Bleeding in Late Pregnancy PDF

# Bleeding in Late Pregnancy ## Antepartum Hemorrhage ### Definition: - It is bleeding from the genital tract after the 28th week of pregnancy and before the end of the second stage of labour. - An illustration shows bleeding from the uterus and placenta. ### Classification - **Placental Site Bl...

# Bleeding in Late Pregnancy ## Antepartum Hemorrhage ### Definition: - It is bleeding from the genital tract after the 28th week of pregnancy and before the end of the second stage of labour. - An illustration shows bleeding from the uterus and placenta. ### Classification - **Placental Site Bleeding (62%)** - **Placenta Previa (22%)**: Bleeding from separation of a placenta wholly or partially implanted in the lower uterine segment. - **Abruptio Placenta (30%)**: Premature separation of a normally implanted placenta. - **Marginal Separation (10%)**: Bleeding from the edge of a normally implanted placent. - **Non-Placental Site Bleeding (28%)** - **Vasa Previa**: Bleeding from ruptured fetal vessels. - Rupture Uterus. - Bloody Show - Cervical ectopy, polyp or cancer. - Vaginal varicosity. - An illustration shows bleeding from the cervix, and another shows ruptured fetal vessels. ## Placenta Previa ### Definition: - The placenta is partially or totally attached to the lower uterine segment. ### Incidence: 0.5% of pregnancies. - It is more common in multiparas and in twin pregnancy, due to the large size of the placenta. - An illustration shows the difference between a normal placenta and a placenta previa. ### Degrees (Types) - **First Degree (Type I = P.P. Lateralis = Low-lying Placenta)**: The lower edge of the placenta reaches the lower uterine segment but not the internal os. - **Second Degree (Type II = P.P Marginalis)**: The lower edge of the placenta reaches the margin of the internal os but does not cover it. - **Third Degree (Type III = P.P, Incomplete Centralis)**: The placenta covers the internal os when it is closed or partially dilated, but not when it is fully dilated. - **Fourth Degree (Type IV = P.P. Complete Centralis**) The placenta covers the internal os completely, whether the cervix is partially or fully dilated. - Illustrations are shown for each degree, from low lying, marginal, partial previa, and complete previa. ## Diagnosis ### Symptoms - Causeless, painless, and recurrent bright red vaginal bleeding. ### Signs - **General Examination**: The general condition of the patient depends upon the amount of blood loss. - **Abdominal Examination**: - The uterus is corresponding to the period of amenorrhea, relaxed and not tender. - The fetal parts and heart sound (FHS) can be easily detected. - Malpresentations ### Vaginal Examination - P/V is indicated only if active treatment is initiated. - Should be done with the following precautions: - In the operating room. - Under general anaesthesia. - Cross matched blood is in hand. - Operating theatre is ready for immediate caesarean section. ## Abruptio Placenta (Accidental Hemorrhage) ### Definition: - Premature separation of a normally situated placenta, after the 28th week of pregnancy and before delivery of the fetus. - An illustration shows a placental abruption. ### Etiology - Unknown, but the following factors may be associated with: - Hypertensive disorders of pregnancy (30%) - Trauma, as during external version. - Sudden drop of intrauterine pressure, as in rupture of membranes in polyhydramnios - Folate deficiency, and may be vitamin C, K, or E deficiency - Torsion of the uterus - Smoking ## Diagnosis ### Symptoms: - Acute constant severe abdominal pain, which may be localized or diffuse. - Dark vaginal bleeding results from escape of blood from the retroplacental haematoma. - Cessation of fetal movement is common. ### Signs: - **General Examination**: - Shock - Blood pressure is subnormal due to haemorrhage, normal due to falling from previous hypertension, or high due to slight bleeding in hypertensive patient. - Tachycardia. - **Abdominal Examination**: - Uterus is large for date and increasing gradually in size due to retained blood. - Uterus is very tender and hard (board-like) - Fatal parts are difficult to be felt. - FHS may be absent due to fetal death in severe cases, or distressed in mild cases. - **Vaginal Examination**: Done under the same precautions as in placenta previa, may reveal. - Vaginal bleeding is dark, as it is retained for some time before escape. - If the cervix is dilated, the placenta is not felt.