Late pregnancy (Ante-

partum) bleeding

Presented by
Dr. Eman Mohammed Eraky
Lecturer
Maternal & newborn health nursing
 Late pregnancy (Ante-partum) bleeding

Bleeding from the genital tract after the

28th week of pregnancy OR during the
1st stage of labor.
 Classifications
1- Placental site bleeding (95%)
• Placenta Previa
• Abruption Life-Threatening
• Ruptured vasa previa
• Uterine scar disruption
2- Extra-placental bleeding (5%):
• Cervical polyp
• Cervicitis or cervical ectropion
• Vaginal trauma
• Cervical cancer
• Rupture of varicose veins in the cervix.
 Placenta Previa
Definition:
a placenta implanted in the lower segment of
the uterus.

Bleeding results from small disruptions in

the placental attachment during normal
development and thinning of the lower
uterine segment
 1. Placenta Previa
Types:
1. Placenta Previa
 Prevalence of Placenta Previa
• Occurs in 1/200 pregnancies that reach 3rd
trimester
• Low-lying placenta seen in 50% of ultrasound
scans at 16-20 weeks
– 90% will have normal implantation when scan
repeated at >30 weeks
– No proven benefit to routine screening
ultrasound for this diagnosis
 Types Placenta Previa
1. Total placenta previa:
The internal cervical os is covered completely by placenta,
cesarean delivery is likely.
2. Partial placenta previa:
The internal os is partially covered by placenta, vaginal
delivery might be possible but preferable c.s.
3. Marginal placenta previa:
The edge of the placenta is at the margin of the internal os,
vaginal delivery is likely.
4. Low-lying placenta :
The placenta is implanted in the lower uterine segment such
that the placenta edge actually does not reach the internal os
but is in close proximity to it, Vaginal delivery is likely.
 Incidence
Incidence of placenta previa is approximately 1
in 200 pregnancies, or a 0.5% risk.

Perinatal morbidity and mortality are primarily

related to the complications of prematurity,
because the hemorrhage is maternal.
 Causes
The actual cause is unknown. While it is frequently associated with
several factors as:
1- Maternal age over 35 years:
May be a factor because an older uterus is not as vascular as a
younger uterus. So, the embryo may not implant in the normal
uterine area.
2- Multiparity & Previous births :
Placenta previa can occur in 80% of multiparity of over two
pregnancies.
Previous gestations may have caused permanent damage to the
endometrium where the placenta was located causing the new
placenta to find a new area with each pregnancy.
 Causes cont.
4- Uterine scarring: e.g. C.S
May cause faulty implantation of the placenta.
5- Endometrities:
May damage the vascular network leading to a defect in
the lining of the uterus or causing areas of the uterus to
be unfit for implantation.
6- A large placenta:
May cause the placenta to migrate closer to the internal
cervical os.
 Causes cont.
7- A short cord:
Will sometimes slide the placenta to the lower segment
due to the weight of the fetus.
8- Multiple fetuses:
Can cause a migration of the placenta due to the lack of
space.
9- Impeded endometrial vascularization:
factors that interfere with the adequate blood supply to
the endometrium such as : smoking, pregnancy induced
hypertension, drug addiction &diabetes.
10. Prior placenta previa.
 Clinical manifestations

The most characteristic event in placenta previa is

painless hemorrhage.
Time: near the end of or after the second trimester.
Placenta previa may be associated with placenta
accreta, placenta increta or percreta.
 Diagnosis of Placenta Previa
1.Transabdominal sonography to detect .
▪ placental location
▪ Rule out other causes of bleeding
▪ Determine gestational age
2. MRI : Early diagnosis of placenta previa

N.B. Placenta previa or abruption should always be

suspected in women with uterine bleeding during the
latter half of pregnancy
 Maternal, Fetal and Neonatal Effects
Maternal Effects:
Hemorrhage.
Hypovolemic shock.
Preterm labour.
Premature rupture of membranes.
Puerperal hemorrhage.
Puerperal anemia.
Puerperal infection.
Disseminated Intravascular Coagulation (DIC).
Placenta accreta, increta, or percreta in the next
pregnancies
 Fetal and Neonatal Effects cont.
Prematurity.
Mal presentation.
Small for gestational age.
Congenital abnormalities.
Neonatal anemia.
Fetal mortality rates ranges from 12% to 29% mostly due to
maternal hemorrhage while the fetus will undergoes
intrauterine hypoxia or asphyxia related to diminished and
inadequate oxygenation of the placenta.
 Management of Placenta Previa
1- Taking a History:
When a patient is admitted with vaginal bleeding, the history should
include:
When did the bleeding start, how much bleeding and did the
bleeding stop?
Was this the first episode of bleeding?
What was the color of the blood, (dark or bright red) and were
there any clots present and what was the size?
What was she doing at the time of the bleed?
 Management of Placenta Previa cont.

Did she bleed with any of her other pregnancies?

Does she feel the baby move?
When did she last have sexual intercourse?
Does she feel any contractions?
How is her general health?
Does she have any abdominal pain?
 2- Guidelines for Management of
Placenta Previa
A- Expectant Management: is the treatment of choice if:
The gestational age is less than 36 weeks.
The bleeding is mild (less than 250ml).
The patient is not in labor.

The goal is to obtain the maximum fetal maturity without

risk to the mother or fetus.
 2- Guidelines for Management of
Placenta Previa cont.
Expectant management includes the following:
1- Hospitalization with complete bed rest for 72 hours.

2- Close observation for bleeding.

3- Continuous fetal monitoring to facilitate early detection of fetal distress during

bleeding.
Otherwise, assess every 4 hours with Doppler FHR device or fetoscope.

4- I.V. infusion unless bleeding is minimal.

5- Have a maternal blood sample available at all times in the blood bank for
immediate type and cross match for blood transfusion.
 2- Guidelines for Management of Placenta
Previa cont.
6-Betamethason to enhance fetal pulmonary maturity may be
ordered.
7- Amniocentesis is usually performed between 34 and 36 weeks
of gestation to determine fetal lung maturity.

8- Monitor for signs of preterm uterine contractions stimulated by

prostaglandin release from placental separation
9- Tocolytic therapy, preferably magnesium sulfate.

10- If the patient allowed to return home after stabilization, she

should be instructed to:
▪ Limit her activity . Avoid enemas.
▪ Avoid coitus . Avoid douching.
 2- Guidelines for Management of Placenta
Previa cont.
B- Delivery:
Immediate delivery should be implemented in the following
conditions, regardless of gestational age (is 36 or more weeks):
▪ The fetus is mature.
▪ Excessive bleeding occurs.
▪ Active labor begins unresponsive to Tocolysis.
▪ Intra-amniotic infection.
▪ A coagulation defect ( DIC)
▪ Fetal distress with a viable fetus
▪ Fetal demise or has anomalies that are incompatible with life
 2- Guidelines for Management of Placenta
Previa cont.
a cesarean birth: is indicated if the patient has a
partial or complete placenta previa to prevent the
following:
▪ Profuse bleeding.
▪ Cervical laceration.
▪ Fetal hypoxia.
 3- Nursing Interventions
The patient should be placed on complete bed rest with no
bathroom privileges.
A quite environment: will improve the outcome by
decreasing sensory stimulation.

N.B. Activity and sensory stimulation can increase bleeding

and elevate the basal metabolic rate, which increases
oxygen consumption.

NO VAGINAL EXAMINATION
IV access
 3- Nursing Interventions
Examinations and Monitoring:
▪ Assess Bleeding, Hypovolemic Shock
▪ Lab Tests
▪ Vital Signs
▪ Intake and Output
▪ Emotional Interventions:
Post Partum Nursing Assessment.
 II. Abruptio Placenta
Definition:
Is the premature separation either partial or total of a normally
implanted placenta from the decidual lining of the uterus after 20
weeks of gestation, which causes painful bleeding.

Incidence:
The incidence of abruptio placenta is 1 in 90 to 200 pregnancies.
 Etiology
The primary cause of placental abruption is unknown, but there
are several associated conditions.

Increased age and parity

Preeclampsia
Chronic hypertension
Preterm ruptured membranes
Multifetal gestation
Uterine leiomyoma
 Placental Abruption pathology
deterioration of the spiral arterioles that nourish the deciduas and
supply blood to the placenta, causing deciduas basalis necrosis.

When this process takes place, rupture of those blood vessels

occurs and bleeding quickly results because the uterus is still
distended and cannot contract sufficiently to close off the opened
blood vessels.
Separation of the placenta takes place in the area of the
hemorrhage.
 Placental Abruption pathology cont.
The decidua then splits, leaving a thin layer adherent to the myometrium.
development of a decidual hematoma that leads to separation, compression,
and the ultimate destruction of the placenta adjacent to it.
If the tear is at the margin of the placenta or if it separates the membranes
from the deciduas, vaginal bleeding is evident.

Otherwise, the blood concealed between the placenta and the deciduas.
 Placental Abruption pathology cont.
If it is concealed, pressure can build up enough for blood to be
forced through the fetal membranes into the amniotic sac or into
the myometrial muscle fibers, which is called Couvelaire uterus.
This increase uterine tone and irritability. Clotting occurs with
hemorrhage because the decidual tissue is rich in thromboplastin.
This leads to the formation of retro-placental or a subchorionic
hematoma, causing the release of large quantities of
thromboplastin into the maternal circulation. This can lead to DIC.
 Types
• Revealed:
– Marginal (peripheral) detachment of placenta.
– External hemorrhage.
• Concealed
– Central separation with adherence of edge.
– Retroplacental hematoma provoke more
separation.
– Blood may dissect through the myometrium
between muscle fibers to reach peritoneal cavity
(couvelaire’s uterus)
• Mixed.
Concealed Mixed Revealed
 Sher’s Classification - Abruption

• Grade I mild, often

retroplacental clot
• Grade II identified at delivery
tense, tender abdomen
and live fetus
• Grade III with fetal demise
– III A - without coagulopathy (2/3)
– III B - with coagulopathy (1/3)
 Signs and Symptoms
The classic symptoms of Abruptio placenta are:
Acute, "knife like" abdominal pain, with or without vaginal
bleeding.
Dark vaginal bleeding.
Uterine contractions or uterine rigidity.
A firm, tender uterus and a possible sudden increase in fundal
height on exam.
The amount of external bleeding may not accurately reflect the
amount of blood loss.
 Signs and Symptoms cont.
Abdominal or low back pain.
Fetal distress signs.
Signs of hypovolemia.
Importantly, negative findings with ultrasound
examination do not exclude placental abruption.
Ultrasound only shows 25% of abruptions.
 Complications
A. Maternal complications:
1. Hemorrhagic shock.
2. Coagulopathy/DIC
3. Uterine rupture
4. Renal failure.
5. Ischemic necrosis of distal organs (e.g., hepatic,
adrenal, Pituitary).
6. couvelaire’s uterus
couvelaire’s uterus
 Complications
B. Fetal complications
1. Hypoxia.
2. Anemia.
3. Growth retardation.
4. CNS anomalies.
5. Fetal death.
 Management of the Abruptio Placenta
depending on gestational age and the status of the mother and fetus.
A- Expectant Management: in case of
▪ If the Abruptio placenta is mild.
▪ Gestational age less than 36 weeks
▪ without signs of fetal distress
Expectant mangment as the following:
1- Closely observe for signs of concealed or external bleeding.
2- Monitor fetal wellbeing (FHR monitoring, non stress test and biophysical profiles).
 Management of the Abruptio Placenta cont.

3. Monitor for uterine contractions (stimulated by prostaglandin

release from placental separation). If occur, administer a
tocolytic (magnesium sulfate).

4- Hospitalize, preferably in a facility that can immediately

intervene by cesarean delivery, since the placenta may further
separate at any time and, very quickly, seriously compromise
the fetus unless delivery can be performed immediately.
 Management of the Abruptio Placenta

B. Emergency management:
If the Abruptio placenta is moderate to severe, the
following are the objectives of treatment:
Restore blood loss quickly.
Continuously monitor the fetus.
Correct coagulation defect if present.
Facilitate delivery.
 Management of the Abruptio Placenta

Emergency management depends on the stage of gestation

and the severity of the symptoms.
1. Closely observe the patient.
2. Administer supplemental oxygen.
3. Perform fetal monitoring.
4. Administer IV fluids.
5. Perform aggressive fluid resuscitation to maintain adequate
perfusion, if needed.
 Management of the Abruptio Placenta

6- Monitor vital signs and urine output.

7- Cross match 4 units of packed red blood cells. Transfuse, if
necessary.
8- Perform amniotomy to decrease intrauterine pressure.
9- Immediately deliver the fetus by cesarean delivery if the mother
or fetus becomes unstable or disseminated intravascular
coagulation (DIC) developed.
 Management of the Abruptio Placenta

3- Delivery:
Vaginal delivery attempts if:
The fetus is mature.
The fetus is in a cephalic presentation.
The abruption is moderate.
If the woman is not in labor, it can be initiated by an
amniotomy or oxytocin.
 Management of the Abruptio Placenta

Cesarean delivery should be performed if:

The abruption is moderate to severe.
The fetus is alive and older than 36 weeks.
Fetal distress developed.
The fetus is not in a cephalic presentation.
Bleeding increases during induction of labor.
The uterus fails to relax between contractions.
Labor fails to progress actively.
If the fetus is dead, a vaginal delivery is performed unless
bleeding cannot be controlled.
 4- Nursing Intervention
1- Nursing Assessment:
Rule out placenta previa
no rectal or vaginal exams are done until placenta previa is ruled
out.
vital signs should be taken every 30 minutes until the condition
of the patient is stable.

N.B. Vital signs can be within normal range, even with significant
blood loss because a pregnant woman can loose up to 40% of her
blood volume without showing signs of shock.
 4- Nursing Intervention
urinary output monitoring :good indicator for shock than vital
signs in this case
Monitor :-
▪ Vaginal bleeding (time and amount). It may be necessary to
weigh the pads in order to record the correct blood loss.
▪ Abdominal pain (time and severity).
▪ Toco cardiograph monitoring
 4- Nursing Intervention
▪ assess the abdomen for concealed bleeding (fundal height, uterine
rigidity and tenderness).
▪ If the patient had severe hemorrhaging, asses (state of
consciousness, signs of shock and unstable vital signs).
2- Nursing Intervention for Stabilization
3-Nursing Interventions during Intrapartum
4- Nursing Interventions during Post Partum (The patient is at risk for
hemorrhage).
 III. Uterine rupture
Occurs during labour
Risk factors: - multiple children
uterine scarring e.g. previous caesarean section
S&S
Active labour
Contractions may have decelerate after very strong and painful
contractions
Weak, dizzy, signs of shock- tachycardia, sweating, hypotension
May or may not have significant vaginal bleeding
 Assessment
When did it start?
Onset whilst active or at rest?
Amount of blood loss? Number of sanitary towels? Clots?
Pain- yes/no
Vital signs- changes may indicate significant bleeding.
Gravidity/ Parity
Gestational length/ due date
Obstetric & gynae history/ complications
Previous deliveries- normal, complicated, caesarean
Concerns found in this pregnancy
Number of foetuses
Known orientation of baby
 Management:
Correct ABC’s & rapid transport
100% oxygen target saturation >94%
Left lateral position (15-30 degree tilt) if supine
IV access
Baseline vitals and reassess
Maternity/ sanitary pads
Fetus may be in shock before mother
 IV- Vasa Previa

• Rarest cause of hemorrhage

• Onset with membrane rupture
• Blood loss is fetal, with 50% mortality
• Seen with low-lying placenta, velamentous
insertion of the cord or succenturiate lobe
• Antepartum diagnosis
– Amnioscopy
– Color doppler ultrasound
– Palpate vessels during vaginal examination
 Management – Vasa Previa
• Immediate cesarean delivery if fetal heart
rate is non-reassuring
• Administer normal saline 10 – 20 cc/kg bolus
to newborn, if found to be in shock after
delivery
 Summary
• Late pregnancy bleeding may herald
diagnoses with significant morbidity/mortality
• Determining diagnosis important, as
treatment dependent on cause
• Avoid vaginal exam when placental location
not known
Thank You