Bleeding in pregnancy

 

Vaginal bleeding in pregnancy is not normal — urgent medical consult

If bleeding very heavy (bright with large clots) OR signs of shock — this is an emergency

Problems

  • Even a small amount of visible blood loss can be significant
    • Blood may be hidden inside uterus or vagina and woman can quickly become shocked
  • Baby can become very sick very quickly
  • Painless bleeding can be very serious
  • Severe pain that does not ease between contractions is serious
  • Bleeding and contractions can lead to high-risk birth
  • Doing vaginal exam may make bleeding worse

Do not

  • Do not do vaginal exam unless skilled and asked to by doctor
  • Do not let woman eat or drink anything — may need operation — consider IV fluids

Do first — if emergency
  • Call for help — have helper call for urgent medical consult 
  • Lie woman on left side
  • Give oxygen to 
    • Target O2 sats 94–98%
    • OR if moderate/severe COPD target O2 sats 88–92%
  • IV cannula, largest possible
    • If you can't get IV cannula in — put in intraosseous needle
    • Give normal saline — 1L straight away THEN 125mL/hr or as directed by doctor
    • Medical consult — for pain relief, IV fluids
  • Indwelling urinary catheter when time 
    • Do hourly measures — aim for 0.5mL/kg/hr

If birth about to happen — see Birthing baby and call for help. Get ready for baby who may need resuscitation

Look — in file notes

  • How many weeks pregnant, due date for birth
  • Obstetric ultrasound report if done — where is placenta located (eg low-lying)
  • Problems in this pregnancy — bleeding, diabetes, high BP, twins/multiple pregnancy
  • Obstetric history — pregnancies and births, miscarriages, ectopic pregnancy, termination of pregnancy
  • Gynaecology history — operations, cervical screening history
  • Medical history — especially RHD, PID, STIs
  • Results — blood group, RhD positive or negative, last Hb, GBS

Ask

  • When bleeding started, what she was doing, any bleeding before in this pregnancy
    • How much — spotting or lots of blood
    • Colour — bright (fresh) or dark (old)
    • Any clots or tissue
  • Pain — when it started, where it is
  • Injury — sexual assault, car accident, has she fallen or been hit
  • Any other symptoms — fainting, fever, chills, nausea, vomiting
  • Is baby moving

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Hb
  • U/A
  • Head-to-toe exam — with attention to
    • Pad for amount of blood loss — change pad and record loss
    • Abdomen — feel for tenderness, rebound, guarding
  • Uterus — feel for
    • Fundal height — if fundus above umbilicus
    • Tenderness, pain, hard or soft — if uterus hard — do not palpate further and do not feel for baby’s position.  If uterus soft — feel for position of baby
  • Contractions

Do
  • Collect urine for MC&S, blood for Kleihauer test (test for amount of foetal blood in maternal circulation)
  • If no antenatal care — also collect blood for syphilis, rubella and hepatitis B
  • Medical consult about
    • Findings
    • Sending to hospital
    • Pain relief
    • Antibiotics — consider preterm labour, fever, GBS status positive or unknown. If miscarriage — woman with RHD may need preventive antibiotics
  • If woman RhD negative and no Anti-D antibodies — give RhD-Ig IM
    • 12 weeks or less pregnant and 1 baby — 250 international units
    • 12 weeks or less pregnant and more than 1 baby (twins) — 625 international units
    • More than 12 weeks pregnant — 625 international units
  • Continue management as directed by doctor and/or obstetrician

Causes of bleeding

In first 20 weeks of pregnancy

Ectopic pregnancy

Pregnancy that occurs outside uterus, usually in fallopian tube. Ectopic pregnancy can be life threatening. Tube can rupture and cause massive bleeding inside abdomen

Risk factors

  • History of PID
  • Tubal surgery (eg for previous ectopic pregnancy)
  • IUCD (intrauterine contraceptive device)
  • Progesterone contraception
  • Assisted reproductive technology (eg IVF)

Signs and symptoms

  • Usually vaginal bleeding but not always
  • May have missed 1–2 periods without other symptoms of pregnancy
  • Pain usually one-sided but may spread across abdomen. May have shoulder tip pain
  • Diagnosis is difficult without ultrasound

Miscarriage

Threatened or actual loss (complete or incomplete) of pregnancy

Risk factors

  • Foetal anomalies — risk increases with increasing maternal age
  • Uterine factors — fibroids, uterine malformations, incompetent cervix
  • Substance use — cigarette smoking, amphetamines, cocaine
  • Maternal diseases — poorly controlled diabetes, thyroid diseases,  systemic lupus erythematosus (SLE)

Signs and symptoms

  • Vaginal bleeding — spotting to massive bleeding
  • Abdominal cramping or backache

Other causes

  • Cervical problems — polyps, ectropion cervix, cancer, infection
  • STIs
  • Direct injury
  • Trophoblastic disease (rare pregnancy related tumours)

After 20 weeks pregnant (antepartum haemorrhage)

Placenta praevia

All or part of placenta covers internal os (opening to cervix) — Figure 1.17. Often found on routine ultrasound

  • Blood comes from behind placenta (mother’s blood)
    • Can cause significant painless bleeding
    • Uterus usually soft, not tender
    • Increased risk of bleeding as cervix dilates
  • Baby’s head may not enter pelvis and baby's position may be abnormal — transverse (across uterus), breech
  • Woman may have multiple episodes of bleeding
  • Placenta can block birth canal so vaginal birth is not possible or too dangerous
  • Baby almost always needs to be born by caesarean section and may need to be born early
  • Mother may need blood transfusions

Figure 1.17   

Placental abruption

Part or all of placenta comes away from wall of uterus — Figure 1.18

  • Can occur spontaneously or after minor or major abdominal injury (eg fall, assault, motor vehicle accident)
  • Can occur after taking drugs (eg amphetamines)
  • Usually causes constant pain in abdomen or back — can be mild or very severe
    • Woman can present in labour
    • Uterus may be hard and tender
  • Bleeding may be hidden inside uterus — Figure 1.19. Blood loss may be much greater than appears from vaginal bleeding
    • High risk that baby will die without medical attention
    • Consider in any pregnant woman with abdominal pain, with or without bleeding

Figure 1.18   

Figure 1.19   

Other causes

  • Bleeding from other parts of genital tract — bleeding from cervix after sex, local trauma, polyps, heavy blood and mucus 'show' prior to labour, infection
  • Less common causes
    • Conditions such as cancer
    • Vasa praevia — bleeding from cord vessels (foetal blood)
  • Very small bleed can lead to foetal compromise and/or death