Bleeding During the Second Half of Pregnancy
Not yet clinically reviewed
This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.
Three conditions -placenta praevia, abruptio placentae, and uterine rupture - can quickly become life - threatening to both mother and child. These conditions must be referred to surgical facilities. When no cause of the bleeding is found, consider the possibility of premature labor Placenta praevia may give rise to bleeding during third trimester and carries a high risk of hemorrhage during delivery.
Clinical features and diagnosis
- Sudden, painless, slight or significant b right red bleeding.
- The vaginal exam must be done with extreme care to avoid triggering massive bleeding: uterus is soft; the exam may reveal displacement of the cervix and deformation of the lower uterine segment by the placenta praevia ; if the cervix is dilated , the placenta can be felt in the cervix . Do not repeat the examination.
- If ultrasound is available, vaginal examination can be avoided.
Management
- If labor has not yet started and bleeding is light: advice bed rest and monitoring.
- If labor has started and / or bleeding is heavy: refer to surgical facility
- Abruptio placenta: Hematoma that forms between the placenta and the uterine wall a result of separation of the placenta, prior to foetal expulsion.
Clinical features
- Dark slight bleeding, sometimes absent, or shock not always consistent with the external blood loss as bleeding is internal.
- Sudden, severe, continuous abdominal pain.
- Tightly contracted uterus; often, fetal heart sounds absent (fetal death).
- Often occurs in a context of pre - eclampsia.
Management
Refer to surgical facility. Uterine rupture: Tear in the uterine wall, in most cases during labor, often related to inappropriate use of oxytocin.
Clinical features
- Impending rupture: prolonged labor, agitation, alteration of the general state, poor uterine relaxation, continuous abdominal pain, more severe than the contractions.
- Rupture: disappearance of uterine contractions, shock; sometimes, palpation of the dead fetus expelled into the maternal abdomen.
Management
Refer to surgical facility for emergency laparotomy