Bleeding In Late Pregnancy:
This is
bleeding from the genital tract after 24 week of gestation and before the birth
of the baby. It may place the life of the mother and unborn child at risk.
Any
bleeding of this type is said to have been caused by placental separation. It
may endanger the life of the mother and baby. The origin of this bleeding has
two main sources.
1.
Placental causes
2.
Non-Placental causes
1.
Placental Praevia: Unavoidable haemorrhage
2.
Abruptio Placenta – Accidental haemorrhage
Incidental
causes – Bleeding from other lesion of t he genital tract e.g. Cervical causes
– cervical erosion, cervical l aceration, Polyps, cervical carcinoma.
Vaginal
causes – laceration, vaginitis, ruptured va ricose veins of the vulva.
Any
bleeding from the genital tract during late pregnancy is dealt with as been due
to placental separation until the actual diagnosis is made. Either in the
District or Hospital the first Aid management is the same. Hospitalization in
imperative either the bleeding is slight or severe because she stands the
chance of further bleeding. In all cases:
1.
No vaginal examination is made
2.
Save all soiled linens & pads for Dr’s
inspection.
3.
Enquire the cause of bleeding: Fall, coitus,
continuous or intermittent.
4.
Abdominal examination is done gently – noting pain,
tenderness, uterine contraction and consistency, mal-presentation, high head
and fetal heart rate or movement.
5.
Record is made of the name, age, parity, week of
gestation, blood loss, BIP, Pulse, urine passed, FH and drugs administered.
6.
Ultrasound scanning to locate the placental site.
7.
No enema is given.
Put the
woman to bed, on her side, reassure the woman, monitor vital signs, send for
medical aid immediately, make arrangement to transfer to hospital, give
pethidine 100mg or morphine 15mg or omnopon 20gm i.m., transfer in a
comfortable transport and a midwife and relations must accompany the woman, to
give detail of management.
In addition
to the First Aid treatment
1.
Blood is taken for – Group and cross matching, Hb
estimation, Rhesus factor, clotting time, plasma fibrinogen level and
serological test for syphilis (if not already done).
2.
Intravenous administration of blood, glucose,
Ringers lactate solution, Oxytocin and fibrinogen
3.
Analgesics or sedation e.g. Pethidine 100mg i.m.
4.
Urinalysis Administer oxygen, to increase oxygen
concentration to the fetus.
5.
Vital signs, fetal condition using soniaid, Pulse
5-15mins, FH 10-20min or continuous monitoring B/P 15mins.
6.
Fluid chart record.
7.
Consent for operation.
8.
Reassure the woman and her spouse.
Aim is to
prolong pregnancy
1.
Give the first Aid Treatment
2.
Shave the vulva.
3.
No enema on admission
4.
Speculum examination after 48hrs bleeding has
stopped to rule out cervical causes and confirm diagnosis.
5.
A papanicolaou smear may be taken
6.
She is allowed out of bed after five days of no
bleeding.
7.
Discharge after a week of no other obstetrical
complications to report if bleeding occurs or in labour.
8.
Monitor fetal wellbeing
9.
Give high protein diet
10. Maintain
hygiene.
Aim is to
resuscitate and deliver the baby as soon as possible.
1.
Immediate resuscitation is imperative.
2.
No time must be wasted on obtaining blood.
3.
Admit in the special care unit, procedure for
slight bleeding is carried out.
4.
Check vital signs, fibrinogen and clotting time.
5.
Sedation for apprehension. Analgics for pain
6.
I.V. Infusion of Dextrose 5%, Ringers lactate while
blood is being cross matched.
7.
Transfuse with fresh blood O-ve.
8.
Monitor Fetal Heart rate 10-15mins on cardiograph
9.
Measure abdominal girth for concealed bleeding.
10. Further
management depends on patient’s condition.
When
placenta is partially or wholly implanted in the lower uterine segment; either
anterior or posterior wall. The anterior location is less serious than the
posterior. Bleeding from placenta praevia is unavoidable and inevitable due to
the stretching of the lower uterine segment in later weeks of pregnancy which
tears the anchoring chorionic villi. Bleeding may be slight or severe depending
on how much encroachment in the lower segment. When placenta lies on the
internal Os bleeding is severe during
effacement
and dilatation of the cervix. Bleeding may also be precipitated by coitus.
Hemorrhage of this type places mother and baby at high risk and constituted
obstetric emergency.
Incidence:
About 0.5% of all pregnancies more common in multigravidae.
1.
Painless vaginal bleeding which may be continuous
or intermittent during rest or sleep.
2.
Occasionally is accompanied with uterine
contractions.
3.
Increased bleeding
4.
Mal presentations may be associated – Breech Transv
erse or oblique lie.
5.
High presentation – Non engagement of the presentin
g part.
6.
Unstable lie
7.
Laterally – It pushes the head to one side. Posteri
orlly – Overlapses the head, pushes the head anteriority giving the impression
of cephalo pelvic disproportion.
Placenta
Praevia is classified into degree according to placental location known as
types.
The
majority of the placenta is in the upper uterine segment. Only a tip of the
placenta tissue touches the lower segment. Bleeding is usually mild. Vaginal
delivery is possible, mother and fetus are in good condition.
The
Placenta is partially located in the lower uterine segment near the internal OS
– (Marginal Placenta Praevia). A bit of the placenta touches the internal OS,
vaginal delivery is possible if it anteriorly, bleeding is moderate. The fetus
is usually more affected than the mother, that means fetal hypoxia is common.
The
placenta covers the internal OS but not centrally but does not when the lower
segment starts to stretch and cervix begins to efface and dilates up to 6cm.
Vaginal delivery is not appropriate because the placenta precedes the fetus.
The
placenta lies over the internal OS centrally. The OS is covered completely even
at full dilalation of the cervix and torrential hemorrhage is very likely.
Vaginal delivery should not be considered. Caesarean Section is essential to
save the life of the mother and fetus.
1.
Grande multiparity; Previous C/S,
2.
Multiple Pregnancy, Previous Placenta Praevia
3.
Certain fetal abnormalities.
4.
Age – older mother are more at risk than younger on
es.
5.
Abnormal Placenta – Bipartita and succenturiate pla
centae
·
Commonly it manifest 34-38wk though sometimes
earlier.
·
On general examination the woman may be clinically
normal.
·
On Abdominal Examination: Difficulty in identifying
the fetal part on palpation.
1.
Fundal height may be normal
2.
Uterus is normal in consistency, no tenderness or
tension
3.
Fetal Heart rate may also be normal – depending on
severity of bleeding.
4.
Presentation may be abnormal e.g. Breech.
5.
High head, oblique or Transverse lie or unstable
·
On vulva Inspection Slight or severe bleeding
·
Fetal movement – Excessive or slow or normal.
·
Rapid respiration, Pulse – Signs of shock in the mo
ther
Objectives
of Management;
·
To control hemorrhage
·
Save mother and infant’s life
Management
depends on the amount of blood loss; may be active or conservative, condition
of the mother or fetus, the location of the placenta, the stage of the
pregnancy. In all cases Hospitalization is necessary.
Mild
bleeding, mother and fetus are well.
The woman
will be on admission
·
Bed rest until bleeding stops.
·
Speculum examination to rule out incidental causes,
after 24hrs of no bleeding.
·
Monitor placental function by using fetal kick
chart.
·
Ultrasound scanning at intervals to locate placenta
·
Monitor fetal growth.
·
Vaginal delivery may be possible – 1 & 2
Anterior
·
Remain on admission till term.
·
Examination under anesthesia (EUA) – from 37weeks
followed by Caesarean Section if a bulge is felt. If not the patient is
induced.
Caesarean
section is necessary in cases of Severe bleeding, Types 3, 4 and 2 posterior
even if fetus is dead, Bad obstetric history, elderly primip, Malpresentation –
Breech. Active bleeding with induction.
Give
emergency treatment
·
Resuscitate
·
Prepare for EUA and C/S
·
C/S if fetal heart is present in respective of
gestational age. In a hospital with facilities for special care of preterm.
i.
I.V. infusion of 5% Dextrose saline
ii.
Blood transfusion – O- negative blood.
Hysterectomy
if bleeding becomes uncontrollable to save the woman’s life.
1.
Post partum hemorrhage due to atony of the uterus
2.
Maternal shock from blood loss (hypovolaemia)
3.
Maternal death maternal mortality
4.
Fetal hypoxia due to placenta separation
5.
Fetal death 5-15% - usually fresh still birth
6.
Placenta acreta, (in up to 15% cases)
7.
Anesthetic & surgical complications.
Bleeding
is due to premature separation of a normally situated placenta occurring after
22wks of pregnancy. (Sometime refered as Abruption – tear asunder) Accidental
ble eding, it is about 2% of all pregnancies. It may occur at any stage of
pregnancy or during labour.
The
aetiology of haemorrhage is not always clear (40%) but it is often associated
with hypertensive disease in pregnancy, sudden reduction in uterine size
polyhydramnious, preterm labour, rupture of membrane, acute emotional state
previous history of placenta abruption. Strenuous physical exercises over
distension of the uterus, road traffic accident, direct trauma to abdomen or
version.
Multiparty,
cigarette smoking, Poor nutritional status, Infection, after the delivery of 1st
twin – Recurs in 10-25% of cases.
In this
case blood escapes from the vagina it is the commonest type. Bleeding may
become severe from slight. It may be accompanied by abdominal pain and
tenderness, delivery of the baby should be accomplished within a few hours (6
hrs) to avoid coagulation failure developing. Bleeding is proportional to the
amount of visible vaginal blood loss.
This
hemorrhage is primarily concealed then later becomes revealed with little
vaginal bleeding. A degree of shock is exhibited which is usually severe
compared with the vaginal bleeding. It is usually associated with blood
coagulation disorders.
This is a
serious condition with high maternal and fetal mortality. It account for 55% of
maternal death. It is associated with severe bleeding but no vaginal bleeding
occurs but large retro-placental clot forms behind the placenta – maternal
surface.
Mother
shows signs and symptoms of hypovolaemic shock, uterine enlargement and severe
pain.
History
of pregnancy induced hypertension, headache, nausea and vomiting, epigastric
pain, following road traffic accident or trauma.
Mild -
general condition is fair, pain on one side of the uterus, there may or may be
no vaginal bleeding, vital signs may be normal and B/P may be raised.
Shock –
B/P may be below 90/60 or more, Severe abdo minal pain, anxiety, Uterus is
tender to touch, No fetal heart beat is heard or not heard, Pulse is rapid and
thready, signs of pre-eclampsia pitied oedema, Urine is scanty – protein is
positive or ne gative, Fetal lie is normal. Amount of visible bleeding is not a
guide to severity of the hemorrhage.
Mild
Admit,
treat as undiagnosed APH, Set up I.V. infusion Destrose 5%, Set up sintocynon
to induce labour, ARM is done if she is over 37 weeks, Observations of vital
signs, blood loss, pallor oedema and record, Vaginal delivery is contemplated.
Severe
1.
Routine blood investigation; Plasma fibrinogen and
clotting time test. The Fi-test Baxter hyland for hypofinogenaemia when
facilities for laboratory test are not available.
2.
Pethidine 100mg, morphine 15mg to relief pain
3.
Blood transfusion of at least 2 litres of fresh
blood within 1hr
rapidly .Fibrinogen 4-6g intravenously followed b y 1gm at ½ hourly
until clotting mechanism is normal – fresh blood is the best source.
4.
Monitor Renal secretion – at least 30mls per hour.
Record fluid intake – urinalysis for protein.
5.
When Clotting defect is controlled Caesarean
Section is done.
6.
Record weight of retro placental clot.
7.
EUA is done in the theatre. Rupture the membranes
to reduce intra uterine pressure and induce labour. Oxytocin is set up to start
uterine contraction.
8.
Vigilant observation of the vital signs,
contractions and Fetal heart beats.
9.
Usually labour is rapid.
10. To
prevent PPH deliver the placenta by controlled cord traction.
11. Examine
the placenta for retro placental clots .
12. Prepare
for resuscitation of an asphyxiated baby – pediatrician should be around.
1.
Observe carefully for renal function – Acute
renal failure.
2.
Restrict fluid intake to 1000mls daily.
3.
Low Protein diet, low sodium and potassium,
Estimate blood area, Potassium for 3 days.
4.
Accurate fluid balanced chart.
5.
Report signs of Oliguria (less than 500mls daily.
6.
Treat anaemia – Transfusion or give haematinics.
1.
Disseminated intravascular coagulation (DIC) – mode
rate & severe
2.
PPH. Due to convelaire uterus or DIC.
3.
Renal failure – hypovolaemia, poor kidney perfusion
.
4.
Pituitary necrosis resulting from prolonged and
severe hypotension – shock.
5.
Increased mortality for the infants – 50-80%
This is a
situation of appropriate of blood within the vessels. Consumption of clothing
factors, fibrin and platelets occurs, resulting in failure of the blood to clot
at bleeding site. DIC is secondary to some other disease process e.g. placenta
abruption, intra uterine death amniotic fluid embolism, pre-clampsia and
eclampsia management.
Midwife
should watch out for this complication in conditions that predispose to it. She
should be alert for signs of clotting abnormality.
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