Bleeding in pregnancy and labor

Part one

- average frequency 2-5% of pregnancy

- the second place in the structure of maternal and fetal mortality

reasons of bleeding in pregnancy and labor:

1. Bleeding in the earliest terms of pregnancy:
- abortion (spontaneous, artificial)
- ectopic pregnancy
- trophoblastic disease (choryonepithelioma, Molar pregnancy)

2. Bleedings in the latest term of pregnancy and labor:

- placenta previa
- abortion placentae
- rupture of utery

3.Postpartum bleedings:
-hypo-atony of utery
-residuum of placenta
-rupture of utery

4.Embolia by amniotic fluid

5.Hepatic deficiency

Placenta previa(p.p.)
Placenta is implanted in the lowerpole of uterus instead of high up in the fundus, its location is
either over or very near the internal os.
Four degrees:
1.Total p.p:-completely covers the internal os

2.Partial p.p-partially covers internal os

3.Marqinal p.p:-the edqe of placental is palpable at the marqin of the internal os

4.Low lying p.p:-implanted near the internal os

Frequency: occurring 1 out of 200 term pregnancies

Etiology:
1)Maternal factors:
-multiparity (about 80 % of all cases)
- age over 35
- no prior history

2) Factors related to abnormal placentation

- defective vascularization of the decidua (after inflammation)
- scarring of the endometrium (after curettage)
- vessel changes at the placental site
- increased changes of the placental implementation (multiple pregnancies)
- erythroblatosis (often accompanied by large placenta)
- previous operations in the lower segment (myomectomia, cesarean section)

Clinical presentation:
1. Painless vaginal bleeding – most characteristic sign in second half of pregnancy
(especially in the third trimester)
Can occur:
- during rest or activity
- suddenly
- after trauma, coitus or pelvic examination
2. Intrauterine hypoxia
3. Concomitant iron-deficiency anemia

Diagnostic:
Ultrasound diagnostic – the best way
- after 30 weeks (planning examination)
- after episode of bleeding (emergency examination)

ATTENTION:
Between 4 to 6 % of patients have some degree of previa on ultrasound examination before 20
weeks of gestation. It is connected with the development of lower segment of uteri and
progressive placental migration, which is resolving to the third trimester in 90 % cases.

Suggestive findings
1. Malposition of the fetus (breech or transversal lie)
2. Multiple gestation
3. Multiparty or maternal age (after 30)
4. Bleeding after vaginal examination

Management of pregnancy
(suspected or confirmed diagnosis)
- HOSPITALIZATION IMMIDIATELLY – NO VAGINAL EXMINATION !!!
The tactic of the pregnancy conducting depends on the term of pregnancy, quantity of blood
loss and fetal monitoring data.

IN HOSPITAL:
1. Clinical laboratory examination, including fetal monitoring, biochemical profile and
coagulogramma
2. Bed rest
3. Daily control of haemodynamic parameters
4. In a case of preterm pregnancy – attempt to obtain fetal maturation
- prophylaxis of intrautery hypoxia
- tocolic therapy (magnesium sulfate is a medication of choice)
- antianemic therapy
5. Increasing bleeding, repeated bleeding, blood loss more 200 ml
absolutely indication to caesarean section
6. With the absence of bleeding and positive effect of the therapy – planning caesarean
section in terms of 37 – 38 weeks.
LOW-LYING PLACENTA
1. Ultrasound diagnostic (32-34 weeks0
2. Preventive hospitalization (36-37 weeks)
3. Conducting of labor depends on fertus presentation, concomitant risk factors
4. Delivery
1) Caesarean section – planning with concomitant reason
URGENT – due to increasing of bleeding
2) Vaginal way – possible with cephalic presentation, good labor activity, average
mass of fetus
Tactic: after dilatation of cervix to 3-4 sm ⇒ amniotomy ⇒ in a case of bleeding
absence vaginal delivery is possible.

ABRUPTION PLACENTAE (A.P.)

A.P. – normally placenta (not a placental previa) prematurely separates from the uterus before
the delivery of the fertus

The hemorrhage involved in placental abruption includes:

1. External hemorrhage – causes:
o peripheral detachment of the placenta
o escape of blood through the cervix
o external bleeding
2. Concealed hemorrhage – occurs between placenta uterus without external bleeding.
Frequency – 1 out of 100-120 deliveries.

ETIOLOGY:
1. Maternal hypertension (gestosis, eclampsia)
2. After delivery of the first of multiple fetuses
3. Premature rupture of membranes
4. Short umbilical cord
5. Bad habits (smocking, drugs)

Recurrence risk ⇒ HIGH

- 10 % after one abortion
- 25 % after two

CLINIC:
1) pain in abdomen (from mild to knife like pain) in the point of abruption
2) uterine tenderness and hyperactivity
3) changes of fetal movement (intrauterine hypoxia)
4) vaginal bleeding (in 20% of cases bleeding may be concealed)

MANAGEMENT:
1. Hospitalization immediately
2. Ultrasound diagnostic
3. In a case of confirmed of diagnosis – IMMEDIATELY CAESAREAN SECTION

ATTENTION: A.P. ⇒ risk factor No 1 of disseminated intravascular coagulation and secondary

hypovolemia due to blood loss
COMPLICATIONS:
1) Hemorrhagic shock – can occur with either concealed and external bleeding
2) Consumption coagulopathy
3) Couvelaire uterus – caused by widespread extravasations of blood into the uterine
musculature. Blood infiltrate the myometrium, blue discoloration (“murmur
utery”)
MANAGEMENT: HYSTERECTOMY.

HYDATIDIFORM MOLE (MOLAR PREGNANCY)

DEFINITION
– abnormal proliferation of the syncitiotrophoblast replacement of normal placental
trophoblastic tissue by hydropic placental villie
– don’t include the formation of fetus and fetal membranes
– capable of invasion and malignant transgormation into carcinoma
– secrets HCG
CLINIC:
1. Vaginal bleeding
2. Increasing of utery
DIAGNOSIS:
1. Ultrasound diagnostic
Specific sign – snowstorm pattern
2. High concentration of HCG
TREATMENT:
1. Hospitalization
2. Uterine curettage
3. Histological examination