Bleeding in late

pregnancy

Antepartum Hemorrhage

ANTEPARTUM HEMORRHAGE:
Is

defined as bleeding occurring from

the genital tract after the 24th week of

pregnancy, before the birth of the
infant.

CLASSIFICATION:
Placental

previa- Inevitable hemorrhage

occurs from separation of an abnormally situated

placenta. The placenta lies partly or wholly in
the lower uterine segment.

Abruptio

placentae- bleeding occurs from the

premature separation of a normally situated

placenta.

Extraplacental

bleeding- is vaginal bleeding

from some , other part of the birth canal e.g.,

cervical polyp, varicose veins of the vulva, ...etc

COMPLICATIONS OF ANTEPARTUM
HEMORRHAGE:

Maternal risks:

Hemorrhagic shock

Acute renal failure

Disseminated intravascular coagulation

(DIC) or coagulopathy.

Severe anemia

COMPLICATIONS OF ANTEPARTUM
HEMORRHAGE:

Fetal risks:
Prematurity

and birth asphyxia.

Intrauterine

fetal death

Placenta previa:
Is

a condition in

which the placenta

is partly or totally
implanted over the
lower uterine
segment.

PREDISPOSING FACTORS:
Grand

multiparity/Multiple gestation

Advanced

maternal age

Hydrominous
Hypertensive
History

disorders of pregnancy

of previous bleeding.

Previous

cesarean sections

CAUSES:
Persistence

of chorionic villi over the decidua

capsularis .
Implantation of the zygote low down in the
uterine cavity.
In case of deficient blood supply of the decidua,
the placenta acquired wider area of attachment.
Placenta of large size.

INCIDENCE:
Occurs in
5%
of all pregnancies

DEGREES:

Type I: Placenta previa lateralis.

Type II: Placenta previa marginalis.

Type III: Incomplete central placenta previa.

Type IV: Complete central placenta previa.

Degrees of Placenta Previa

A. Type one/low laying/Lateral Placenta
previa
Majority of the placenta is in the upper
uterine segment.
Vaginal delivery is possible
Blood loss is mild.
Mother and fetus are in good health
condition.

B. Type II placenta previa/marginal/Marginalis

The placenta is partially located in the lower
uterine segment near the internal cervical os.
Vaginal delivery is possible particularly if the
placenta is anterior.
Blood loss is moderate.
Mother & fetus condition is varying. May be
mother is in shock and fetal hypoxia may occur.
Fetal hypoxia is more likely to occur than
maternal shock.

C. TYPE III Placenta previa/Partial/Partialis

The placenta is located over the internal os but
not centrally.
Vaginal delivery is inappropriate because of the
placenta precedes the fetus.
Blood loss is severe, particularly when lower
segment stretches and cervix begins effacement
and dilates in the pregnancy.

D. Type IV placenta previa/central/total/totalis

The placenta is located centrally over the internal
os.
Vaginal delivery should not be considered.
Blood loss is very severe.
Lower segment Caesarean section (LSCS ) is
essential in order to save the life of mother and
fetus.

SIGNS AND SYMPTOMS:

Symptoms:
Vaginal

bleeding:
- painless: except during labor
- causeless: not associated with toxemia or trauma
- recurrent: in severe degree,(the 3rd & 4th degrees)
- may be moderate, mild or severe.
- bright red in color i.e fresh blood.
Symptoms attributed to blood loss, such as:
- easy fatigability.
- palpitation.
Hemorrhagic shock, if bleeding is severe.

Signs:

General

signs:
- depend on the amount of blood loss such as:
pale, anemic, air hunger, cold extremities,
drowsiness, tachycardia, subnormal temperature
and lowered BP.
Local abdominal signs:
- the uterus is lax and not tender
- malpresentation is common.
- presnting part is not engaged.
Vaginal signs:
- Usually P.V precipitates a fatal hemorrhage

DIAGNOSIS:
Localization

of the placenta:

-Through U/S
Differential diagnosis:
- accidental hemorrhage
- incidental hemorrhage.
- spontaneous rupture of the uterus
- bleeding piles or urethral polyp
mistaken for hemorrhage from the
genital tract

EFFECTS OF PLACENTA ON PREVIA

ON PREGNANCY AND LABOR:
Lower the general resistance of the patient
Abnormal presentation and position.
Premature labor.
Prolonged labor
More chance of surgical intervention.
Post partum hge
Fetal malformation.
Fetal hypoxia and mortality.
Maternal shock.
Maternal mortality

MANAGEMENT:( AT
HOSPITAL)
I- Conservative treatment:
If

bleeding is slight, observe carefully and

correct anemia.
If bleeding is moderate or severe, blood
transfusion.

MANAGEMENT:( AT
HOSPITAL)
II- Active treatment:
Artificial rupture of membrane is indicated when:
- bleeding is slight.
- the placenta is of the 1st or 2nd degree.
- the fetus lies longitudinally.
- the patient is in labor, with good uterine
contraction.
Cesarean section is indicated if:
- the patient has lost a large amount of blood.
- placenta of 3rd & 4th degrees.
- old primigravida or multipara.
- severe bleeding on P.V.

ROLE OF THE NURSE:

Immediate referral regardless the amount of
bleeding
History taking, pelvic or u/s examination.
Bed rest and restriction of physical activity
Avoid constipation, enemas, vagina examination
( if necessary, it must be done in the operating
room).
Follow strict aseptic technique to avoid infection.
Continuous observation of bleeding and signs of
shock
Continuous fetal assessment every 4 hrs.

ROLE OF THE NURSE:

Maintain fluid balance.
Record intake and output
Observe v/s.
Be sure that laboratory work done.
Observe for signs of premature labor
Continuous observation natally and
postnatally for possibility of
postpartum hge and infection.

BLEEDING IN LATE
PREGNANCY
Antepartum
Hemorrhage

ABRUPTIO PLACENTA :
Is

bleeding during the last

three months of pregnancy, the

first or second stage of labor,
due to premature separation of
a normally situated placenta.

CAUSES:
Trauma
Vit

C and K deficiencies.

Torsion

of the pregnant uterus.

Traction
Sudden

uterus.

on a short umbilical cord.

reduction of the size of the

TYPES:
1.

Revealed.

2.

Concealed

3.

Combined

SIGNS AND SYMPTOMS:

These depend on the type of

hemorrhage present:
Revealed

bleeding:
- vaginal bleeding
- signs of blood loss are present
- lax uterus between contraction
- painful contractions are present
- fetal parts are easily felt.
- fetal head may be fixed or engaged in
the pelvis

SIGNS AND SYMPTOMS:

Concealed:

- Sudden, severe abdominal pain

followed by fainting and vomiting.
- Shock is always present.
- Patient become pale and irritable.

- Systolic pressure decreases while diastolic

remain increased.
- The abdomen is very tender and rigid
- The uterus is very hard and larger than expected
- IN severe shock, no uterine contractions are felt
- Some scanty dark bleeding.
- Edema of lower limbs.

SIGNS AND SYMPTOMS:

Combined

accidental bleeding:
- The blood is partially revealed
and partly concealed.
- Signs and symptoms depend on
the amount of blood loss and
whether it is more revealed or
concealed.

DIFFERENTIAL DIAGNOSIS:
Placenta

previa

Incidental
Ruptured
Twisted
Acute

bleeding

uterus

ovarian cyst.

surgical emergencies.

COMPLICATIONS:
Hemorrhage
Acute

renal failure

Postpartum
Pituitary

hemorrhage

necrosis

MANAGEMENT
Depend upon the severity of the abruption, the gestational age,
and maternal and fetal status
Principles:

Correct general condition

Empty the uterus.
Prevent or treat postpartum hemorrhage.

General treatment:

Treatment of toxemia
Replacement of blood loss.
Treatment of shock

Obstetric treatment:

In the presence of painful uterine contractions: artificial rupture of

membrane.
In the presence of labor pain: IV syntocin drips.
When labor pains are established: the treatment is continued as above
When the drip is failed, CS must be done.

Initial interventions for women with potentially severe acute abruption:

1. Immediately initiate continuous fetal monitoring.
2. Secure intravenous access with at least one, and preferably two, widebore intravenous lines.
3. Closely monitor the mother's hemodynamic status (heart rate, blood
pressure, urine output).
4. Urine output should be maintained at above 30mL/hourand
monitored with a Foley catheter.
Note: Assessment of multiple parameters is important because normal
blood pressure may mask hypovolemia if the mother
ashypertensive/preeclampticprior to the abruption.
5. Keep maternal oxygen saturation >95 percent and keep the patient
warm.
6. Estimate the extent of blood loss by collection in a volumetric
containerand/orby weighingpads/towelsused to absorb vaginal
bleeding.
7. Draw blood for a complete blood count, blood type and Rh, and
coagulation studies.
8. A crude clotting test can be performed at the bedside by placing 5 mL
of the patient's blood in a tube with no anticoagulant for 10 minutes .
Failure to clot within this time or dissolution of an initial clot implies
impairment of coagulation, and is suggestive of a low fibrinogen level.

NURSING MANAGEMENT:
1. Continuous evaluate maternal and fetal physiologic status,
particularly:
Vital Signs
Bleeding
Electronic fetal and maternal monitoring tracings

Signs of shock rapid pulse, cold and moist skin, decrease

in blood pressure
Assessment and recording of I&O.
Never perform a vaginal or rectalexaminationor take any
action that would stimulate uterine activity.
2. Asses the need for immediate delivery.
If the client is in active labor and bleeding cannot be
stopped with bed rest, emergency cesarean delivery may be
indicated.

3. Provide appropriate management.

place

the woman on bed rest in a lateral position to prevent

pressure on the vena cava.
Insert a large gauge intravenous catheter into a large vein for
fluid replacement. Obtain a blood sample for fibrinogen level.
Monitor the FHR externally and measure maternal vital signs
every 5 to 15 minutes. Administer oxygen to the mother by mask.
Prepare for cesarean section, which is themethodof choice for
the birth
Prevent

post partum hemorrhage through continuous

observation of bleeding, lochia and uterine contractility
4.Provide client and family teaching.
5. Address emotional and psychosocial needs.
Outcome for the mother and fetus depends on the extent of
the separation, amount of fetal hypoxia and amount of
bleeding.

More thanks for

patience