maternal bleeding

Ectopic Pregnancy

• Occurs when a fertilized egg implants outside of the uterus, typically within the fallopian tubes.
• Affects 1-2% of pregnancies.
• Most common between 6-8 weeks gestation but can occur as late as 20 weeks.
• Can be life-threatening for the mother.

Signs and Symptoms of Ectopic Pregnancy

• Vaginal bleeding
• Lower abdominal pain
• Sharp cramps, often one-sided
• Pain in the neck, rectum, or shoulder
• Feeling faint or collapsing

Placental Abruption

• Partial or complete detachment of the placenta from the uterine wall.
• Doubled risk with smoking.
• Also more likely in pregnancies with high blood pressure, drug use, trauma, and infections.
• Symptoms include vaginal bleeding (may not be visible externally), constant abdominal pain, and a hard, rigid abdomen.

Placenta Praevia

• Placenta is embedded near to or over the opening of the womb (cervix).
• Can cause "silent" bleeds, meaning vaginal bleeding without pain.

Ante-Partum Haemorrhage (APH)

• Defined as vaginal bleeding 50ml or greater during any gestation.
• Any fresh bleeding after 20 weeks, regardless of amount, is a red flag.

Management of Bleeding During Pregnancy Greater than 20 Weeks and APH

• Determining the cause of bleeding may not be possible in the field.
• Pre-alert the nearest obstetric unit.
• If the patient is unstable, transport directly to the emergency department.
• Cannulate the patient if a paramedic is already on scene.

Red Flags and Amber Flags for Determining Transport Destination

• One red flag or two amber flags indicate a time-critical situation.
• Transport to a maternity unit with obstetrics on site if the gestational age is 20 weeks or more and the woman is stable.
• Transport to an emergency department with obstetrics on site if the gestational age is less than 20 weeks, or if the woman is unstable (e.g., life-threatening hemorrhage, recent seizure, decreased GCS).

Maternal Physiology and Observation in Pregnant and Postpartum Patients

• Pregnant and postpartum women have up to 50% additional circulating blood volume.
• This means they may appear well, despite having significant blood loss.

Haemorrhage

• Haemorrhage can be revealed (evident blood loss) or concealed (within the abdomen or uterus).

Causes of Bleeding During Pregnancy

• Early Ante-partum Bleeding (before 20 weeks):
  • Miscarriage
  • Ruptured ectopic pregnancy
• **Late Ante-partum Bleeding (20 weeks to birth): **
  • Low-lying placenta
  • Placental abruption
  • Uterine rupture
  • Ruptured vasa praevia
• Post-partum Bleeding (from birth to four weeks postpartum):
  • Tone (atonic uterus)
  • Tear (trauma to the vulva from birth)
  • Tissue (retained products)
  • Thrombin (clotting disorders)

Miscarriage

• Loss of a pregnancy before 24 completed weeks gestation.
• The majority of miscarriages occur in the first 12 weeks of pregnancy (1st trimester).
• Around 15% of confirmed pregnancies result in miscarriage.

Factors Associated with Increased Miscarriage Risk

• Previous miscarriages
• Smoking
• Obesity
• Substance abuse
• Maternal Age (over 35)

Signs and Symptoms of Miscarriage

• Bleeding; light or heavy, often with clots or jelly-like tissue.
• Pain; central, crampy, suprapubic, or dull backache; can be as intense as labor pains.
• Hypotension and bradycardia; can indicate cervical shock due to retained tissue in the cervix.

Care During Suspected Miscarriage

• Ensure any baby or pregnancy tissue is conveyed to the hospital.

Post-partum Haemorrhage (PPH)

• Significant blood loss after childbirth.
• It is a common, but potentially life-threatening complication.
• Requires prompt diagnosis and management.

Causes of Post-partum Haemorrhage

• Uterine atony (the uterus does not contract properly after delivery).
• Trauma (tears in the birth canal).
• Retained placental tissue.
• Clotting disorders.

Recognizing PPH

• Visualized blood loss of 500mls or more.
• Heavy bleeding post birth that doesn't stop (e.g., saturated inco sheet with 500mls).
• Signs of clinical deterioration after birth, regardless of the amount of blood loss observed.

PPH Management

• Fundal massage (under direction).
• Medications (seek help early).
• IV access.
• Tranexamic acid.
• Use gauze to apply pressure to any tears.
• Oxygen and fluids as per observations.
• Rapid extrication and conveyance.

Key Learning Points

• Maternal Assessment Card should be used from conception to 4 weeks post-partum because physiological changes may alter observation parameters..
• One red flag or two amber flags require a pre-alert to the nearest obstetric unit.
• Haemorrhage may be revealed or concealed.
• Document all pregnancy and post-partum bleeding in a Datix report..