Bleeding in Pregnancy PDF

# Bleeding in Pregnancy ## Presentation by Dr. Radwa Rasheedy **Ass. Prof. of Obstetrics and Gynecology, Ain Shams University,** **21-Oct-24** ## Introduction - Bleeding during pregnancy is a concerning symptom that can range from benign causes to life-threatening conditions. - Recognising the...

# Bleeding in Pregnancy ## Presentation by Dr. Radwa Rasheedy **Ass. Prof. of Obstetrics and Gynecology, Ain Shams University,** **21-Oct-24** ## Introduction - Bleeding during pregnancy is a concerning symptom that can range from benign causes to life-threatening conditions. - Recognising the types and causes of bleeding, understanding the pathophysiology, and knowing when to escalate care is crucial in ensuring the safety of both the mother and foetus. ## Types of Bleeding During Pregnancy - **Early Pregnancy Bleeding:** - **Late Bleeding (Antepartum Hemorrhage):** ## Initial Assessment - **I am Pregnant**: - Diagnosis of pregnancy - Dating of pregnancy - **I am Bleeding:** - Evaluation - Differential diagnoses according to gestational age - Management according to the cause ## Diagnosis of Pregnancy - **History:** - **Pregnancy test:** - **Transvaginal Ultrasound:** ## Pregnancy Dating - The clinical methods of gestational age assessment are history, using the date of the last menstrual period (LMP) to calculate the estimated date of delivery ("due date" or EDD), physical examination, and ultrasound. ## Evaluation - The most important thing to evaluate is whether the situation is life-threatening or not. - The first step when confronted with vaginal bleeding during pregnancy is to assess the hemodynamic stability of the individual, based on the degree of hypovolemia and vital signs. ## Hemodynamic Instability - **History:** - Passing blood clots - The blood soaking through her clothes - Soaking a pad in 1 hour - Feeling lightheaded - Significant pelvic pain or cramping - **Examination:** - Orthostatic changes in blood pressure and pulse - Hypotension and tachycardia/faint/thready pulse - The patient's abdomen should be examined for intraabdominal bleeding (e.g., ruptured ectopic pregnancy) ## Hypovolemia Stages: - **Stage 1:** 500 to 1000 milliliters of blood have been lost. Blood pressure is usually normal, but there may be palpitations, tachycardia, and slight dizziness. - **Stage 2:** 1000 to 1500 milliliters have been lost. Systolic blood pressure drops to 80 to 100 mmHg, tachycardia is obvious, and there may be weakness and sweating. - **Stage 3:** 1500 to 2000 milliliters have been lost. Systolic blood pressure drops between 70 and 80 mmHg, and there may be restlessness, pallor, and low urine output. - **Stage 4:** More than 2000 milliliters have been lost, systolic blood pressure is less than 70 mmHg, and symptoms may include cardiovascular and respiratory collapse, loss of consciousness, and anuria. ## Severe Bleeding During Pregnancy - HEART (Management Approach) - **Help:** - Call for help, assign roles, crowd control, and family support - **Equipment:** - Bring what is needed to the room, including medical kit, cart, ultrasound, etc. - **Assess:** - Continuously assess comfort, vital signs, etc. - **Resuscitate:** - Establish two large-bore IVs, administer oxygen, IV fluids, and medications as directed. - **Treat:** - Identify the cause and control the bleeding. ## Bleeding in Early Pregnancy - Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women. It may be any combination of light or heavy, intermittent or constant, painless or painful. The four major sources of bleeding in early pregnancy are: - **Ectopic pregnancy:** - **Miscarriage (threatened, inevitable, incomplete, complete):** - **Molar pregnancy:** - **Cervical, vaginal or uterine pathology (e.g., polyps, inflammation/infection):** ## Presentation of Early Pregnancy Bleeding - A triad of symptoms: - Amenorrhea + Bleeding + Pain ## Common Causes of Early Pregnancy Bleeding - **Bleeding related to miscarriage is the most common cause of bleeding in early pregnancy.** - **Ectopic pregnancy is relatively common and the most serious etiology as rupture of the extrauterine pregnancy is a life-threatening complication.** ## Common Causes of Early Pregnancy Bleeding (Visual Representation) - This image shows four common causes of early pregnancy bleeding: - Spontaneous abortion - Ectopic pregnancy - Molar pregnancy ## Abortion - **Definition:** Termination of pregnancy before the age of fetal viability. - **Presentation:** Females present with a period of amenorrhea/vaginal bleeding +/- abdominal cramps. - **Types and Presentations:** Presentation differs according to the type of abortion: - **Threatened abortion:** It is an attempt of the uterus to expel the products of conception. - **Vaginal bleeding:** Minimal or mild. - **Pain:** Mild suprapubic dull aching in character. - **Cervix:** Closed. - **Inevitable abortion:** It is a type of abortion which can’t be prevented. - **Vaginal bleeding:** Severe with passage of blood clots. In some cases, it can lead to hypovolemic shock. - **Pain:** Severe suprapubic colicky pain. - **Cervix:** Open. - **Incomplete abortion:** Part of the products of conception is expelled. - **Vaginal bleeding:** Persistent painful profuse bleeding with intermittent passage of some of the products of conception. - **Pain:** Severe suprapubic colicky pain. - **Cervix:** Open. - **Complete abortion:** All products of conception are expelled. - **Vaginal bleeding:** Diminishes and gradually stops. - **Pain:** With diminishing uterine cramps. - **Cervix:** Closed. - **Missed abortion:** Retention of non-viable products of conception. - **Vaginal bleeding:** Brownish vaginal discharge, which may be an early symptom. - **Pain:** Usually absent. - **Cervix:** Closed. ## Visual Representation of Miscarriage Types - This image depicts four common types of miscarriage: - Threatened miscarriage - Inevitable miscarriage - Incomplete miscarriage - Missed miscarriage ## Diagnosis of Miscarriage - **Speculum Exam:** - **Cervix CLOSED:** - **Vaginal sonogram findings:** - Viable IUP: Threatened Abortion. - Non-viable IUP: Missed Abortion. - **Cervix OPEN:** - **Vaginal sonogram findings:** - POC intact: Inevitable abortion. - POC some gone: Incomplete abortion. - POC all gone: Completed abortion. ## Ectopic Pregnancy - **Definition:** A pregnancy in which the foetus develops *outside* the uterine cavity, typically in a fallopian tube. - **Rare sites (2-5%):** - Ovaries - Broad ligaments - Abdominal cavity and peritoneum - Cervix ## Visual Representation of Normal Pregnancy Implantation - This image illustrates the process of normal pregnancy implantation, starting with the fertilization of the egg and ending with the implantation of the blastocyst in the uterus. ## Types of Ectopic Pregnancy - **Undisturbed Tubal Pregnancy:** - **Pain:** Usually the main presenting symptom is unilateral lower abdominal dull aching pain (due to tubal distension). - **Vaginal bleeding:** Usually absent or mild. - The patient is hemodynamically stable. - **Disturbed Tubal Pregnancy:** - **Pain:** Is very prominent and may include: - Unilateral colicky pain - Unilateral sharp stabbing pain - Diffuse acute abdominal pain - Shoulder pain - **Vaginal bleeding:** Typically preceded by amenorrhea. However, some women may misinterpret bleeding as normal menses. - **Examination:** Varies according to the severity of intraperitoneal hemorrhage. ## Molar Pregnancy - **Definition:** Occurs after aberrant fertilization with proliferation of trophoblastic tissue. - It is a result of fertilization of an empty ovum by two sperms or a single sperm that duplicates the chromosomes. - **Presentation:** Women typically present with missed menstrual periods, vaginal bleeding, which results from the separation of the tumor from the underlying decidua, and may be associated with vesicles (grape-like clusters of tissue). - **Diagnosis:** There is a marked elevation in serum hCG (human chorionic gonadotropin) levels. ## Management According to the Cause - **Threatened Abortion:** - **Reassurance:** - **Rest:** Physical and mental. - **Progesterone support:** - **Incomplete Abortion:** - **Surgical Evacuation (SE):** When bleeding is excessive or contents are considerable. - **Medical Evacuation:** When bleeding is mild and contents are minimal. Misoprostol is often used. - **Inevitable Abortion:** - **Hospitalization and Anti-shock measures (if needed):** - **Termination of Pregnancy (TOP):** - **SE (for 1st trimester inevitable abortions):** - **Medical Evacuation (using IV oxytocin drip for 2nd trimester cases):** - **Missed Abortion:** - **Conservative:** Wait a few weeks for spontaneous expulsion if there is minimal or no bleeding. - **Surgical Induction of Abortion:** Suction evacuation/SE & curettage (IUFD < 12 weeks). - **Medical Induction of Abortion:** Misoprostol is the first choice in 2nd trimester IUD. - **Ectopic Pregnancy:** - **Disturbed Tubal Pregnancy (Hemodynamically Unstable Patient):** Immediate surgical intervention to stop the bleeding is vital, usually by laparotomy. - **Undisturbed Tubal Pregnancy:** Management can be medical with methotrexate or surgical with laparoscopy. ## Visual Representation of Ectopic Pregnancy - This image shows two examples of ectopic pregnancy found during laparoscopy: - Example A - Example B ## Visual Representation of Ectopic Pregnancy (Different Stage) - This image shows two more examples of ectopic pregnancy in different stages. - Example A - Example B ## Management of Molar Pregnancy - **Suction and evacuation:** - **Follow up hCG levels until negative:** - **Adequate contraception for at least 6 months:** ## Common Causes of Early Pregnancy Bleeding (Summary Table) | Condition | Description | Symptoms | |---|---|---| | Threatened Abortion | Vaginal bleeding with or without cramping, but the pregnancy continues. | Vaginal bleeding, mild cramping. | | Inevitable Abortion | Heavier bleeding with cervical dilation, indicating the pregnancy will not continue. | Heavier bleeding, cervical dilation. | | Incomplete Abortion | Some pregnancy tissue remains in the uterus, causing continuous bleeding. | Vaginal bleeding, tissue expulsion, cramps. | | Complete Abortion | All pregnancy tissue is expelled; bleeding gradually stops. | Minimal bleeding, passage of tissue, cramps. | | Ectopic Pregnancy| Fertilized egg implants outside the uterus, usually in the fallopian tube, causing pain and bleeding. This is a medical emergency! | Pain, vaginal bleeding, dizziness, faintness. | | Molar Pregnancy | Abnormal growth of the trophoblastic tissue due to abnormal karyotyping. | Vaginal bleeding, rapid growth of uterus, high hCG levels. | ## Antepartum Hemorrhage - **Definition:** Bleeding from or in the genital tract occurring from 24+0 weeks of pregnancy and prior to delivery of the foetus. ## Common Causes of Late Pregnancy Bleeding - This image shows four common causes of late pregnancy bleeding: - Placenta previa - Placental abruption - Premature delivery - Expulsion of the mucus plug ## Placenta Previa - **Definition:** Placenta that encroaches partially or totally on the lower uterine segment (LUS). - **Placenta Accreta:** Placenta is abnormally adherent to the uterine wall. ## Types of Placenta Previa - This image shows four types of placenta previa: - Normal placenta - Low-lying placenta - Partial placenta previa - Total placenta previa ## Placenta Previa (Symptoms and Risk Factors) | Symptoms | Description | |---|---| | **Abdominal Pain** | - Painless: may be painful if the patient is in labor. | | | - Bleeding is usually bright red in colour (recently occurring). | | **Vaginal Bleeding** | - The first attacks of vaginal bleeding are usually mild, but recurrent attacks may be severe. | | | - If labour pains start severe bleeding may cause hypovolaemic shock in a short period of time. | | **Risk factors (RF)** | - Causeless: May be due to sexual activity or vaginal examination | ## Placenta Previa (Signs and Examination) | Signs | Description | |---|---| | **General Examination**| - General condition: is in proportion with the amount of vaginal bleeding. | | | - **Single mild attack:** the general condition is usually not affected. | | | - **Recurrent or moderate attacks:** pallor and anaemia are usually present. | | | - **Severe attack:** signs of hypovolaemic shock. | | **Fundal Level** | - **= to the date of amenorrhea** | | **Fundal & Umbilical Grips** | - The abdomen usually lax. | | | - Uterus is soft and not tender. | | | - Foetal pats: are easily felt. | | | - + Multiple pregnancy. | | **Pelvic Grips** | - Malpresentations and non-engagement are common. | | | - If placenta is anterior, it may be felt as a soft mass or bulge. | | | - If placenta is posterior, it may be felt as a soft mass or bulge. | | **Auscultation** | - Fetal heart sound (FHS): normal, distressed, or absent (according to severity). | | | - Pelvic examination is generally contraindicated. | ## Placental Abruption - **Definition:** The premature separation of a normally implanted placenta from the uterine wall before the baby is born. - **Causes:** There is no single, clear cause, but several factors can increase the risk: - High blood pressure during pregnancy (preeclampsia or eclampsia) - Previous placental abruption - Multiple pregnancies - Trauma to the abdomen - Cocaine use - Smoking cigarettes - Certain medical conditions - Certain medications ## Visual Representation of Placental Abruption - These two images illustrate the difference between a normal placental implantation and placental abruption. - Image 1: Normal placental implantation, showing the placenta attached to the top of the uterus. - Image 2: Placental abruption, showing a part of the placenta separating from the uterus with blood trickling down the uterine wall. ## Types of Placental Abruption - This image shows different types of placental abruption according to the amount of separation: - **Partial separation (mild abruption):** Vaginal bleeding is minimal with no fetal monitor abnormalities. Localized uterine pain and tenderness. - **Marginal separation (moderate abruption):** Moderate vaginal bleeding (from 25-50% of the placental surface) is separated. Fetal monitoring may show tachycardia, decreased variability, or mild late decelerations. - **Complete separation with concealed hemorrhage (severe abruption):** Continuous knife-like uterine pain and board-like rigidity. More than 50% of the placental separation occurs. Fetal monitor shows severe late decelerations, bradycardia, or even fetal death. ## Placental Abruption (Symptoms) | Symptoms | Revealed Type | Concealed Type | |---|---|---| | **Abdominal Pain** | - Usually present but mild. | - Prominent, sudden, severe, and progressive. | | **Vaginal Bleeding** | - Mild, moderate, or severe. | - Usually absent. | | | - Dark brown or bright red in color | | | - Attack is usually single due to immediate termination. | ## Placental Abruption (Signs and Examination) | Signs | Revealed type | Concealed type | |---|---|---| | **Fundal Level** | - **=** to the period of amenorrhea. | > the period of amenorrhea. | | **Fundal & Umbilical Grips** | - Normal uterine contractions. | - The uterus is hypertonic. | | | - Normal uterine tone between contractions. | - Uterus is very tender & hard (board-like rigidity). | | | - Could feel foetal parts. | - Difficult to feel foetal parts. | | **Pelvic Grips** | - No increased incidence of malpresentations. | - The head is usually engaged due to increased intrauterine pressure. | | | - The head is usually not engaged allowing bleeding to be revealed. | | **Auscultation** | - FHS: normal, distressed, or absent (according to severity). | | | - Pelvic examination is generally contraindicated. | ## Vasa Previa (A Rare But Serious Complication) - **Definition:** A rare but serious obstetric complication where fetal blood vessels, unprotected by the umbilical cord or placenta, cross the cervical os beneath the fetal presenting part. - **Risk:** These vessels are at risk of rupture when the membranes rupture, leading to rapid fetal hemorrhage and potentially fatal outcomes. ## Visual Representation of Vasa Previa - This image shows the typical arrangement of blood vessels in vasa previa: - **Normal umbilical cord insertion:** The umbilical cord is attached to the placenta centrally. - **Velamentous cord insertion:** The umbilical cord is attached to the membranes rather than the placenta, and the fetal blood vessels pass through the membranes to reach the placenta. - **Velamentous cord insertion with vasa previa:** The fetal blood vessels pass through the membranes and cross the cervical os before reaching the placenta. ## Assessment of Bleeding in Pregnancy - **History:** - Ask about the onset, duration, and characteristics of bleeding (light, heavy, color, clotting). - Inquire about any associated symptoms such as pain, dizziness, or passage of tissue. - Obtain a history of previous pregnancies, miscarriages, or known conditions like placenta previa. - **Examination:** - **Vital signs:** Check for tachycardia, hypotension, or shock symptoms, especially in heavy bleeding. - **Abdominal examination:** Assess for uterine tenderness, contractions, or rigidity. - **Speculum examination:** Evaluate for cervical dilation, active bleeding, or tissue at the cervical os. - **Ultrasound:** - **Placental position:** - **Confirm fetal viability:** - **Assess for placental abruption:** ## Management of Late Pregnancy Bleeding - **Stabilization and Monitoring:** Includes providing oxygen, IV access, and fluid, while closely monitoring the patient's vital signs. - **Blood Loss Management:** Blood transfusion may be required to address significant blood loss, and a complete blood count (CBC) should be performed to assess the severity of anemia. - **Treat the cause:** The specific treatment will depend on the underlying cause of the bleeding. - **Emotional and Psychological Support:** Provide emotional and psychological support to the patient and their family. ## Treating the Cause - **Placenta Previa:** - **Bed rest or hospital admission depending on the severity of bleeding:** - **Plan a caesarean section near term**: - **Hysterectomy in cases of placenta accreta spectrum (main line of management) or persistent bleeding after placental separation**: - **Placental abruption:** - **Emergency care:** Includes delivery if the fetus is viable and the condition is life-threatening. - **Monitor and stabilize the mother:** Prepare for rapid caesarean section if needed. - Hysterectomy in cases of uncontrollable bleeding (very rare but may be necessary). ## Summary of Late Pregnancy Bleeding (Table) | Condition | Description | Symptoms | |---|---|---| | Placenta previa | The placenta partially or fully covers the cervix, causing obstruction of the birth canal. | Painless vaginal bleeding. | | Placental abruption | The placenta detaches from the uterine wall prematurely, cutting off blood supply to the fetus. | Painful bleeding, uterine tenderness. | | Preterm labor | Labor that begins before 37 weeks of gestation. | Vaginal bleeding, cramping, contractions. | | Vasa previa | Fetal blood vessels cross or run near the internal cervical os, risking rupture during labor. | Risk of rupture and fetal hemorrhage. | ## Quiz - What are the common causes of bleeding in the first trimester of pregnancy? - What are the primary causes of late pregnancy bleeding? - How to approach a case of bleeding in ectopic pregnancy?