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


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


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


Genital Tract Infections Bacterial vaginosis Vaginal mycoplasma infection

Medical Disorders Diabetes Thyroid disease Hypertensive disorders Renal disease


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


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


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


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


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


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


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


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


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


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


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


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

bleeding in pregnancy

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