TABLE 21.1 SUMMARY OF PRIMARY CAUSES OF BLEEDING DURING PREGNANCY Time Type Cause First and Threatened. Unknown; second spontaneous _ possibly trimester miscarriage chromosomal (early: under or uterine 16 weeks; abnormalities late: 16 to 24 weeks) Imminent Unknown (inevitable) reasons but miscarriage _possibly poor placental attachment Missed Unknown miscarriage Assessment Vaginal spotting, perhaps slight cramping ‘Vaginal spotting, cramping, cervical dilatation ‘Vaginal spotting, perhaps slight cramping; no apparent loss of pregnancy Cautions Caution women not to use tampons to halt bleeding as this can lead to infection. Disseminated intravascular coagulation is associated with missed miscarriage.Incomplete spontaneous miscarriage Complete spontaneous miscarriage Unknown; possibly chromosomal or uterine abnormalities Unknown but possibly chromosomal or uterine abnormalities High risk for uterine infection and hemorrhage Vaginal spotting, cramping, cervical dilatation, but incomplete expulsion of uterine contents ‘Vaginal spotting, cramping, cervical dilatation, and complete expulsion of uterineEctopic (tubal) Second Gestational trimester trophoblastic (hydatidiform Implantation of Sudden May have repeat zygote at site unilateral ectopic pregnancy other than in lower in future if tubal uterus, abdominal scaring is bilateral associated quadrant with tubal pain: constrictures minimal vaginal bleeding, possible signs of hypovolemic shock or hemorrhage Abnormal Overgrowth of Retained trophoblast of highly malignant trophoblast —_positive (choriocarcinoma); cells; human follow for 6 fertilization chorionic months to | year or division gonadotropin with hCG testing defect (hCG) test; no fetus present on ultrasound; bleeding from vagina of old or fresh blood accompanied hy eystThird trimester Premature dilatation Placenta previa Premature separation of the placenta (abruptio placentae) Cervix begins to dilate and pregnancy is lost at about 20 weeks; unknown cause but cervical trauma from dilatation and curettage (D&C) may be associated. Low implantation of placenta possibly because of uterine abnormality Unknown, cause; associated with hypertension; placenta separates from uterus before birth of fetus Painless bleeding leading to expulsion of fetus Painless bleeding at beginning of cervical dilatation Sharp abdominal pain followed by uterine tenderness; vaginal bleeding; signs of maternal hypovolemic shock, fetal distress Can have cervical sutures placed to ensure a second Pregnancy Don’t allow a vaginal examination to minimize placental trauma. Disseminated intravascular coagulation is associated with condition.Preterm labor Many possible Show (pink- Preterm labor may be etiologic stained halted if the cervix factors such vaginal is less than 4 cm as trauma, discharge) dilated and the substance accompanied — membranes are abuse, by uterine intact. hypertension —_ contractions Corticosteroids are of becoming administered to aid pregnancy, —regularand —_fetal lung or cervicitis; effective maturity. increased chance in multiple gestation, maternal 1165 illness.