Bleeding in early pregnancy

2 February 2016
Presentation Outline

 Expected learning outcomes

 Introduction
 Effects of early PV bleeding on the mother.
 The role of the midwife
 The principles of managing early PV bleeding
Expected learning outcomes

By the end of the lesson, students should be

able to:
 Outline the role of the midwife in managing
women who present with vaginal bleeding
during pregnancy.
 Discuss the principles of managing women
presenting with vaginal bleeding
Expected learning outcomes cont..

 Outline the causes of bleeding in early

pregnancy
 Describe the classification of miscarriages
 Discuss the management of women who
present with miscarriages at health facilities
Introduction

 Why should be midwives be concerned

about bleeding per vagina (PV) during
pregnancy?
Introduction

 Any form of PV bleeding in early pregnancy

is considered abnormal.
 Any form of PV bleeding in pregnancy
causes anxiety in the mother.
 The midwife should be sensitive to this
emotional situation when caring for women
bleeding PV.
Midwife’s role in managing pregnant women
presenting with PV bleeding

 Initial and subsequent encounters

– The midwife should obtain accurate health history
– Obtain circumstances around the bleeding
– Check vital signs and note abnormalities
– Manage the abnormalities and report /refer where
indicated
Midwife’s role in managing pregnant women
presenting with PV bleeding

 Initial and subsequent encounters

– General physical examination (head to toe)
– Specific physical examination (focused)
– Identify any deviations from normal
– Perform relevant investigations and note results
– Timely referral for further management
Midwife’s role cont..

 Make yourself available

 Provide the relevant support
 Provide the relevant information (counselling
the woman, partner and family)
 Effective coordination and collaboration of
care among different healthcare providers
care
Principles of management cont...

 Estimate the amount of blood lost

 Observe the colour of blood lost-red/dark
brown
 Is the woman still bleeding now?
 Recent episodes of headache, nausea
and /or vomiting.
 Currently -any pain
 Careful recording of all observations
The aim of management

 The aim is to:

– establish the cause
– preserve life (maternal or foetal life)
Assess maternal condition

 General appearance
 Colour,skin
 Any pain-nature and intensity, triggering
factor
 Check for signs of dehydration-dry/moist skin
 Respirations, pulse and blood pressure.
Assess foetal condition

 Foetal condition depends on the gestational

age
 Ask about fetal movements if foetal viability
 Note any foetal movements
 Auscultate foetal heart for
– Rhythm
– Regularity
– Normal beats ,110-160) betas per minute
Assess foetal condition

 If the time is before foetal viability,use the

Ultrasound scan (USS) to assess:
– gestational age
– foetal heart rate
– foetal movements
 Causes of vaginal bleeding in early
pregnancy

 At times the cause is unknown

 Some of the causes include:
 Miscellaneous causes
– Implantation bleed
– cervical lesions
– Cervical polyps
Causes of vaginal bleeding in early
pregnancy

– Carcinoma of the cervix

 Spontaneous miscarriage
 Ruptured tubal ectopic pregnancy
 Hydartidform mole
 Placenta praevia –occurs in the second
trimester
Miscellaneous causes

 Implantation bleeding
– Occurs when the trophoblast erodes the
endometrial epithelium to facilitate implant
– May be confused with a menstrual period
Implantation bleeding

 Characteristics of implantation bleeding

– Occurs 7-9 days following implantation of the
blastocyst.
– Lighter than a normal menstrual period of the
individual
– Bright red in colour
– Sets quickly when the blastocyst is embedded.
 Management-reassure the mother
Cervical lesions

 Cervical lesions include:

– cervical ectropion and
– cervical polyps
Cervical lesions cont...

 Cervical ectropion
– Oestrogen causes proliferation of
columnar epithelium cells
– The columnar epithelium cells pouts in the
eternal cervical os
– These columnar epithelium cells encroach
on the squamous epithelial cells
Cervical ectropion cont..

 Due to vascularity of the cells there may be:

– Intermittent bleeding may occur
– Spontaneous bleeding usually following
sexual intercourse
 Treatment
– not normally required-reassure
– usually resolves in the puerperium
Cervical Polyps

 These are small vascular pedunculated

growths attached to the cervix( Fraser
& Cooper ,2012:93).
 Can be viewed on speculum
examination
Cervical Polyps cont..

 They consist of :
– Squamous or columnar epithelial cells
over a connective tissue with rich blood
vessels (Crafter &Brewster,2014:223)
– Cause bleeding –no treatment is required;
reassure.
– Treat if bleeding is severe or in case of
malignancy.
Carcinoma of the cervix

 Common gynecological malignancy

occurring in pregnancy .
 Incidence;1:2200
pregnancies(Copeland & Landon,2011
as quoted by Crafter
Brewster,2014:223).
Carcinoma of the cervix cont.…

 Signs and symptoms:

– Vaginal bleeding –most common
– Increased vaginal discharge

 Diagnosis
– VIA-Visual inspection using acetic acid
– Papanicolau smear (Pap Smear)
– Colposcopic examination-identify extend of lesion
Treatment of carcinoma of the cervix

 Depends on gestational age and

 Stage of the disease
 Educate the woman and her family on the
available options and their outcome
 Allow the woman and her family to make an
informed decision.
Treatment of carcinoma of the cervix
cont..

 Early stages-delay treatment or

– Cone biopsy to remove affected part

 Late stages
– decide on mode of delivery
– most likely caesarean section and
– total abdominal hysterectomy
Treatment of carcinoma of the cervix
cont..

 Followed by:
– chemotherapy and
– radiotherapy
Spontaneous miscarriage

 Spontaneous miscarriage is the termination

of pregnancy before 24 weeks.
 Incidence:15-20% of booked pregnancies
 The majority occur in the first trimester
 1-2% occur between 13-24weeks
Causes of spontaneous miscarriage

 There are foetal and maternal causes

Foetal causes of spontaneous
miscarriage

 Genetic causes are mainly

chromosomal defects such as:
– autosomal trisomies (50% of the
abnormalities)
– monosomy x or
– polyploidy-20% each
 Disease of the fertilised ovum
Maternal causes of spontaneous
miscarriage

 Disease -illness and infection

 Drugs
 ABO incompatibility
 Psychological factors
 Endocrine factors
Maternal causes of spontaneous
miscarriage

 Local disorders of the genital tract

– A retroverted uterus
– Developmental defects e.g.
bicornuate uterus
– Cervical incompetence
 Autoimmune factors
Disease and illness

 Diseases acquired during pregnancy may:

– interfere with trans placental oxygenation.
– hence trigger a miscarriage e.g. rubella and any
pyrexia.

 Chronic disorders e.g. renal disease

complicated with hypertension
Drugs

 Large doses should be avoided

 Contact with toxic substances
ABO Incompatibility

 ABO incompatibility between mother and

embryo
Psychological and endocrine
factors

 Stress can affect the function of the :

– Hypothalamic region of the brain and
– The pituitary gland
Local disorders of the genital tract

 Risk of STIs resulting in:

– lower genital tract infection (infection of the
vagina and cervix)
– risk is increased in women aged 16-
25years
 Common infections include:
– Chlamydia trachomatis and
– Neisseria gonorrhoea
Retroverted uterus

 A retroverted uterus may not be able to rise

out o the pelvis
 Diagnosis is done in early pregnancy through
and USS
 The anomaly can be corrected
Developmental defects-Bicornuate
Uterus

 Bicornuate uterus and myomas can distort

the uterine cavity
 This anomaly may also distort the uterine
cavity and inhibit uterine enlargement.
 This may result in a miscarriage
Cervical incompetence

 Painless dilatation of the cervix

 Occurs in the second or third trimester
 Membranes bulge through the cervical os
 Miscarriage or preterm delivery may occur
Causes of cervical incompetence

 Congenital weakness of the cervix

 Cone biopsy
 Trauma to the cervix e.g. due to dilatation
and curettage (D&C)
Diagnosis of cervical
incompetence

 History –subsequent unexplained

miscarriages
 Speculum examination
Management of cervical
incompetence

 Cervical cerclage –research is on going

– Non -absorbable suture inserted at 14
weeks
– This suture is inserted at the level of
the internal os and
 Removed at term or prior to onset of labour
at term
Ruptured ectopic pregnancy

• Occurs when the ovum develops in the

fallopian tubes and the fallopian tube
eventually ruptures.
• Management:
• Resuscitation
• Inform the doctor
• Doctor will decide on a Salpingectomy
Possible outcomes of potential
miscarriage (abortion)

 Refer to word document

Management of miscarriages

 Reassurance
 Foetal viability-monitor pregnancy
 Complete-no further treatment
 Incomplete :
– Resuscitation
– Surgical evacuation of the uterus
 Prophylactic antibiotics
Indications for evacuation

 Persistent heavy bleeding

 Haemodynamic instability
 Evidence of infected retained tissue
 Suspected gestational trophoblastic disease
Complications of surgery

 Perforation of the uterus

 Cervical tears
 Intra-abdominal trauma
 Bleeding
 Intrauterine adhesions
Medical management

 Use of:
– prostaglandins with /without
– antiprogesterone
Expectant management

 Exclude infection and heavy bleeding

 Wait for spontaneous expulsion of the
products of conception
 May take several weeks
 More successful in incomplete miscarriages
References
 Crafter,H. and Brewster ,J. in Mashall,J. and Raynor, M.(2014). Myles
Textbook for Midwives .Sixteenth Edition.International Edition.Churchill
Livingstone.Elservier.London.
 Joan Dippenaar and Dicky da Serra (2013).Revising Editors.Sellers’
Midwifery.Second Edition.Juta.Cape Town. South Africa.
 Fraser , D.M. and Cooper , M.A. (2012). Midwifery. Survival Guide. Se
cond Edition. Elsevier Limited. London.
 Fraser , D.M. and Cooper , M.A. (2009). Myles Textbook for Midwives.
15
th
Edition. Elsevier .Churchill Livingstone.
 Fraser , D.M. and Cooper , M.A. (2003). Myles Textbook for Midwives.
14
th
Edition. Elsevier Limited. London.
Take home assignment

 Read about the causes of bleeding in late

pregnancy i.e. in the second and third
trimesters.