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Bleeding in Pregnancy

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frank hemorrhage or passage of blood clots). chap. 11 (55%) were judged to be spontaneous and nine (45%) were judged to be induced. foreign body or cancer of the cervix Diagnosis History Taking Personal history Obstetric history Record the first day of the last menstrual period. Record any vaginal bleeding that has occurred during pregnancy and note whether it has been mild (spotting or less than an average blood loss during menstruation or a brown vaginal discharge) or severe (more than a menstrual period. Arab Republic of Egypt. Possible Causes All types of abortions Ectopic pregnancy Trauma Molar pregnancy Local causes e. According to the Egypt National Maternal Mortality Study (ENMMS) 2000.g. 2000. of the 20 cases involving abortion in the survey. 2002 Standards of Practice for Integrated MCH/RH Services: First Edition. 7 3 Egypt NMMS. Definition Escape of blood from the genital tract before 20 weeks of gestation. However. cervicitis. Basic Essential Obstetric Care: Protocols for Physicians (Cairo.. June 2005 201 . Identifying deaths due to abortion and correctly classifying them as spontaneous or induced is notoriously difficult.Chapter 7 Bleeding in Pregnancy2 This chapter deals with bleeding in early pregnancy (before twenty weeks gestation). 2004). Healthy Mother/Healthy Child Project. Bleeding Before 20 Weeks Gestation Problem in Egypt Abortion is the major cause of bleeding in the first twenty weeks of pregnancy. polyps. Ministry of Health and Population. 4% of all maternal deaths and 4% of all direct obstetric deaths were caused by abortion. The maternal mortality ratio was٢ /١٠٠،٠٠٠ for spontaneous abortion and 2/100. 2 This chapter is taken from Ministry of Health and Population.000 for induced abortion3. bleeding after twenty weeks gestation. antepartum hemorrhage and procedures for first aid management and referral of the patient to the hospital. Cairo.

June 2005 . oliguria and fainting. blood pressure and temperature Signs of shock including sweating. colic or menstrual-like cramps.Standards of Practice for Integrated MCH/RH Services Record any lower abdominal pain. signs of trauma or infection. the size of the uterus if palpable. any palpable masses or rebound tenderness Local examination Meticulous examination of the external genitalia and vagina for lesions. cold clammy skin. Hb) 202 Standards of Practice for Integrated MCH/RH Services: First Edition. Record any fainting episodes or dizziness. First aid management If the patient is hemodynamically unstable or there is severe vaginal bleeding begin first aid management Insert two wide bore IV cannulae (size 16 or 18) Obtain a blood sample to type and cross match blood (ABO. Speculum examination to document suspected local causes such as: The presence of blood or products of conception in the vagina cervix The condition of the cervix: Cervicitis Polyp or tumor Gentle birnanual examination documenting: Open or closed cervix Size and consistency of the uterus Pain and/or adnexal masses Laboratory Examinations Blood group and Rh factor Urine analysis Complete blood count or at least hemoglobin to check for anemia Pelvic ultrasound if available Management Management will depend on the amount of bleeding and the general condition of the patient. RH. Abdominal examination Note tenderness or rigidity. Physical Examination General examination Pulse.

Consider an ectopic or molar pregnancy when a patient presents with bleeding prior to twenty weeks gestation. Timely referral of a patient with bleeding in early pregnancy to a higher health care facility level can save lives. there is mild vaginal bleeding. The key to early diagnosis is high clinical suspicion. ultrasound is available. If the patient is hemodynamically stable. If not. Treat the woman with respect. Show concern for her feelings and her experience. If she does not feel well. making sure that counseling has taken place. missed abortion. the following treatment is recommended: Bed rest No sexual relations Weekly follow-up in the outpatient clinic Seek immediate medical attention at the hospital if bleeding or lower abdominal pain/discomfort increases If the patient is hemodynamically stable not available or diagnosis includes ectopic pregnancy. refer the patient to the hospital for further management. Monitor blood pressure and pulse every five minutes. Important Considerations The key to good treatment is early diagnosis.Chapter 7 Bleeding in Pregnancy Immediately start a crystalloid (Ringer's or saline) infusion at fast drip rate (1 liter/hour) Provide 100% oxygen via mask and warm the patient. Monitor the urine output every 30 minutes. he/she will provide counseling. or molar pregnancy. Insert Foley catheter. Standards of Practice for Integrated MCH/RH Services: First Edition. counsel her later when she feels better. Referral Refer to a higher level of health care facility according to guidelines. and the case is diagnosed as threatened abortion. Family Planning Counseling following Postabortion Treatment The health care provider may need to follow-up on the patient after her discharge from the hospital. June 2005 203 . Consider if a patient was anemic before she became pregnant. After first aid management is started the patient should be referred to the next level of health care facility level.

Possible Causes Placenta previa Placental abruption Trauma Tumors 204 Standards of Practice for Integrated MCH/RH Services: First Edition.000. Help her get her preferred contraceptive method if she had not already started. Ask if she has practiced family planning before and if there were any problems during use or counsel her about the preferred method to use. was 32/100. Make follow-up appointments or referrals for any other reproductive health problems or needs. Provide the information that is appropriate for her. delay in recognizing the problem or seeking medical care (27%) and lack of blood (23%). especially if the abortion was induced. The maternal mortality ratio for hemorrhage. All family planning methods are suitable. Find out about the woman's needs and situation. Her health care provider can help her get and use a family planning method. Bleeding After 20 Weeks Gestation (Antepartum Hemorrhage) Problem in Egypt Hemorrhage is the leading cause of maternal mortality in Egypt. A large majority of APH deaths were associated with placental abruption while the remainder was due to placenta previa.The ENMMS 2000 reported that hemorrhage accounted for 38% of all maternal deaths and almost half (48%) of all direct obstetric deaths.000. Definition Antepartum hemorrhage is bleeding from or within the genital tract after twenty weeks of gestation. Every woman treated for abortion complications needs to know the following facts: She can become pregnant again within two weeks. June 2005 . hemorrhage (APH) was 8/100.Standards of Practice for Integrated MCH/RH Services Keep counseling in a private atmosphere. Ask the woman if she wants to become pregnant again soon. The most important avoidable factors in deaths associated with antepartum hemorrhage were substandard care by obstetricians once the woman reached a health facility (61%). She can delay or prevent another pregnancy by using a family planning method. Do not pressure her to use contraception if she wants to get pregnant again soon in case of spontaneous abortion. The maternal mortality ratio for antepartum.

There are often signs of hypovolemia (tachycardia. vomiting. A patient with placental abruption may be nonmotensive because this condition is very common in hypertensive patients. Coagulopathies occur in 30% of cases in which the abruption is severe enough to kill the fetus. Lower abdominal pains or colic Symptoms of hypovolemia (nausea. dizziness) The presence or absence of fetal movements Urinary symptoms Past history of medical diseases such as hypertension History of sexual intercourse before the onset of bleeding History of trauma or previous surgery Standards of Practice for Integrated MCH/RH Services: First Edition. There is usually no pain and the uterus is soft. June 2005 205 . Fetal parts are difficult to feel and fetal heart sounds may be absent. oliguria. Dark brownish-colored amniotic fluid suggests a placental abruption. Some bleeding may be severe enough to endanger the patient’s life. Placenta previa Placenta previa is the implantation of the placenta in the lower uterine segment with different grades of encroachment on the cervix. but may be precipitated by sexual intercourse. important causes of antepartum hemorrhage are placenta previa and placental abruption. The principal danger in placenta previa is heavy blood loss when labor begins or during uterine contractions prior to the initiation of true labor. Placental abruption Placental abruption is the premature separation of a normally implanted placenta that may be precipitated by sudden increase in blood pressure or trauma. vomiting.Chapter 7 Bleeding in Pregnancy Infection Vasa previa Rupture of the uterus The two major. hypotension. Bleeding is usually causeless. Diagnosis Personal history History taking Length of pregnancy more than twenty weeks gestation Vaginal bleeding even spotting should be taken seriously. The uterus may be painful and tense (as if in a tetanic contraction). nausea. and shock) in the absence of visible external hemorrhage.

Management Because the amount of bleeding may be misleading. Provide 100% oxygen through a mask and warm the patient. the management of a pregnant woman with vaginal bleeding after twenty weeks gestation should entail first aid management and referral to a higher health -cart facility level.Standards of Practice for Integrated MCH/RH Services Physical Examination General examination Take the pulse.1). Obtain a blood sample to type and cross match blood (ABO. Local examination Meticulously examine the external genitalia and vagina for lesions. RH. Referral Refer according to guidelines (see BEOC Appendix A. and temperature Examine for signs of shock (cold clammy skin) Lower limb edema. rigidity and the presence or absence of fetal heart sounds. The amount of vaginal bleeding may be misleading as mild vaginal bleeding may occur in cases of concealed placental abruption. 206 Standards of Practice for Integrated MCH/RH Services: First Edition. June 2005 . Insert Foley catheter. Laboratory Examinations Blood group and Rh factor Hematocrit complete blood count with platelet count or hemoglobin level. signs of trauma or infection. Monitor blood pressure and pulse every five minutes. whichever is available Urine analysis Note: Never perform a vaginal examination. Abdominal examination Perform an abdominal examination noting uterine size softness. Hb). Immediately start a crystalloid (Ringer's or saline) infusion at fast drip (1 liter/hour). Monitor the urine output every 30 minutes. First Aid Management Insert two wide bore IV cannulae (size 16 or 18). tenderness. blood pressure.

Complications of Placenta Previa Placenta accrete. Other complications due to a prolonged state of shock including renal failure and adult respiratory distress syndrome may occur. the coagulopathy resolves without treatment in a matter of days once delivery takes place is there is no active bleeding. Fetal death.Chapter 7 Bleeding in Pregnancy Complications of Placental Abruption Renal failure. Do not under estimate the amount of hemorrhage. These patients may need massive blood transfusions to save their lives. Uterine atony. A 50% abruption is sufficient to cause fetal death. The possibility of maternal coagulopathy is 30%. As many as 15% of patients with a placenta previa will also have a placenta accreta. in most cases. which his seen almost exclusively when the fetus is dead. Sometimes. a hysterectomy is the only way to save the mother's life. Coagulopathy. June 2005 207 . Can lead to sudden maternal death. Uterine atony is due to the passage of blood between the muscle fibers of the myometrium (Couvelaire uterus). The principle cause of maternal death is renal failure due to prolonged hypertension. Coagulopathy may be sever enough to cause disseminated intravascular coagulation (DIC). There is a high risk of mortality and. Standards of Practice for Integrated MCH/RH Services: First Edition. Amniotic fluid embolism.

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