Bleeding during pregnancy and before 28 weeks of gestation

1. Bleeding in Pregnancy

2. To recognise the presentation of
complications of abortion
To practise effective
management including MVA

3. Causes of Bleeding in Late Pregnancy
??
Please make a list of all the causes you can think off

4. Life-Threatening
Causes of Bleeding in Late Pregnancy
• Placenta Praevia
• Abruption
• Uterine scar disruption
• ‘Bloody show’
• Cervix: ectropion; cervicitis; polyp; carcinoma
• Vaginal trauma
The cause of APH often remains ‘INDETERMINATE’

5. Examination - APH
• ABC
• Pulse, Blood Pressure, Temperature
• Assess fundal height (GA)
• Fetal lie (abnormal?)
• Estimated fetal weight (clinical/ultrasound)
• Confirm presence of fetal heart beat
• Gentle speculum exam
• NO digital vaginal exam unless placental location known

6. Placenta Praevia
What are the SYMPTOMS??

7. Patient History – Placenta Praevia
• Painless bleeding
2nd or 3rd trimester or at term
often following intercourse
occasionally pre-term contractions

8. Placenta Praevia

9. Marginal Praevia

10. Treatment – Placenta Praevia
• With no active bleeding (< 37 weeks)
expectant management
no intercourse or digital examination
• With late pregnancy bleeding
Assure patient circulatory stability
Caesarean Section indicated

11. Placental Abruption
What are the SYMPTOMS??

12. Patient History - Abruption
• Pain = ‘hallmark’ symptom
mild cramp to severe pain
back pain – think posterior abruption
uterus may be “tense and tender” or
“woody”
frequent, palpable contractions
Uterus is “irritable”

13. Patient History - Abruption

14. Placental Abruption
• Premature separation of normally sited placenta from
uterine wall
partial
complete

15. Placental Abruption

16. Placental Abruption

17. Epidemiology of Abruption
Occurs in 1-2% of pregnancies
• Risk factors
hypertensive diseases of pregnancy
smoking
trauma
overdistension of the uterus
“placental insufficiency” / IUGR
Malaria

18. Bleeding with Abruption
• Amount of “revealed” bleeding may be misleading
• Bloody amniotic fluid
• Retroplacental clot (“concealed” haemorrhage)
• Risk of disseminated intravascular coagulopathy
(DIC)

19. Treatment of Abruption
• Assess fetal and maternal stability
• Amniotomy & expedite vaginal delivery
• May require CS (review fetal/maternal status)
Availability of blood and clinical scenario
will determine mode of delivery
Blood loss is underestimated – early
resort to transfusion
• Prepare for neonatal resuscitation

20. Uterine Rupture
• Occult dehiscence vs symptomatic rupture
• Obstructed labour commonest cause globally
• Other causes:
Previous caesarean section
trauma

21. Signs of Impending Uterine Rupture
• Maternal tachycardia
IMPORTANT - this may be the only sign
• Fetal heart rate changes
• Vaginal bleeding
• Continuous pain
• Haematuria
• Any of these may be the only presenting feature

22. Signs of manifest Uterine Rupture
• Vaginal bleeding
• Sudden, severe pain
• Contractions stop
• Acute Fundal Height changes or absence of
FHR
• Loss of engagement of head
• Palpable fetal parts through maternal abdomen
• Profound maternal tachycardia and hypotension

23. Early pregnancy
Bleeding???

24. Definition ??