vaginal bleeding is abnormal blood discharge from vagina during pregnancy, after pregnency, any time from conception. types: Ante partum hemmorhage post partum hemmorhhage , all types of abortions, their types and managements .

2. RAJOSI KHANRA
M.Sc.1st year
MANAGEMENTS
OF
VAGINAL
BLEEDING

3. OBJECTIVES
A DEFINITION OF VAGINAL BLEEDING
B TYPES OF VAGINAL BLEEDING
● Incomplete abortion
● Complete abortion
● Threatened abortion
● Antepartum hemorrhage
● Postpartum hemorrhage
C MANAGEMENTS OF TYPES OF BLEEDING

4. VAGINAL BLEEDING
Any discharge of blood
from the vagina.
It can happen any time
from conception (when the
egg is fertilised) to the end
of pregnancy.

5. TYPES OF VAGINAL BLEEDING
Before 20 weeks
of pregnancy
After 20 weeks
of pregnancy
During and after
24 hours of delivery
● Incomplete
abortion
● Complete
abortion
● Threatened
abortion
● Antepartum
hemorrhage
● Primary PPH
● Secondary
PPH

6. Incomplete
Abortion
When the entire products of
conceptions are not expelled
instead a part of it is left inside
the uterine cavity.

7. CLINICAL FEATURES
Expulsion of fleshy mass per vaginam
Continuation of pain in lower abdomen
Persistence of vaginal bleeding
1
2
3

8. ● Uterus smaller than period of amenorrhea.
● Patulous cervical os often admitting tip of the finger.
● Varying amount of bleeding.
INVESTIGATION
● Ultrasonography
EXAMINATION

9. ● If retained POC are seen in vagina,
remove them gently with a finger.
The procedure must be carried out
under aseptic techniques.
● If the bleeding does not stop/ the
woman is in shock, give IV fluid
rapidly.
● Send the woman to the MO with a
referral slip.
MANAGEMENT

10. IN RECENT CASES
Evacuation of the retained products of conceptions.
mg is used
DRUGS
Tab Misoprostol 200
vaginally every 4 hours.

11. EARLY ABORTION
Dilation and Evacuation
using manual vacuum
aspiration syringe.
LATE ABORTION
Uterus is evacuated under general
anaesthesia and products are removed
by ovum forceps or blunt curette.
After that dilation and curettage is to
be done to remove the bits of tissue
left behind.

12. COMPLETE ABORTION
When the products of
conception are expelled
fully as a mass, it is called
complete miscarriage.

13. CLINICAL FEATURES
History of expulsion of POC
Lower abdominal pain
1
2
3 Vaginal bleeding becomes trace or absent

14. ● Uterus is smaller than the period of amenorrhea and softer
than normal.
● Cervical os is closed.
● Bleeding is traceable.
● Expelled fleshy mass is found completely.
EXAMINATION
INVESTIGATION
● Trans-vaginal ultrasound

15. MANAGEMENT
● Observe the woman for 4–6 hours. Advise her to take rest.
● If the bleeding decreases or stops, explain the facts to her,
reassure her and advise her to go home after you have
checked her vital signs.
● Advise her to return to you or the MO if the bleeding
reoccurs.
INSTITUTIONAL MANAGEMENT
● Evacuation of uterine curettage should be done.

16. THREATENED
ABORTION

17. CLINICAL FEATURES

18. EXAMINATION
INVESTIGATION
● The uterus and cervix are
softer than normal, and the
fundal height corresponds
to the period of gestation.
● Closed external OS.
● Transvaginal screening

19. Diazepam
- 5 mg tablet
- twice daily
DRUGS

20. MANAGEMENT
● If the bleeding decreases or stops, explain the
facts to the woman, reassure her and advise her to
go home after you have checked her vital signs.
● Advise her to avoid stressful exercise/work
● To avoid sexual intercourse.
● Advise her to take bed rest.
● Send her to the MO with a referral slip for further
advice.

21. ADVICE ON DISCHARGE
● The patient should limit her activities for at least
2 weeks and avoid heavy work.
● Coitus is avoided during this period.
● She should be followed up with repeat
sonography at 10-14 days’ time.
● Advise the woman to return for follow up and to
go directly to the MO for treatment.
● Self- care
● Family planning

22. ANTEPARTUM
HAEMORRHAGE
Defined as bleeding from
or into the genital tract
after 28 th week of
pregnancy but before the
birth of the baby.

23. APH
PLACENTAL
BLEEDING
UNEXPLAINED EXTRA-PLACENTAL
CAUSES
● Placenta
previa
● Abruptio
placenta

24. SYMPTOMS
● Vaginal bleeding

25. ● The size of the uterus is proportionate to
the period of gestation.
● The uterus feels relaxed,soft and elastic.
● Persistence of malpresentation.
● Fetal heart sound is present.
EXAMINATION

26. ● The patient is immediately put to bed.
● To assess the blood loss by inspecting of the
clothing.
● To assess the degree of anaemia
● Quick but gentle abdominal examination to mark
the height of the uterus, to auscultate the foetal
heart sound and to note any tenderness on the
uterus.
● Vagianl examination must not be done.
MANAGEMENT

27. PLACENTA
PREVIA

28. When the
implanted
completely
placenta is
partially or
over the
lower uterine segment is
called placenta previa.

29. CAUSES
A.Dropping down theory
B.Big surface area of placenta
C.Defective decidua

30. ● Multiparity
● Maternal age older than 35 year
● Prior placenta previa
● Prior curettage
● Placental abnormality
● Multiple pregnancies
RISK FACTORS

31. TYPES OF DEGREES

32. VAGINAL BLEEDING

33. EXAMINATION
● Size of uterus- proportion to the period of
gestation.
● Uterus feels relaxed,soft.
● Persistence of malpresentation like breech
or transverse or unstable lie.
● Foetal heart sound is usually present.

34. ● Regular antenatal care.
● Antenatal diagnosis of low lying placenta at 20 weeks with
routine ultrasound.
● Significance of warning haemorrhage should not be
ignored.
MANAGEMENT

35. AT HOME
➔ The patient is immediately put to bed.
➔ Inspection the clothing soaked with blood
➔ Check vital signs
➔ Quick but gentle abdominal examination to mark
the height of the uterus, to auscultate foetal heart
sound and to note any tenderness on the uterus.
➔ Vaginal examination must not be done.
➔ Transfer to hospital.

36. ABRUPTIO
PLACENTAE
Where bleeding occurs
due to premature
separation of normally
situated placenta.

37. ● General factors- a) high birth order
b) advancing age of mother
c) poor socio-economic condition
d) smoking
● Hypertension
● Trauma
● Folic acid deficiency
● Uterine decompression
CAUSES

38. Bleeding is slight.
Bleeding
mild to moderate.
Bleeding
Moderate to severe.
GRADE: 0
Clinical features
may be absent.
GRADE: 1(40%)
GRADE:2 (45%)
GRADE:3 (15%)

39. Abdominal
Discomfort
Dark colour
bleeding
CLINICAL FEATURES

40. ● Early detection and effective therapy of pre-eclampsia
and other complications of pregnancy.
● Avoidance of trauma.
● To avoid sudden decompression of the uterus.
● To avoid supine hypotension.
● Routine administration of folic acid from early
pregnancy.
MANAGEMENT

41. POSTPARTUM
HEMORRHAGE
PPH is defined as the loss of
500 ml or more of blood
during or within 24 hours of
the birth and up to six weeks
after delivery.

42. PRIMARY SECONDARY
TYPES OF PPH
Haemorrhage
occurs within 24
hours following
the birth of the
baby.
Haemorrhage
occurs beyond
24 hours.

43. ● Atonic
● Traumatic
● Retained tissues
● Thrombin
CAUSES OF PPH

44. MANAGEMENT

46. PRIMARY PPH
● Evaluate her general condition and look for signs of shock (cold,
clammy skin), check the level of consciousness, pulse (should
not be weak or fast, at 110 per minute or more), blood pressure
(systolic should not be less than 90 mmHg), respiration (the RR
should not be more than 30 breaths per minute) and
temperature.
● Monitor the vital signs every 15 minutes and estimate the
amount of blood loss.
● Give the woman an Oxytocin injection (10 IU, intramuscular
stat).
● Massage the uterus to expel blood and blood clots. Blood clots
trapped in the uterus will inhibit effective contractions.

47. ● Establish an intravenous line and start an
intravenous infusion of Ringer Lactate or normal
saline. Do not use dextrose solutions unless others
are unavailable.
● Add 20 IU of oxytocin to 500 ml of Ringer
Lactate/normal saline that is running intravenously
at the rate of 40–60 drops per minute.
● If the bleeding persists and the uterus continues to be
in the relaxed state (i.e. it is soft ), make
arrangements for transporting the woman to the
FRU, where facilities for blood transfusion and
appropriate surgical care are available.

48. ● Do not give the woman anything to eat or drink since she
may require an obstetric intervention under anaesthesia.
● If the woman is bleeding heavily, i.e. soaking one pad or cloth
in less than five minutes, or if she is in shock, give her fluids
rapidly (60 drops per minute) through another drip.
● Raise the foot end of the bed so that her head is lower than
her body. This will help increase the flow of blood to the
heart.
● Keep the woman warm and covered with a blanket. If she is
in shock, she might feel cold even in warm weather.
● Utilise the intervening time to perform bimanual
compression.

49. BIMANUAL COMPRESSION

50. SECONDARY PPH
● Give an Oxytocin injection (10 IU, intramuscular) stat.
● Start an intravenous infusion: inject 20 IU of Oxytocin into
500 ml of Ringer Lactate/ normal saline and administer at the
rate of 40–60 drops per minute.
● An infection is suspected if there is fever and/or foul-smelling
vaginal discharge.
● Give the woman the first dose of antibiotics (Ampicillin
capsule, 1g orally; Metronidazole tablet, 400 mg orally; and a
Gentamicin injection, 80mg intramuscular stat).
● Refer the woman to the FRU.

53. Bleeding during pregnancy is
common, especially during the first
trimester, and usually it's no cause for
alarm. But because bleeding can
sometimes be a sign of something
serious, it's important to know the
possible causes, and get checked out
by your doctor to make sure you and
your baby are healthy.

54. BIBLIOGRAPHY
● https://nhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/sba_guidelines_for_skilled_attendance_
at_birth.pdf
● Konar Hiralal, DC Dutta’s Textbook of Obstetrics,9th
edition,Jaypee Brothers Medical Publishers (2019), Page
no.- 385,228,151.

55. THANK
YOU!!