BLEEDING IN PREGNANCY
A
woman presents at 20 weeks’
gestation reporting vaginal
bleeding. The bleeding
occur- red 2 h ago and was bright
red. She reported
no abdominal pain with the bleeding and she
had not had any previous episodes. She had
had intercourse the
previous evening.
Her last cervical smear was normal 2
years ago.
This is her first
pregnancy and her current obstetric history is unremarkable with normal
first-trimester scan and Down’s syndrome
screening. She reports
that her booking
blood tests had been normal.
She
is extremely anxious
when seen, concerned that she is going to have a miscarriage.
The blood pressure is 105/65 mmHg
and pulse 86/min. Abdominal examination confirms
that the uterus reaches to 1 cm below the
umbilicus. The uterus
is soft and
non-tender. The fetal heart
is heard with the hand-held fetal Doppler ultrasound probe. Speculum examin- ation reveals a reddened
area around the external cervical
os, with an inflammatory
appearance and a small amount
of contact bleeding. The os itself
is closed.
·
What is the most likely cause of the bleeding?
·
How would you manage this woman?
One
of the commonest causes of bleeding in pregnancy is a cervical
ectropion, and this is
suggested in this case by the examination findings. An ectropion can often look florid and inflamed even in the absence of infection.
An
ectropion may occur
at any time in a woman’s reproductive life but tends
to be prevalent:
·
in
pregnancy
·
after puberty
·
with the combined oral contraceptive pill.
Postcoital bleeding often suggests
an ectropion or other cervicitis. However, caution should be exerted as an ectropion is very common
in pregnancy and
could be an inciden-
tal finding when there is in fact a uterine
source of bleeding. Thus the findings
in this case are
very suggestive of bleeding secondary to an ectropion but do not
fully rule out
a uter- ine source of the
blood loss.
The
woman should generally be reassured about
the likely cause
of the loss.
She should be given anti-D if Rhesus
negative, as a fetomaternal haemorrhage could potentially have occurred if this was uterine bleeding.
Swabs should be taken
during the speculum
examination to rule out chlamydia, as well as microscopy, culture and sensitivity for organisms including group B streptococcus and candida.
Above the gestational age
of fetal viability (23–24 weeks), a woman would
normally be admitted for observation
for possible further bleeding and risk of premature delivery. However at 20 weeks
with no possibility of fetal viability, there is no advantage to admis-
sion to hospital with light bleeding.
Bedrest has not been shown to be of benefit in cases of vaginal bleeding
in pregnancy.
She
should be advised
that the ectropion is not harmful
to the pregnancy but may result in further bleeding episodes, in which case
she should be seen again
in the obstetric department.
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