Vaginal bleeding in later pregnancy and labour

PROBLEMS

• Vaginal bleeding after 22 weeks of pregnancy.

• Vaginal bleeding in labour before delivery.

TABLE S-5

   Types of bleeding

GENERAL MANAGEMENT

• SHOUT FOR HELP. Urgently mobilize all available personnel.

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

 Do not do a vaginal examination at this stage. 

• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly.  If shock develops, it is important to begin treatment immediately. 

•  

  Start an IV infusion and infuse IV fluids.

DIAGNOSIS

TABLE S-6

Diagnosis of antepartum haemorrhage 

MANAGEMENT

ABRUPTIO PLACENTAE

Abruptio placentae is the detachment of a normally located placenta from the uterus before the fetus is delivered.

• Assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

• Transfuse as necessary, preferably with fresh blood.

• If bleeding is heavy (evident or hidden), deliver as soon as possible:

- If the cervix is fully dilated, deliver by vacuum extraction;

- If vaginal delivery is not imminent, deliver by caesarean section.

Note: In every case of abruptio placentae, be prepared for postpartum haemorrhage.

• If bleeding is light to moderate (the mother is not in immediate danger), the course of action depends on the fetal heart sounds:

- If fetal heart rate is normal or absent, rupture the membranes with an amniotic hook or a Kocher clamp:

- If contractions are poor, augment labour with oxytocin;

- If the cervix is unfavourable (firm, thick, closed), perform caesarean section.

- If fetal heart rate is abnormal (less than 100 or more than 180 beats per minute):

- Perform rapid vaginal delivery;

- If vaginal delivery is not possible, deliver by immediate caesarean section.

COAGULOPATHY (CLOTTING FAILURE)

Coagulopathy is both a cause and a result of massive obstetric haemorrhage. It can be triggered by abruptio placentae, fetal death in-utero, eclampsia, amniotic fluid embolism and many other causes. The clinical picture ranges from major haemorrhage, with or without thrombotic complications, to a clinically stable state that can be detected only by laboratory testing. 

Note: In many cases of acute blood loss, the development of coagulopathy can be prevented if blood volume is restored promptly by infusion of IV fluids (normal saline or Ringer’s lactate).

• Treat the possible cause of coagulation failure:

- abruptio placentae;

- eclampsia.

• Use blood products to help control haemorrhage:

- Give fresh whole blood, if available, to replace clotting factors and red cells;

- If fresh whole blood is not available, choose one of the following based on availability: 

- fresh frozen plasma for replacement of clotting factors (15 mL/kg body weight);

- packed (or sedimented) red cells for red cell replacement;

- cryoprecipitate to replace fibrinogen;

- platelet concentrates (if bleeding continues and the platelet count is less than 20 000).

RUPTURED UTERUS

Bleeding from a ruptured uterus may occur vaginally unless the fetal head blocks the pelvis. Bleeding may also occur intra-abdominally. Rupture of the lower uterine segment into the
broad ligament, however, will not release blood into the abdominal cavity (Fig S-2).

Figure S-2

  Rupture of lower uterine segment into broad ligament will not release blood into the abdominal cavity 

• Restore blood volume by infusing IV fluids (normal saline or Ringer’s lactate) before surgery.

• When stable, immediately perform caesarean section and deliver baby and placenta. 

• If the uterus can be repaired with less operative risk than hysterectomy would entail and the edges of the tear are not necrotic, repair the uterus. This involves less time and blood loss than hysterectomy.

Because there is an increased risk of rupture with subsequent pregnancies, the option of permanent contraception needs to be discussed with the woman after the emergency is over. 

• If the uterus cannot be repaired, perform subtotal hysterectomy. If the tear extends through the cervix and vagina, total hysterectomy may be required.

PLACENTA PRAEVIA

Placenta praevia is implantation of the placenta at or near the cervix (Fig S-3).

Figure S-3

 Implantation of the placenta at or near the cervix. 

Warning: Do not perform a vaginal examination unless preparations have been made for immediate caesarean section. A careful speculum examination may be performed to rule out other causes of bleeding such as cervicitis, trauma, cervical polyps or cervical malignancy. The presence of these, however, does not rule out placenta praevia.

• Restore blood volume by infusing IV fluids (normal saline or Ringer’s lactate).

• Assess the amount of bleeding:

- If bleeding is heavy and continuous, arrange for caesarean delivery irrespective of fetal maturity;

- If bleeding is light or if it has stopped and the fetus is alive but premature, consider expectant management until delivery or heavy bleeding occurs:

- Keep the woman in the hospital until delivery;

- Correct anaemia with ferrous sulfate or ferrous fumerate 60 mg by mouth daily for 6 months;

- Ensure that blood is available for transfusion, if required;

- If bleeding recurs, decide management after weighing benefits and risks for the woman and fetus of further expectant management versus delivery.

CONFIRMING THE DIAGNOSIS

• If a reliable ultrasound examination can be performed, localize the placenta. If placenta praevia is confirmed and the fetus is mature, plan delivery.

• If ultrasound is not available or the report is unreliable and the pregnancy is less than 37 weeks, manage as placenta praevia until 37 weeks.

• If ultrasound is not available or the report is unreliable and the pregnancy is 37 weeks or more, examine under double set-up to exclude placenta praevia. The double set-up prepares for either vaginal or caesarean delivery, as follows:

- IV lines are running and cross-matched blood is available;

- The woman is in the operating theatre with the surgical team present;

- A high-level disinfected vaginal speculum is used to see the cervix. 

• If the cervix is partly dilated and placental tissue is visible, confirm placenta praevia and plan delivery.

• If the cervix is not dilated, cautiously palpate the vaginal fornices:

- If spongy tissue is felt, confirm placenta praevia and plan delivery; 

- If a firm fetal head is felt, rule out major placenta praevia and proceed to deliver by induction.

• If a diagnosis of placenta praevia is still in doubt, perform a cautious digital examination:

- If soft tissue is felt within the cervix, confirm placenta praevia and plan delivery (below);

- If membranes and fetal parts are felt both centrally and marginally, rule out placenta praevia and proceed to deliver by induction.

DELIVERY

• Plan delivery if:

- the fetus is mature;

- the fetus is dead or has an anomaly not compatible with life (e.g. anencephaly);

- the woman’s life is at risk because of excessive blood loss.

• If there is low placental implantation (Fig S-3 A) and bleeding is light, vaginal delivery may be possible. Otherwise, deliver by caesarean section.

Note: Women with placenta praevia are at high risk for postpartum haemorrhage and placenta accreta/increta, a common finding at the site of a previous caesarean scar.

• If delivered by caesarean section and there is bleeding from the placental site:

- Under-run the bleeding sites with sutures; 

- Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute.

• If bleeding occurs during the postpartum period, initiate appropriate management. This may include artery ligation or hysterectomy.

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