Bleeding during pregnancy

Assessment of the patient

Scene size up

Primary assessmen

t

History taking

Secondary assessmen

t

reassessment

Points in history taking

determine nature of bleeding :

Amount ?

Was patient active or resting at time of bleeding ?

When did the bleeding started ?

Painful or painless ?

If painful ask OPQRST to determine pain nature and character ?

Stress on type of pain : colicy , sharp , dull aching .

Important points in examination

Orthostatic changes in vital signs , in case of compensated shock ( both

indicates significant blood loss ).

Abdominal examination for grey turner signs and Cullen sign of internal

hemorrhage .

Avoid vaginal examination . examination of female with

vaginal bleeding

underestimates amount of

blood loss due to physiological

changes

Signs of internal

hemorrhage

A . Cullen sign : bluish discoloration around umbilicus.

B . Grey turner line :

Bluish discoloration in the flanks.

General lines of treatment

Address ABC :

a. Administer 100% supplemental oxygen via non rebreathing mask at

15 L/min.

b. Start an IV line of normal saline with a large-bore IV catheter.

c. Infuse at the rate necessary to maintain blood pressure.

d. Use loosely placed trauma pads over the vagina to try to stop the

blood flow.

Provide rapid transport :

a. Notify the facility of the patient’s condition while en route

b. Keep the woman recumbent and lying on her left side

Obtain an ECG and baseline vital signs and continuously

reassess while en route , watch out for signs of shock.

fetal monitoring continuously throughout the management .

Causes of vaginal bleeding during pregnancy

1. Abortion .

2. Ectopic pregnancy .

3. Placental abnormalities .

4. Bleeding during third trimester .

Abortion

Definition : expulsion of the fetus and uterine contents before the 20th week of

gestation.

Mostly occur during the first trimester before the placenta is matured.

classification :

1- Spontaneous abortion 5- Missed abortion

2- Induced abortion 6- Incomplete abortion

3- Habitual abortion 7- Septic abortion

4- Inevitable abortion

Spontaneous abortion

Spontaneous abortion (miscarriage) : is an abortion which occurs naturally.

Causes include:

a. Acute or chronic illness in the pregnant woman.

b. Maternal exposure to toxic substances.

c. Fetal abnormalities.

d. Abnormal attachment of the placenta.

Can be

avoided

Induced abortion Intentional , criminal or elective abortion : abortion that is induced either

for criminal or medical causes.

as paramedics , care must be given to the patient as usual despite of your

ethical or religious believes , you should show empathy and compassion .

You are in the business of

saving people not

lecturing them

Habitual abortion

Definition : three or more consecutive pregnancies that end in miscarriage .

Causes include:

a. Chromosomal and endocrine disorders.

b. Ovarian issues.

c. Uterine malformations.

d. Cervical conditions.

e. Infections.

f. Lifestyle factors.

Threatened abortion

Definition : any vaginal bleeding in the first half ( 20 weeks ) of pregnancy

(usually first trimester).

Usually associated with mild abdominal cramping.

It differs from inevitable abortion that cervix is closed and bleeding is minimal .

Can progress to an complete abortion or may subside.

Treatment : complete bed rest so the condition can be monitored.

Prehospital treatment : transport and support.

Inevitable ( imminent ) abortion

Definition : an abortion that has progressed to a stage where termination of the

pregnancy cannot be avoided , ( abortion can not be avoided ).

Signs and symptoms :

a. Severe abdominal pain from strong uterine contractions

b. Vaginal bleeding, often massive

c. Cervical dilation.

Prehospital management of inevitable abortion aims at :

a. Maintain blood pressure.

b. Prevent hypovolemia.

c. Watch for signs of shock

Inevitable abortion

Incomplete abortion Definition : abortion where parts of product of conception remains inside

uterus.

Complication : vaginal bleeding will continue increasing risk of shock .

Management : as general guidelines plus

a. Consult medical control if products of conception are protruding from the

vagina.

b. Collect all products of conception and give to the receiving facility.

c. Allow the patient to view the fetus if she wishes.

d. Be prepared for strong emotions.

Missed abortion Definition : retention of product of conception in uterus after abortion for 2 months

or more .

The fetus dies during the first 20 weeks of gestation but remains in utero.

Diagnosis :

A. History : history of threatened abortion, with cessation of vaginal bleeding

and a gradual diminishing of signs of pregnancy.

B. Examination : ♠ Uterus feels like a hard mass.

♠ Fetal heartbeat cannot be heard.

Management : provide emotional support and transport , address ABCs .

Septic abortion

Definition : uterus becomes infected during or shortly ( within hours) after

abortion.

Diagnosis :

a. History : fever and bad-smelling vaginal discharge.

b. Physical examination : Fever and abdominal tenderness.

Hypotension may indicate septic shock.

Complication : can progress to septicemia and septic shock in severe cases.

Ectopic pregnancy

Ectopic pregnancy Definition : life threatening condition in which the fertilized ovum is implanted

outside normal site of implantation.

pathology :

Fetus can develop to term .

Normal signs and symptoms of pregnancy are present .

Sites include : fallopian tube ( commonest ) , cervix , ovary and abdominal

cavity.

Complication : rupture leading to internal hemorrhage .

Sites of ectopic

pregnancy

1. Tubal (commonest )

2. Cervical .

3. Ovarian .

4. Intraabdominal.

Clinical presentation :

Symptoms :

1.Symptoms of pregnancy ( amenorrhea , morning sickness )

2.Abdominal pain , which is sever with rupture ectopic

3.Syncope in case of shock

Signs :

4. Abdominal tenderness

5. Signs of acute abdomen and internal hemorrhage in case of rupture.

Management : general guidelines + rapid transport + emotional support.

Abdominal pain

in female in

child bearing

period is ectopic

pregnancy until

proved other

wise

Placental causes of vaginal bleeding

Definition : Premature separation of the placenta from the uterine wall.

incidence

Most common in the last trimester, but can happen in the second as well.

Causes :

Maternal hypertension ( commonest ).

Trauma , assault and falls .

Drug abuse , alcohol and smoking .

More common with previous history of abruptio placenta.

Abruptio placenta , placental abruption

Clinical presentation :

Symptoms :

1. Vaginal bleeding with bright red blood.

( Sometimes the blood does not reach the vagina, so doesn't appear).

2. Sudden onset of severe abdominal pain

3. No longer feeling the fetus moving.

Physical examination

4. Signs of shock, often out of proportion of apparent blood loss.

5. Tender abdomen and rigid uterus on palpation.

6. Fetal heart sounds may be absent.

Abruptio placenta

Management :

General outlines + careful and rapid transport +

reassess continuously for shock + fetal

monitoring .

Placenta previa

Definition : Placenta that is implanted low in the uterus and partially or fully

covers the cervical canal.

Chief complaint is usually painless vaginal bleeding with bright red blood.

Leading cause of vaginal bleeding in the second and third trimesters.

Complications include:

1. Disseminated intravascular coagulation .

2. Hemorrhage .

3. Low fetal birth weight .

signs :

The uterus is soft and non tender.

Do not palpate deeply in any woman with third-trimester bleeding.

May induce heavy bleeding if she does have placenta previa.

Third trimester bleeding

Bleeding during third trimester is of the greatest danger due to :

Large volume of blood present

Compensatory mechanisms present as a result of pregnancy.

pregnant woman can lose 40% of circulating volume before hypovolemia is

apparent.

Summary

Bleeding in obstetric patient require good assessment , rapid transport and

continuous reassessment for signs of shock.

Vaginal examination is better avoided in patient with vaginal bleeding .

Abortion is expulsion of product of conception before 2o weeks of gestation.

Tubal pregnancy is most common type of ectopic pregnancy.

Placenta previa is leading cause of bleeding in third trimester.

Hypotension in patient with septic abortion is grave and means septic shock.

Any questions ?