Abnormal Bleeding in
Pregnancy and Labour
Dr. Chitra Setya
MD
Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
Definition
Antepartum haemorrhage---It is
bleeding from the genital tract after the
28th week of pregnancy and before the
end of the second stage of labour .
Postpartum haemorrhage–
haemorrhage following delivery.
Antepartum Bleeding
Causes
• Abruptio Placentae
• Placenta praevia
• Rupture of uterus
• Carcinoma of cervix
• Trauma
• Cervical polyp
• Unknown origin
Placenta praevia
• Definition : The placenta is
partially or totally attached to
the lower uterine segment.
• Incidence : 0.5% , more
common in multiparas and in
twin pregnancy due to the large
size of the placenta.
Placenta praevia
Types:
1. Total : internal os
completely covered.
2. Partial : internal os
partially covered
3. Marginal : edge of
placenta at the margin of int. os
4. Low lying placenta
Placenta praevia
Placenta praevia
Placenta praevia
Risk factors
• Chronic hypertension
• Multiparity (second or succeeding
pregnancy)
• Multiple gestations (i.e., twins, etc.)
• Older maternal age
• Previous cesarean delivery
• Tobacco use
• Prior uterine curettage (D&C)
Placenta praevia
Diagnosis
Symptoms:
• Causeless, painless and recurrent
bright-red vaginal bleeding;
• It is causeless, but may follow sexual
intercourse or vaginal examination.
• It is painless, but may be associated
with labour pains .
• It is recurrent, but may occur once in
slight placenta praevia lateralis.
Placenta praevia
Signs:
• General examination:
Depends on extent of blood loss
• Abdominal examination:
• The uterus is corresponding to
the period of amenorrhoea,
relaxed and not tender.
Placenta praevia
• The foetal parts and heart sound
(FHS) can be easily detected.
• Malpresentations, particularly
transverse and oblique lie and
breech presentation are more
common as well as nonengagement of the head.
Placenta praevia
Treatment
At Home
• Arrange for immediate
transfer to the hospital.
• No vaginal examination and
no vaginal pack, only a
sterile vulval pad is applied.
Placenta praevia
• No oral intake as anaesthesia
may be required.
• Antishock measures as
pethidine IM, fluids and blood
transfusion may be given in the
way to the hospital if bleeding
is severe.
Placenta praevia
At Hospital
• Assessment of the patient's
condition, general and abdominal
examination and resuscitation if
needed.
• At least 2 units of cross matched
blood should be available.
Placenta praevia
If the patient is not in labour
• If the bleeding is severe,
continue antishock measures
and do immediate caesarean
section .
• If the bleeding is slight, look to
the gestational age :
Placenta praevia
− If completed 37 weeks (36 weeks
by some authors) or more,
pregnancy is terminated by
induction of labour or caesarean
section
− If less than 37 weeks (36 weeks by
others), conservative treatment is
indicated till the end of 37 (or 36)
weeks but not more.
Placenta praevia
Conservative treatment:
• The patient is kept hospitalized
with bed rest and observation
till delivery.
• Anaemia should be corrected if
present.
• Observation of foetal wellbeing.
• Anti-D immunoglobulin is given
for the Rh-negative mother.
Placenta praevia
If the patient is in labour:
• Vaginal examination is done
using precautions. According
to the findings, the patient will
be delivered either vaginally
or by caesarean section.
Placenta praevia
Vaginal delivery is allowed if the
following findings are fulfilled:
• Placenta praevia is lateralis or
marginalis anterior,
• bleeding is slight,
• vertex presentation,
• adequate pelvis with no soft tissue
obstruction.
Caesarian section--- normal mode of
delivery
Placenta praevia
Complications of Placenta Praevia
• Maternal: mortality rate: 0.2%.
• Foetal:
• Foetal mortality rate is 20 %.
• Prematurity.
• Asphyxia.
• Malformations (2%).
Abruptio placenta
Placental abruption is the premature
separation of a normally-implanted placenta
from the uterine wall.
Risk factors :
• Older maternal age
• Hypertension (high blood pressure)
• Tobacco, cocaine, or methamphetamine use
• Clotting abnormalities
• Abdominal trauma
• Previous placental abruption
• Uterine fibroids
Abruptio placenta
Signs and symptoms of placental
abruption:
• Vaginal bleeding
• Sudden onset of labor, with
persistent pain between
contractions
• Tenderness over uterus
• Back pain
• Signs of shock if blood loss is
significant
Abruptio placenta
Management -- Depends on gestational
age and status of mother & fetus
- live& mature fetus– immediate caesarian
section with fluid & blood replacement
- maternal condition stable with premature
fetus – expectant management under close
supervision
- severe placental abruption with a dead
fetus – vaginal delivery preferred
Antepartum bleeding
•
•
•
•
•
Rupture of uterus
Carcinoma of cervix
Trauma
Cervical polyp
Unknown origin
Post partum haemorrhage
Defined as the loss of 500ml or more
of blood after completion of the third
stage of labour
Causes:
-- Uterine atony
-- Retained placenta
-- Genital lacerations- vaginal,
cervical tears
Post partum
haemorrhage
Uterine atony : Causes
Large infant, forceps delivery, intrauterine
manipulation, use of anaesthetic agents,
multiple fetuses.
Treatment:
•
•
•
•
Manual removal of the placenta
Oxytocin- 20 units in 1000ml fluid IV
Methylergonovine 0.2 mg IM
Prostaglandins 0.25mg IM
Post partum
haemorrhage
Retained placenta > 30 minutes seen in
•
•
•
•
•
~ 6% of deliveries.
Risk increased with: prior C/S, curettage ,
uterine infection, increased parity.
Most patients have no risk factors.
Occasionally succenturiate lobe left
behind.
Attempt to remove the placenta by usual
methods.
Excess traction on cord may cause cord
tear or uterine inversion.
Post partum
haemorrhage
Birth trauma
• Vaginal, cervical tears --- to be
repaired
• Hematoma --- drain
Absent fetal movements
Dr. Chitra Setya
MD
Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
Fetal Movements




First fetal movement occurs around 8-9
weeks
For primiparas fetal movement often not felt
till 18wks or later
For multiparas fetal movement is felt around
15 –16 wks
Simplest and oldest form of fetal welfare
assessment
Fetal movements
Procedure:

The test is valid after 30 weeks of pregnancy.

The mother counts the fetal movements in 3
hours during the period of 12 hours e.g. from
9 am to 9 p.m , - The count is multiplied by 4
to get the fetal movements in 12 hours. If
count < 10 – further testing
Fetal movements


Count-to -ten Cardiff system : 10
movements in 12 hrs
Cessation of the fetal movement 12-24
hours before stoppage of the heart --"movement alarm signal".
Fetal movements
Advantages:
- Informative
and non-invasive.
- Pregnant woman can monitor herself.
- No cost.
- Accurate gestational age not required.
Fetal movements
Drawbacks:
- Awareness of the fetal movement differs from
mother to mother.
- Cessation of fetal movement may occur due to
intrauterine sleep.
- Sedation of the fetus occurs if mother is on sedatives.
- Sudden death of the fetus may occur without
preceding slowing of the fetal movement as in
abruptio placenta or it may be preceded by increased
flurry movements.
Fetal movements
Assessment of fetal activity
1.
2.
3.


Maternal perception
Tocodynamometer
Ultrasound
Fetuses have sleep- activity cycles with sleep
cycles extending upto 23 min.
Activity decreases with decreased amniotic fluid
volume
Fetal movements
Electronic monitoring
Non Stress test
Done with 2 transducers placed to assess fetal heart
and uterine contractions
Fetal movements
Fetal movements
NST
Reactive test:
Two or more fetal movements are
accompanied by acceleration of FHR of 15
beats/ minute for at least 15 seconds’
duration. Reactive test means that the fetus
can survive for one week, so the test should
be repeated weekly.
Non -reactive test:
No FHR acceleration in response to fetal
movements so contraction stress test is
indicated.
Fetal movements
Ultrasound Doppler monitoring
Check the FHR, Fetal movements and the
blood flow to the uterus and the baby
Pregnancy outcome
Pregnancy outcome was the same for mothers
who measured fetal movements and those
who did not but it is still considered good for
early detection of fetal well being as well for
mother– baby bonding
Fetal Movements
ACOG recommendations
Daily fetal kick count to be maintained in
the 3rd trimester
Notify the health provider if the count is
decreased
Fetal Movements
Summary
- Fetal movement record is a simple ,harmless
& cost effective way to assess fetal well –
being
- Pregnancies with decreased fetal movements
are at an increased risk of adverse pregnancy
outcome
- It also helps in “Bonding” between the mother
and fetus
Premature rupture of
membranes
Dr. Chitra Setya
MD
Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
Premature rupture of membranes
Rupture of membranes before the onset of labour
at any stage of gestation
Occurs in 3% of all pregnancies
Responsible for 1/3rd causes of preterm birth
Causes significant fetal complications– sepsis,
prematurity, cord prolapse, abruptio placenta, fetal
death
Premature rupture of membranes
Risk Factors
Lower socioeconomic class
Previous preterm birth
H/O STD
Multiple pregnancy
Polyhydramnios
Procedures– cervical
encirclage,amniocentesis
Premature rupture of membranes
Diagnosis
History
Examination
Vaginal swab
Ultrasound assessment
- amniotic fluid
- fetal assessment
Premature rupture of membranes
Treatment --- depends on
- gestational age,
- amount of amniotic fluid
- fetal state
- infection
Premature rupture of membranes
Expectant management
Antibiotic therapy -- Ampicillin with Metronidazole
Corticosteroid therapy- to accelerate lung maturity
Betamethasone 12mg I/M 24hrs apart –2 doses
Dexamethasone 5mg 12 hrly - 4 doses
Tocolytics- to delay onset of labour
Risks
Maternal risks– infection
Fetal risks– pulmonary hypoplasia, limb
abnormalities,infection
Premature rupture of membranes
Summary of treatment
History, examination, USG
24 – 31 wks
32 – 33 wks
34 – 36 wks
Bed rest
Antibiotics
Steroids
Deliver 34 wks
Bed rest
Antibiotics
Steroids
Deliver 34 wks
Antibiotics
Deliver
Premature rupture of membranes
Complications
Delivery within one week
Respiratory distress syndrome
Cord compression
Cord prolapse
Chorioamnionitis
Abruptio placentae
Antepartum fetal death
Molar Pregnancy
Dr. Chitra Setya
MD
Sr. Consultant Obstetrician and
Gynaecologist, Apollo Hospital Noida
Molar Pregnancy
Definition and Etiology



Hydatidiform mole is a pregnancy characterized
by vesicular swelling of placental villi and usually
the absence of an intact fetus.
The etiology -- unclear, but appears to be due to
abnormal gametogenesis and fertilization
Incidence-- 1 out of 500-600
Molar Pregnancy
Risk factors
1. Maternal age > 40 years
< 15 years
2. Paternal age > 45 years
3. Previous hydatidiform mole 1st: 1% , 2nd 15-28%
4. Vitamin A deficiency
5. Consanguinous marriages
6. Previous spontaneous abortion
7. More common in orients
Molar Pregnancy
Molar pregnancy - Complete
- Partial
Complete mole - Mass of tissue is completely
made up of abnormal cells
There is no fetus and nothing can be found at the
time of the first scan.
Partial mole - Mass may contain both these
abnormal cells and often a fetus that has severe
defects.
Molar Pregnancy
History
Amenorrhoea
Vaginal bleeding
Excessive nausea & vomiting
Passage of vesicles
Examination
Uterine size> period of pregnancy
Soft boggy feel of uterus- with no fetal parts felt
Signs of anaemia
Molar Pregnancy
Diagnosis of hydatidiform mole


Quantitative beta-HCG – value > 10,000mIU/ml
Ultrasound is the standard criterion for
identifying both complete and partial molar
pregnancies. The classic image is of a
“snowstorm” pattern
Molar Pregnancy
Signs and Symptoms of Complete
Hydatidiform Mole
 Vaginal bleeding
 Hyperemesis ( severe vomiting)
 Size inconsistent with gestational age( with no
fetal heart beating and fetal movement)
 Preeclampsia
 Theca lutein ovarian cysts
Molar Pregnancy
Signs and Symptoms of Partial Hydatidiform
Mole




Vaginal bleeding
Absence of fetal heart tones
Uterine enlargement and preeclampsia is
reported in only 3% of patients.
Theca lutein cysts, hyperemesis is rare.
Molar Pregnancy
Differential diagnosis



Abortion
Multiple pregnancy
Polyhydramnios
Molar Pregnancy
Treatment
Suction dilation and curettage :
 Complete evacuation of the uterus
 USG to confirm complete evacuation
 Serum β-HCG weekly till undetectable & monthly for 6
months
 Serum β- HCG expected to be undetectable by8-12 wks
 Advise contraception till then– condoms, OC pills after
HCG negative
Molar Pregnancy
Indications for chemotherapy






Serum B-HCG >20,000IU/L or urinary B-HCG >
30,000 IU/L 4 wks post evacuation
Rising level of B- HCG anytime post evacuation
Positive B-HCG levels 6 mths post evacuation
Evidence of metastasis
Persistant vaginal bleeding with +ve B- HCG
Methotrexate is the drug used
RCOG Recommendations
1.
2.
3.
4.
5.
6.
7.
Ultrasound has limited value in detecting partial molar pregnancies.
In twin pregnancies with a viable fetus and a molar pregnancy, the
pregnancy can be allowed to proceed.
Surgical evacuation of molar pregnancies is advisable.
Routine repeat evacuation after the diagnosis of a molar pregnancy is
not warranted.
Registration of any molar pregnancy is essential.
The combined oral contraceptive pill and hormone replacement therapy
are safe to use after hCG levels have reverted to normal.
Women should be advised not to conceive until the hCG level has been
normal for six months or follow-up has been completed (whichever is
the sooner).
Grade C recommendation