Puerperal blood loss, occurring outside the rules. In women of childbearing age, always inquire whether the bleeding is related to pregnancy.
In all cases:
– Quickly assess the extent of blood loss.
– If major bleeding or shock or if a surgical procedure (laparotomy, caesarean section) is required:
• Insert an IV line and Ringer lactate infusion; constant monitoring (pulse, BP)
• Prepare for a possible transfusion (grouping of the patient and potential donors)
• in case of transfusion, transfused blood tested at least HIV, hepatitis B and hepatitis C.
– In case of transfer to a surgical facility, difficult transport conditions can worsen the bleeding: the patient should be infused and accompanied by family members may donate blood.
– Ultrasound is not necessary but facilitates certain diagnoses (ectopic pregnancy, placenta praevia, for example).
– Prevent or treat anemia associated.
Bleeding unrelated to pregnancy:
– Review speculum and vaginal examination:
• Research the origin of the bleeding [vagina, cervix, uterine cavity]; appearance of the cervix;
• search for a mobilization uterine pain, increased volume or deformation of the uterus.
– Friable mass, hard, ulcerative budding on the collar: Possible cervical cancer (surgical).
– Inflammatory Col, minor bleeding, purulent cervical discharge, pelvic pain absent or moderate, no fever: cervicitis.
– Col inflammatory, painful uterine mobilization, purulent cervical discharge, moderate or minimal bleeding, pelvic pain, with or without fever: salpingitis.
– Uterine body enlarged, irregular: uterine fibroids (surgical treatment only in case of significant bleeding managers large fibroids).
– Body and normal cervix: consider poorly tolerated contraceptive, uterine body cancer (especially after menopause), urinary schistosomiasis in sub-Saharan Africa.
Bleeding during the first half of pregnancy:
The two diagnoses to firstly consider are ectopic pregnancy and abortion.
Ectopic pregnancy (EP):
Pregnancy that grows outside of the uterus, usually in a fallopian tube. Always think to a USG with a woman of childbearing age who present with pelvic pain and / or bleeding. The clinical forms are numerous and can wrongly towards appendicitis, intestinal obstruction, salpingitis or abortion. The major risk is the rupture of ectopic pregnancy with intra-abdominal hemorrhage.
Clinical features and diagnosis:
– Context of amenorrhea (may fail), or irregular.
– Brown blood losses and scarce or loss of blood red of varying importance; Sometimes table hemorrhagic shock associated with minimal bleeding, unrelated to the importance of shock (intra-abdominal hemorrhage).
– Pelvic pain; sometimes distended abdomen, defense.
– On vaginal: Sensitive adnexal mass; pain in the cul-de-sac
Douglas (hemoperitoneum); cervix closed.
– The diagnosis of pregnancy is confirmed by a quick test positive pregnancy (urine test) but a negative pregnancy test does not rule out an ectopic pregnancy.
– When ultrasound is available, viewing an intrauterine pregnancy eliminates the GEU. An empty uterus associated with an intra-peritoneal effusion makes plausible an ectopic pregnancy, especially if the pregnancy test is positive.
What to do:
When in doubt (negative pregnancy test and no evidence of rupture and stable hemodynamics), hospitalization for surveillance, if possible in a surgical environment. Otherwise, transfer in a surgical environment for emergency laparotomy.
Threatened abortion:
Clinical signs:
In a context of amenorrhoea: minimal loss of red blood, pelvic pain, closed cervix.
What to do:
– Look for foreign bodies or vaginal wound consistent with induced abortion; remove foreign bodies, clean the wound, update tetanus immunization.
– Treat pain: paracetamol PO or antispasmodic.
– To rest.
Abortion in progress:
Clinical signs:
Red blood loss, varying abundance, mixed with ovular debris, uterine contractions, open collar.
What to do:
– Look for foreign bodies or vaginal wound consistent with induced abortion; remove foreign bodies, clean the wound, update tetanus immunization.
– Treat pain: anti-inflammatory and antispasmodic
– Depending on the age of pregnancy:
Before 10 weeks of gestation: the expulsion is often full. Monitor, intervene only in case of heavy bleeding (aspiration).
Between 10 and 12 weeks of pregnancy: uterine evacuation is often necessary.
• Manual vacuum aspiration is the preferred method (easier to perform, less traumatic and painful than curettage).
• The administration of misoprostol (600 mcg PO single dose) can avoid the surgical procedure but there is a risk of failure. Check uterus is empty within days. If this fails, use the instrumental method is unavoidable.
Beyond 12 weeks LMP: do not break the membranes, leaving the work to be done. The placenta is usually evacuated with the fetus. In case of doubt the examination of the placenta or in case of bleeding, digital dissection quickly after the expulsion. This action, if it is delayed, it becomes impossible due to the retraction of the cervix, it is then necessary to perform curettage, with a significant risk of uterine perforation.
– If septic abortion (pelvic pain, uterine sensitive, fetid losses): antibiotic therapy, see original puerperal infections.
Bleeding during the second half of pregnancy:
-The Three diagnoses placenta previa, retro-placental hematoma and rupture utérine- involve quickly the life of the mother and child. Their management is done in a surgical environment.
When no cause is found, consider the possibility of preterm labor.
Placenta previa:
Placenta covering the internal orifice of the neck portion or whole. The placenta previa is expressed by bleeding in Q3 and poses a significant risk of bleeding during childbirth.
Clinical features and diagnosis:
– Sudden bright red bleeding, more or less abundant, painless.
– The vaginal exam must be extremely careful not to trigger cataclysmic hemorrhage: soft uterus, possible perception of a deviation of the cervix and deformation of the lower segment due to placenta previa; If the cervix is dilated, possible perception of the placenta in the cervix. Do not repeat the exam.
– Ultrasound, if available, can avoid vaginal examination.
What to do:
– Bleeding is minimal, the work is not triggered: bed rest and monitoring.
– The bleeding is significant and / or work is in progress: transfer in a surgical environment.
Retro-placental hematoma:
Hematoma between the placenta and the uterine wall, constituting by placental abruption before birth of the child.
Clinical signs:
– Blood loss blackish, scanty, sometimes absent or shock, not always related to the visible blood loss as bleeding is intraabdominal.
– Pelvic pain brutal, intense, continues.
– Uterus contracted continuously (uterus wood); often disappearance of fetal heart sounds (fetal death).
– Often context of preeclampsia.
What to do:
Transfer surgical environment.
Uterine rupture:
Tearing the uterine wall, occurring in most cases during labor, often favored by the improper use of oxytocin.
Clinical signs:
– Pre-break: stagnation of labor unrest, poor general condition, defects in uterine relaxation, continuous abdominal pain, more violent contractions.
– Rupture: disappearance of uterine contractions, shock, sometimes palpation of the dead fetus expelled into the maternal abdomen.
What to do:
Forward surgical environment for emergency laparotomy.
Preterm labor (MAP):
Clinical signs:
Regular uterine contractions and cervical changes (deleted and open) before 37 weeks gestation (before the start of the ninth month). The MAP does not always accompanied with bleeding. If present, blood loss is minimal.
What to do:
– Strict Rest in bed
– Leave birth in the following cases: pregnancy is greater than 37 weeks; the cervix is dilated more than 3-4 cm; there is significant bleeding; in case of fetal distress or if the child died; in cases of amniotic infection or preeclampsia.
– Otherwise, tocolysis: nifedipine PO (short-acting capsule): 10 mg to be repeated every 15 minutes if uterine contractions persist (maximum 4 doses or 40 mg) and 20 mg every 6 hours for 48 hours at default, salbutamol infusion IV for up to 48 hours: dilute 5 mg (10 ampoule containing 0.5 mg) in 500 ml glucose 5% or sodium chloride 0.9% to obtain a solution containing 10 micrograms / ml.
Begin the infusion at a rate of 15 to 20 micrograms / minute (30 to 40 drops / minute).
If contractions persist, increase the rate of 10 to 20 drops / minute every 30 minutes to stop the contractions. Do not exceed 45 micrograms / minute (90 drops / minute).
Maintain effective throughput for an hour after stopping contractions then halve the rate every 6 hours.
Monitor maternal pulse, reduce the flow in case of tachycardia (> 120 / minute).
Do not administer simultaneously nifedipine and salbutamol.
Either tocolysis is effective and contractions stop or fade: in both cases, do not continue tocolysis beyond 48 hours.Put to rest for the remainder of the pregnancy.
Either tocolysis is not effective, contractions persist and labor begins: preparing for the care of premature newborns.
Postpartum Hemorrhage:
Haemorrhage within 24 hours (usually immediately) after delivery and whose volume exceeds 500 mL of normal delivery. This is often a retained placenta or uterine inertia. Uterine rupture or tear the cervix or vagina can also be the cause.
What to do:
– If systolic BP <90 mmHg, elevate the legs (keep or set foot in the stirrups of the delivery table).
– Under general anesthesia and antibiotic prophylaxis (ampicillin or cefazolin IV, 2 g single dose): Immediate placenta if the placenta is not delivered and systematic uterus to reduce potential clots and placental debris and check for uterine rupture .
– Then oxytocin: 10 IU in 500 ml of Ringer’s lactate at a rate of 80 drops / minute.
At the same time, administer 5 to 10 IU by slow IV directly, repeat if necessary until the uterus is firm and retracted without exceeding a total dose of 60 IU.
– Check for wound of the cervix or vagina with a review with valves (or with a speculum).
– Uterine massage to expel any clots and aid uterine retraction.
– Continue hemodynamic monitoring. Bleeding should diminish and the uterus remain firm.
– Measure hemoglobin.
– Ask an indwelling catheter to facilitate uterine retraction.
For more information on the management of bleeding related to pregnancy, refer to the obstetrics guide in isolation, MSF.