Tuesday, 13 November 2018

Bleeding in Pregnancy

<23 Weeks - Early Pregnancy 
This has been covered here: https://www.rcemlearning.co.uk/foamed/induction-bleeding-in-early-pregnancy/

Later Pregnancy
https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/

Antepartum Haemorrhage
>24 weeks gestation
Placenta praevia - stage depends how much of the os is covered by the placenta. Bright red and painless bleeding.
Placental abruption - complete or partial separation of the placenta. Causes lots of bleeding which may be concealed. Normally associated with continuous abdominal pain.
Vasa praevia - the fetal blood vessels run everywhere, not protected by the placenta. They may run over the cervix. High perinatal mortality - easy to rupture the fetal blood vessels. Can cause painless bleeding.
AntiD may be needed after a potentially sensitising event.

Hopefully all of these will be identified by screening, and hopefully these patients will present to the maternity assessment unit, not the ED!

PostPartum Haemorrhage
Primary PPH - in first 24hours. Secondary PPH - up to six weeks. Again, hopefully these patients will present to MAU not ED.

In pregnancy, problems are the 4Ts
 Tone, trauma, tissue, thrombin.
 Tone: uterine massage, bimanual compression, catheterise, give syntrometrin

Bleeding should slowly stop after a 12 weeks. It's often significantly less after the first few hours, and should change from  bright red to brown (lochia).
The commonest cause is endometritis. There may be retained products - start IVs, get an USS. If there's no RPOC, there could still be endometritis. The uterus in endometritis will remain palpable after 14days after delivery.  Endometritis is a clinical diagnosis.
I think bleeding persistently after delivery needs to see O&G.
Bleeding that stops and starts again is probably "new" bleeding.


https://www.bmj.com/content/358/bmj.j3875?sso=
http://www.emdocs.net/postpartum-endometritis-ed-setting-presentation-evaluation-management/


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