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Bleeding during pregnancy
Assessment of the patient
Scene size up
Primary assessmen
t
History taking
Secondary assessmen
t
reassessment
Points in history taking
determine nature of bleeding :
Amount ?
Was patient active or resting at time of bleeding ?
When did the bleeding started ?
Painful or painless ?
If painful ask OPQRST to determine pain nature and character ?
Stress on type of pain : colicy , sharp , dull aching .
Important points in examination
Orthostatic changes in vital signs , in case of compensated shock ( both
indicates significant blood loss ).
Abdominal examination for grey turner signs and Cullen sign of internal
hemorrhage .
Avoid vaginal examination . examination of female with
vaginal bleeding
underestimates amount of
blood loss due to physiological
changes
Signs of internal
hemorrhage
A . Cullen sign : bluish discoloration around umbilicus.
B . Grey turner line :
Bluish discoloration in the flanks.
General lines of treatment
Address ABC :
a. Administer 100% supplemental oxygen via non rebreathing mask at
15 L/min.
b. Start an IV line of normal saline with a large-bore IV catheter.
c. Infuse at the rate necessary to maintain blood pressure.
d. Use loosely placed trauma pads over the vagina to try to stop the
blood flow.
Provide rapid transport :
a. Notify the facility of the patient’s condition while en route
b. Keep the woman recumbent and lying on her left side
Obtain an ECG and baseline vital signs and continuously
reassess while en route , watch out for signs of shock.
fetal monitoring continuously throughout the management .
Causes of vaginal bleeding during pregnancy
1. Abortion .
2. Ectopic pregnancy .
3. Placental abnormalities .
4. Bleeding during third trimester .
Abortion
Definition : expulsion of the fetus and uterine contents before the 20th week of
gestation.
Mostly occur during the first trimester before the placenta is matured.
classification :
1- Spontaneous abortion 5- Missed abortion
2- Induced abortion 6- Incomplete abortion
3- Habitual abortion 7- Septic abortion
4- Inevitable abortion
Spontaneous abortion
Spontaneous abortion (miscarriage) : is an abortion which occurs naturally.
Causes include:
a. Acute or chronic illness in the pregnant woman.
b. Maternal exposure to toxic substances.
c. Fetal abnormalities.
d. Abnormal attachment of the placenta.
Can be
avoided
Induced abortion Intentional , criminal or elective abortion : abortion that is induced either
for criminal or medical causes.
as paramedics , care must be given to the patient as usual despite of your
ethical or religious believes , you should show empathy and compassion .
You are in the business of
saving people not
lecturing them
Habitual abortion
Definition : three or more consecutive pregnancies that end in miscarriage .
Causes include:
a. Chromosomal and endocrine disorders.
b. Ovarian issues.
c. Uterine malformations.
d. Cervical conditions.
e. Infections.
f. Lifestyle factors.
Threatened abortion
Definition : any vaginal bleeding in the first half ( 20 weeks ) of pregnancy
(usually first trimester).
Usually associated with mild abdominal cramping.
It differs from inevitable abortion that cervix is closed and bleeding is minimal .
Can progress to an complete abortion or may subside.
Treatment : complete bed rest so the condition can be monitored.
Prehospital treatment : transport and support.
Inevitable ( imminent ) abortion
Definition : an abortion that has progressed to a stage where termination of the
pregnancy cannot be avoided , ( abortion can not be avoided ).
Signs and symptoms :
a. Severe abdominal pain from strong uterine contractions
b. Vaginal bleeding, often massive
c. Cervical dilation.
Prehospital management of inevitable abortion aims at :
a. Maintain blood pressure.
b. Prevent hypovolemia.
c. Watch for signs of shock
Inevitable abortion
Incomplete abortion Definition : abortion where parts of product of conception remains inside
uterus.
Complication : vaginal bleeding will continue increasing risk of shock .
Management : as general guidelines plus
a. Consult medical control if products of conception are protruding from the
vagina.
b. Collect all products of conception and give to the receiving facility.
c. Allow the patient to view the fetus if she wishes.
d. Be prepared for strong emotions.
Missed abortion Definition : retention of product of conception in uterus after abortion for 2 months
or more .
The fetus dies during the first 20 weeks of gestation but remains in utero.
Diagnosis :
A. History : history of threatened abortion, with cessation of vaginal bleeding
and a gradual diminishing of signs of pregnancy.
B. Examination : ♠ Uterus feels like a hard mass.
♠ Fetal heartbeat cannot be heard.
Management : provide emotional support and transport , address ABCs .
Septic abortion
Definition : uterus becomes infected during or shortly ( within hours) after
abortion.
Diagnosis :
a. History : fever and bad-smelling vaginal discharge.
b. Physical examination : Fever and abdominal tenderness.
Hypotension may indicate septic shock.
Complication : can progress to septicemia and septic shock in severe cases.
Ectopic pregnancy
Ectopic pregnancy Definition : life threatening condition in which the fertilized ovum is implanted
outside normal site of implantation.
pathology :
Fetus can develop to term .
Normal signs and symptoms of pregnancy are present .
Sites include : fallopian tube ( commonest ) , cervix , ovary and abdominal
cavity.
Complication : rupture leading to internal hemorrhage .
Sites of ectopic
pregnancy
1. Tubal (commonest )
2. Cervical .
3. Ovarian .
4. Intraabdominal.
Clinical presentation :
Symptoms :
1.Symptoms of pregnancy ( amenorrhea , morning sickness )
2.Abdominal pain , which is sever with rupture ectopic
3.Syncope in case of shock
Signs :
4. Abdominal tenderness
5. Signs of acute abdomen and internal hemorrhage in case of rupture.
Management : general guidelines + rapid transport + emotional support.
Abdominal pain
in female in
child bearing
period is ectopic
pregnancy until
proved other
wise
Placental causes of vaginal bleeding
Definition : Premature separation of the placenta from the uterine wall.
incidence
Most common in the last trimester, but can happen in the second as well.
Causes :
Maternal hypertension ( commonest ).
Trauma , assault and falls .
Drug abuse , alcohol and smoking .
More common with previous history of abruptio placenta.
Abruptio placenta , placental abruption
Clinical presentation :
Symptoms :
1. Vaginal bleeding with bright red blood.
( Sometimes the blood does not reach the vagina, so doesn't appear).
2. Sudden onset of severe abdominal pain
3. No longer feeling the fetus moving.
Physical examination
4. Signs of shock, often out of proportion of apparent blood loss.
5. Tender abdomen and rigid uterus on palpation.
6. Fetal heart sounds may be absent.
Abruptio placenta
Management :
General outlines + careful and rapid transport +
reassess continuously for shock + fetal
monitoring .
Placenta previa
Definition : Placenta that is implanted low in the uterus and partially or fully
covers the cervical canal.
Chief complaint is usually painless vaginal bleeding with bright red blood.
Leading cause of vaginal bleeding in the second and third trimesters.
Complications include:
1. Disseminated intravascular coagulation .
2. Hemorrhage .
3. Low fetal birth weight .
signs :
The uterus is soft and non tender.
Do not palpate deeply in any woman with third-trimester bleeding.
May induce heavy bleeding if she does have placenta previa.
Third trimester bleeding
Bleeding during third trimester is of the greatest danger due to :
Large volume of blood present
Compensatory mechanisms present as a result of pregnancy.
pregnant woman can lose 40% of circulating volume before hypovolemia is
apparent.
Summary
Bleeding in obstetric patient require good assessment , rapid transport and
continuous reassessment for signs of shock.
Vaginal examination is better avoided in patient with vaginal bleeding .
Abortion is expulsion of product of conception before 2o weeks of gestation.
Tubal pregnancy is most common type of ectopic pregnancy.
Placenta previa is leading cause of bleeding in third trimester.
Hypotension in patient with septic abortion is grave and means septic shock.
Any questions ?