Bleeding in pregnancy
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Transcript of Bleeding in pregnancy
BLEEDING IN PREGNANCYEarly Pregnancy Bleeding – Antepartum Haemorrhage
Spontaneous Abortion• Threatened Miscarriage• Inevitable Miscarriage
Implantation Bleeding
Decidual Bleeding Ectopic Pregnancy
EARLY PREGNANCY BLEEDING
Spontaneous Abortion• Threatened Miscarriage• Inevitable Miscarriage
EARLY PREGNANCY BLEEDING
Spontaneous Abortion
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
Spontaneous
Abortion
Threatened
Pregnancy
Progresses
Birth of Viable Infant
Missed
Carneous Mole
Inevitable
Incomplete
Septic
Complete
Spontaneous AbortionCauses
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
Spontaneous AbortionCauses
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
Spontaneous AbortionCauses
Genital Tract Infections Bacterial vaginosis Vaginal mycoplasma infection
Medical Disorders Diabetes Thyroid disease Hypertensive disorders Renal disease
Spontaneous AbortionCauses
Endocrine Abnormalities Poor development of the corpus luteum Inadequate secretory endometrium Low serum progesterone levels
Uterine Abnormalities 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
Spontaneous AbortionCauses
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
Cervical Weakness 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
Spontaneous AbortionCauses
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
Spontaneous AbortionCauses
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
Spontaneous AbortionCauses
Despite detailed investigations,no cause can be found for the
majority of cases of spontaneous abortion
Spontaneous AbortionThreatened Miscarriage
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
Spontaneous AbortionThreatened Miscarriage
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
Spontaneous AbortionInevitable Miscarriage
Signs and Symptoms Pain: Severe, rhythmical Bleeding: Heavy, clots Cervical Os: Open with dilation Uterus: If palpable, smaller than
expected
Spontaneous AbortionInevitable Miscarriage
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
Spontaneous AbortionIncomplete Miscarriage
Signs and Symptoms Pain: Severe Bleeding: Heavy, profuse Cervical Os: Open with dilation Uterus: Tender and painful Other: Tissue present in cervix
Shock
Spontaneous AbortionIncomplete Miscarriage
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
Spontaneous AbortionComplete Miscarriage
Signs and Symptoms Pain: Diminishing or absent Bleeding: Minimal or absent Cervical Os: Closed Uterus: If palpable, firm and
contracted
Spontaneous AbortionComplete Miscarriage
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
Spontaneous AbortionMissed Miscarriage
Signs and Symptoms Pain: Absent Bleeding: Some spotting possible,
brown loss Cervical Os: Closed Uterus: If palpable, smaller than
expected
Spontaneous AbortionMissed Miscarriage
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
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease GTD general term that covers
Hydatidiform mole (benign) Choriocarcinoma (malignant)
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease 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
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease 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
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease 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
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease 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
Spontaneous AbortionMissed Miscarriage – Gestational Trophoblastic Disease 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
Spontaneous AbortionSeptic Miscarriage
Signs and Symptoms Pain: Severe or variable Bleeding: Variable, may be offensive Cervical Os: Open Uterus: Bulky, tender and
painful on examination
Spontaneous AbortionSeptic Miscarriage
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
Spontaneous AbortionMidwifery Assessments
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
Spontaneous AbortionMidwifery Responsibilities 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
Implantation Bleeding
EARLY PREGNANCY BLEEDING
Implantation Bleeding
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
Decidual Bleeding
EARLY PREGNANCY BLEEDING
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
Ectopic Pregnancy
EARLY PREGNANCY BLEEDING
Ectopic Pregnancy
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)
Ectopic PregnancyRisk Factors
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)
Ectopic PregnancySigns of Ectopic Pregnancy
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
Ectopic PregnancyClinical Presentation
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
Ectopic PregnancyDiagnosis 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
Ectopic PregnancyDiagnosis
Nowadays occurrence of an extra-uterine pregnancy is diagnosed with a combination of serum hCG levels
and ultrasound scan
Ectopic PregnancyTreatment
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
Ectopic PregnancySurgical Treatment
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
Ectopic PregnancyExpectant Treatment
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
Placental Abruption
Placenta Praevia
ANTEPARTUM HAEMORRHAGE
Antepartum Haemorrhage
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
Antepartum HaemorrhageEffects on the Fetus
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
Antepartum HaemorrhageEffects on the Mother
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
Antepartum HaemorrhageCauses of Bleeding in Late Pregnancy
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
Antepartum HaemorrhageInitial Assessment of Physical Condition
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
Antepartum HaemorrhageInitial Assessment of Physical Condition
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
Antepartum HaemorrhageInitial Assessment of Physical Condition
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
Differential Diagnosis
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?
Differential Diagnosis
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?
Antenatal HaemorrhageSupportive Treatment
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
Section 88 Maternity NoticeReferral Guidelines
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)
Placental Abruption
ANTEPARTUM HAEMORRHAGE
Placental Abruption
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)
Placental Abruption
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
Placental AbruptionMild Separation of the Placenta
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
Placental AbruptionManagement of Mild Separation of the Placenta 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
Placental AbruptionManagement of Mild Separation of the Placenta 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
Placental AbruptionModerate Separation of the Placenta
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
Placental AbruptionManagement of Moderate Separation of the Placenta 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
Placental AbruptionManagement of Moderate Separation of the Placenta 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
Placental AbruptionSevere Separation of the Placenta
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
Placental AbruptionSevere Separation of the Placenta
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
Placental AbruptionManagement of Severe Separation of the Placenta 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!
Placenta Praevia
ANTEPARTUM HAEMORRHAGE
Placenta Praevia
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
Placenta PraeviaDegree of Placenta Praevia
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
Placenta PraeviaDegree of Placenta Praevia
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
Indications of Placenta Praevia
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
Management of Placenta Praevia 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