BLEEDING IN SECOND HALF OF

PREGNANCY
DR DOHBIT SAMA
DEPT. OBS/GYN
FMBS, UY I.

INTRODUCTION

Bleeding in the third trimester constitutes the leading

cause of maternal mortality in our country
Also a major cause of perinatal morbidity and
mortality
Would require medical evaluation in 5 10% of
pregnancies
Some are mild bleeding even though caused at
times by a life threatening disorder

PLAN

1. Introduction
2. Classification
3. Management principles
4. Hypovolemic shock
5. The unstable and the stable patient
6. Ultrasound and vaginal examination
7. Management
8. Conclusion

INTRODUCTION 2
Almost

always maternal blood is lost

Foetal blood loss is possible if the placenta is
traumatized as in cases of vasa praevia
Foetal blood confirmed by observing
nucleated red cells in the vagina and by
electrophoresis

CLASSIFICATION
Obstetric

causes are more hazardous

In 2 3% of pregnancies the patients lose
more than 800mls
Mostly due to premature placenta separation
(abruptio), and placenta praevia

CLASSIFICATION 2
Less

common causes are circumvallate

placenta
Marginal sinus rupture, peripheral portion of
intervillous space; considered as variants of
ABRUPTIO
Clotting disorders and
Uterine rupture (before or during labour)

CLASSIFICATION 3
Bloody

show is the most common cause in

late pregnancy.
Blood lose may be enough to cause concern
in the mother
Medical intervention is almost never
necessary

CLASSIFICATION 4
Obstetric causes

Non obstetric

Bloody show

Ca cervix or dysplasia

Placenta praevia

Cervicitis(trichom,gonococcu
s, HSV, chlamydia)

Abruptio placentae

Cervical polyps

Vasa praevia

Cervical eversion

DIC

Vaginal laceration

Uterine rupture

Vaginitis

Marginal sinus bleed

Vaginal varicosities etc

MANAGEMENT PRINCIPLES
Patient

handled in a good hospital setting

NO VAGINAL EXAMINATION, NO RECTAL
EXAMINATION until placenta praevia is ruled
out
Or preparations are ready to deal with
massive haemorrhage (double setup)
Quick recognition of hypovolemic shock

HYPOVOLEMIC SHOCK
Pallor,

syncope, thirst, dyspnoea,

restlessness, agitation, anxiety, confusion,
falling BP, tachycardia, thready pulse,
oliguria, cold extremities etc.
Most healthy gravidas will remain stable until
1500cc of blood is lost. Thereafter they will
rapidly decompensate
Apply ABCDs in the unstable patient

HYPOVOLEMIC SHOCK - ABCDs

Patent

airway
Trendelenburg with left tilt
Patent IV lines
The D is continuous foetal monitoring using
the Doppler ultrasound
IV filling and prepare for blood transfusion
At times invasive hemodynamic monitoring
may be necessary

ABCDs
Team

work with reanimators

Vasoactive drugs like phenylephrine

THE STABLE PATIENT

The

cause must be quickly identified

Bedside ultrasound examination to locate the
placenta and evaluate the foetal wellbeing
Measure and mark the fundal height
Leopolds to look for engagement = PP.
Continuous hemodynamic monitor!!!

THE STABLE PATIENT 2

Laboratory:

blood type and cross-match,

FBC, baseline coagulation status,
D-Dimer and PDF (fibrin split products) when
abruptio is suspected
The use of CA-125 in abruptio; takes time!
The Kleihauer-Betke test in the rhesus
negative patient
Meet the conditions for vaginal examination

VAGINAL EXAM
Placenta

praevia must have been excluded

Speculum examination to look for non
obstetric causes
Digital examination to look for labor
After excluding the other causes, abruptio
becomes the assumed diagnosis

ECHOGRAPHY
Transvaginal

in experienced hands is safe

and more useful in posterior placentas
Otherwise the transabdominal route is safer
Amniocentesis may be done to assess foetal
maturity

MANAGEMENT OPTIONS
Immediate

delivery

Continued

labour

Expectant

management, all depend on the

diagnosis. In 90% of cases of 3rd trimester
bleeding, the bleeding stops within 24 hours.

PLACENTA ABRUPTIO

It is separation of the placenta from its site of

implantation before the foetus is delivered
Occurs 1 in 77-89 deliveries
The severe form leading to foetal death occurs 1 in
500-750 deliveries
30% of 3rd trimester bleeding
50% before labour
Unremittent abdominal (uterine) or back pain
Irritable, tender and often hypertonic uterus

PLACENTA ABRUPTIO 2
Visible

or external in 80%
Concealed (20%) bleeding
Foetal distress may be present
10% with DIC
Other complications related to blood loss and
shock
Revisit placenta praevia and uterine rupture

CONCLUSION
Third

trimester bleeding is a serious obstetric

complication
Very careful diagnostic workup is essential in
management
Blood loss remains a major cause of
maternal mortality in our milieu

THANK YOU

MERCI