = 47.0% (Total) Marginal Show Cervicitis Trauma Vulvovaginal varosities Genital tumours Genital infections Haematuria Vasa praevia Other
  53. 53. AntepartumHaemorrhage InitialAssessmentofPhysicalCondition  Take a detailed history from the woman  Take observations: Temperature, Pulse, Respiratory Rate, Blood Pressure  Observe for any pallor or breathlessness  Assess the amount of blood loss  Perform a gentle abdominal examination, observing signs that the woman is going into labour
  54. 54. AntepartumHaemorrhage InitialAssessmentofPhysicalCondition  Ask the mother is the baby has been moving as much as normal  Attempt to auscaltate the fetal heart  Insert large bore canula, take bloods for FBC, Cross match, LFTs, Clotting times, Kleihaur if necessary  Obstetric referral  Anti-D administration if applicable  Steroids if <34 weeks gestation
  55. 55. AntepartumHaemorrhage InitialAssessmentofPhysicalCondition On no account must any vaginal or rectal examination be done; nor may an enema or suppository be given to a woman suffering from an Antepartum Haemorrhage
  56. 56. DifferentialDiagnosis  Pain  Did the pain precede bleeding and is it continuous or intermittent?  Onset of bleeding  Was this associate with any event such as coitus?  Amount of blood loss visible  Is there any reason to suspect that some blood has been retained in utero?  Colour of the blood  Is it bright red or darker in colour?  Degree of shock  Is this commensurate with the amount of blood visible or more severe?
  57. 57. DifferentialDiagnosis  Consistency of the abdomen  Is it soft or tense and board-like?  Tenderness of the abdomen  Does the mother resent abdominal palpation?  Lie, presentation and engagement  Are any of these abnormal when account is taken of parity and gestation?  Audibility of the fetal heart  Is the fetal heart heard?  Ultrasound scan  Does a scan suggest that the placenta is in the lower uterine segment?
  58. 58. AntenatalHaemorrhage SupportiveTreatment  Provide woman and partner with emotional reassurance  Give rapid fluid replacement (warmed) with a plasma expander, and later with whole blood if necessary  Give analgesia  If at home, arrange transfer to hospital  Subsequent management depends on the definite diagnosis
  59. 59. Section88 MaternityNotice ReferralGuidelines Previous Obstetric History  LEVEL 2 (Code 3001) - Previous Placental Abruption Current Pregnancy  LEVEL 2 (Code 4004) - Antepartum Haemorrhage  LEVEL 3 (Code 4020) - Placenta Praevia (At or >32 weeks)
  60. 60.  Placental Abruption ANTEPARTUMHAEMORRHAGE
  61. 61. PlacentalAbruption  Premature separation of a normally situated placenta, occurring after the 24th week of pregnancy  Aetiology is not always clear, some predisposing factors are:  Pregnancy-induced hypertension or pre-eclampsia  A sudden reduction in uterine size, e.g. SRM with polyhydramnios or after the birth of a first twin  Short umbilical cord  Direct trauma to the abdomen (risk remains for 2 days following trauma)  High parity  Previous caesarean section  Cigarette smoking or illicit drug use (esp. Cocaine)
  62. 62. PlacentalAbruption  Blood loss may be:  Revealed  Concealed  Mixed  Separation may be:  Mild  Moderate  Severe  Complications of Placental Abruption:  Disseminated Intravascular Coagulation  Postpartum Haemorrhage  Renal Failure  Pituitary Necrosis
  63. 63. PlacentalAbruption MildSeparationofthePlacenta  Separation and the haemorrhage are minimal  Mother and fetus are in a stable condition  No indication of maternal shock  Fetus is alive, with normal heart sounds  Consistency of uterus is normal  No tenderness on abdominal palpation
  64. 64. PlacentalAbruption ManagementofMildSeparationofthePlacenta  Ultrasound scan  Determine placental location  Identify any degree of concealed bleeding  Monitoring of fetal heart rate  Frequently to assess fetal condition whilst bleeding persists  CTG should be carried out once or twice daily  Admission to hospital  Women who are not yet 37 weeks gestation may be cared for in an antenatal ward for a few days  May be discharged if there is no further bleeding and placenta has been found to be in the upper uterine segment
  65. 65. PlacentalAbruption ManagementofMildSeparationofthePlacenta  Induction of Labour  May be offered for woman who have passed the 37th week of pregnancy  Especially if there has been more than one episode of mild bleeding  Further management  Heavy bleeding or evidence of fetal distress may indicate that a caesarean section is necessary
  66. 66. PlacentalAbruption ModerateSeparationofthePlacenta  Separation of about one-quarter  Considerable amount of blood may be lost, some of which will escape from the vagina and some will be retained as a retroplacental clot or an extravasation into the uterine muscle  Mother will be shocked, with tachycardia and hypotension  Degree of uterine tenderness with abdominal guarding  Fetus may be alive, although hypoxic and intrauterine death is also a possibility
  67. 67. PlacentalAbruption ManagementofModerateSeparationofthePlacenta  Fluid replacement  Should be monitored with the aid of a central venous pressure line  Monitoring of fetal condition  Should be assessed with continuous CTG if the fetus is alive  Immediate caesarean section may be indicated once the woman’s condition is stablised
  68. 68. PlacentalAbruption ManagementofModerateSeparationofthePlacenta  If fetus is alive or has already died, vaginal birth may be contemplated  Such a birth is advantageous because it enables the uterus to contract and control the bleeding  Spontaneous labour frequently accompanies moderately severe abruption, but if it does not, then amniotomy is usually sufficient to induce labour  Syntocinon may be used with great care, if necessary  Delivery is often quite sudden, after a short labour  Drugs to attempt to cease labour is usually inappropriate
  69. 69. PlacentalAbruption SevereSeparationofthePlacenta  Acute obstetric emergency  Two-thirds of the placenta has become detached  2000 mls of blood or more are lost from the maternal circulation  Most or all of the blood can be concealed behind the placenta  Woman will be severely shocked, perhaps to a degree far beyond what might be expected from the amount of blood loss visible
  70. 70. PlacentalAbruption SevereSeparationofthePlacenta  Woman will have severe abdominal pain with excruciating tenderness; the uterus has a board like consistency  Hypotensive, however woman may be normotensive owing to preceding hypertension  The fetus will almost certainly be dead  Features associated with severe haemorrhage:  Coagulation defects (e.g. DIC)  Renal failure  Pituitary failure
  71. 71. PlacentalAbruption ManagementofSevereSeparationofthePlacenta  Treatment is same as for moderate separation  Whole bloods transfused rapidly and subsequent amounts calculated in accordance with the woman’s central venous pressure  Labour may begin spontaneously in advance of amniotomy and the midwife should be alert for signs of uterine contraction causing periodic intensifying of abdominal pain  However, if bleeding continues of a compromised fetal heart rate is present, caesarean section may be required as soon as the woman is adequately stable  The woman requires constant explanation and psychological support, despite the fact that her shocked condition may mean she is not fully conscious  Pain relief must be considered  Don’t forget the partner!
  72. 72.  Placenta Praevia ANTEPARTUMHAEMORRHAGE
  73. 73. PlacentaPraevia  Placenta partially or wholly implanted in the lower uterine segment on either the anterior or posterior wall  Lower segment of uterus grows and stretches progressively after the 12th week of pregnancy  In later weeks, this may cause the placenta to separate and severe bleeding can occur
  74. 74. PlacentaPraevia DegreeofPlacentaPraevia  Type 1 Placenta Praevia  Majority of placenta is in the upper uterine segment  Blood loss is usually mild  Mother and fetus remain in good condition  Vaginal birth is possible  Type 2 Placenta Praevia  Placenta is partially located in the lower segment near the internal cervical os  Blood loss is usually moderate  Condition of mother and fetus can vary  Vaginal birth is possible, particularly if placenta is anterior
  75. 75. PlacentaPraevia DegreeofPlacentaPraevia  Type 3 Placenta Praevia  Placenta is located over the internal cervical os but not centrally  Bleeding is likely to be severe  Vaginal birth is inappropriate  Type 4 Placenta Praevia  The placenta is located centrally over the internal cervical os  Torrential haemorrhage is very likely  Caesarean section is essential
  76. 76. Indicationsof PlacentaPraevia  Bleeding from vagina is the only sign, and it is painless  Uterus is not tender or tense  Presence of placenta preavia should be considered when:  Fetal head is not engaged in a primigravida (after 36 weeks gestation)  There is a malpresentation, especially breech  The lie is oblique or transverse  The lie is unstable, usually in a multigravida  Location of the placenta under USS will confirm the existence and extent of placenta praevia
  77. 77. Managementof PlacentaPraevia  Management of placenta praevia depends on:  The amount of bleeding  The condition of mother and fetus  The location of the placenta  The stage of pregnancy