Week Nine - Bleeding in Pregnancy

Four Main Causes of Bleeding in EARLY Pregnancy

• implantation

• miscarriage

• ectopic

• non pregnancy related causes

Implantation

• occurs when the pregnancy implants itself into the lining of the uterus usually resolves in a few days

Miscarriage

• expulsion of the products of conception from the uterus via the birth canal before the 20th week

• can be spontaneous or induced

Fetal Causes of Miscarriage

• abnormalites

• poor implantation

• abruption of the ovum

Genital Tract Causes of Miscarriage

• retroverted uterus

• myomas

• cervical incompetance

• bicornuate uterus

Materal Causes of Miscarriage

• disease such as rubella, flu, hypertension

• age

• incompatability

• drugs

Trauma Causes of Miscarriage

• MCA

• direct blow

• criminal interference

• abdo surgery

Threatened Miscarriage

• cervix closed, membranes intact

• presents as slight pain and cramps, varying bleeding

• pregnancy can continue

Inevitable Miscarriage

• cervix is open

• presents as vaginal bleeding

• ROM

• pregnancy will not continue

Missed Miscarriage

• products of conception not viable, retained in the uterus and no signs of abortion

• pregnancy symptoms may continue

• pregnancy not viable, medical intervention

Complete Miscarriage

• expulsion of all products of conception

• usually occurs before 8wks

• no pain, brown bleeding

• no pregnancy remaining

Incomplete Miscarriage

• not all products of conception are expelled

• presents as moderate to profuse bleeding

• abdominal pain/backache

• risk of cervical shock

Ectopic Pregnancy

• fertilised ovum embeds themself outside the uterine cavity, usually in the fallopian tubes

Risk Factors for Ectopic Pregnancy

• narrowing of the fallopian tube (inflammation, infection)

• kinking of the tube (adhesions, scarring)

• damage to the lining of the tube (endo)

Ectopic Pregnancy Presentation

• lower abdo pain localised to affected side

• sharp, stabbing pain.. CONSTANT

• dizziness, nausea etc..

• tachycardia

• postural hypotension

RUPTURED Ectopic Pregnancy Presentation

• sudden severe abdominal pain

• profound shock

• vaginal bleeding

• reffered shoulder tip pain

• LIGHTS & SIRENS!

Sepsis in Pregnancy

• common in incomplete miscarriadge

• will show signs of sepsis + tender uterus, offensive vaginal discharge

• LIGHTS & SIRENS!

5 Checks for Bleeding in Pregnancy

• Check the vagina for bleeding at the introitus (opening)

• Check the thoracic area (any signs of internal bleeding?)

• Check abdominal area (internal bleeding – firm or woody uterus)

• Check pelvis – trauma specific

• Check femurs – trauma specific

Antenatal Bleeding Definition

Bleeding from the birth canal in excess of 15mls from the 20th (approx) week of gestation to the birth of the neonate.

Types of Antenatal bleed

• placenta previa

• vasa previa

• placenta abruption

• uterine rupture

Antenatal Bleed Risk Factors

• maternal age >40

• complex medical history prior to pregnancy

• multigravida

• known abnormalieis

• history of abruption

• coagulopathies

• drug use

• hypertension

• trauma

Placenta Praevia

a placeta that extends near, partially over or beyond the cervical oss.

4 Types of Placenta Praevia

• Grade I: placenta lies in lower segment but does not reach internal os

• Grade II: edge of placenta is attached to lower segment of uterus and reaches internal os

• Grade III: edge just covers internal os, will bleed once cervix dialates past 3-4cm

• Grade IV: placenta centrally covers the internal os - torrential haemorrhage is likely

Causes of Placenta Praevia

• delay in implantation

• multiparity

• multiple pregnancy

• uterine scarring

• large placenta

Presentation of Placenta Praevia

• painless recurrent frank blood bleeding

• premature labor

• asymptomatic or shock

• fetal malpresentation

Vasa Praevia Definition

• fetal vessels crossing or running in close proximity to the inner cervical os

• vessels course within the membranes

Vasa Praevia Presentation

• can be detected during transvaginal ultrasound

• painless vaginal bleeding frank blood

• lack of fetal movements

• usually late 3rd trimester pregnancy

• if rupture occurs high chance of fetal demise

Placental Abruption Definition

• premature seperation of the placenta from the uterine lining after 20 weeks

• bleeding from maternal venous sinuses

• can be concealed or visible

Placental Abruption Process

Bleeding from maternal venous sinuses into placental bed -> further separates placenta -> blood retained behind placenta -> infiltrates myometrium -> extravasation causing marked damage such as bruising & oedema

Placental Abruption Presentation

• vaginal bleeding may or may not occur

• hypovolaemic shock

• abdo pain ++

• tender uterus

• anxious/impending doom

• concealed bleeding into uterine muscle

Placental Abruption Complications

• disseminated intravascular coagulation

• post partum haemorrhage

• renal failure

• pituitary necrosis

• distressed baby

• foetal death in utero

Uterine Rupture

• tear in the uterus during labor

Uterine Rupture Presentation

• sudden cessation of contractions

• severe constant pain

• fetal death

• maternal shock disprotional with clinical signs

• concealed haemorrhage

Uterine Rupture Risk Factors

• previous csection

• other uterine surgery

• grand multiparity

• undiagnosed cephalopelvic disproprtion

• macrosomic baby

• placenta praevia

• external cephalic version

• uterine abnormalities

How much blood volume can a pregnant patient lose before vital signs change?

50%

Antepartum Haemorrhage Management AV

• no altered perfusion?

• = left lateral tilt & transport to obstetric hospital

• altered perfusion?

• = left lat tilt, transport to obstretric hospital, saline 40ml/kg as required

• pain relief