Bleeding in the Second Half of Pregnancy

Bleeding in the second half of pregnancy occurs in 4% of all pregnancies. In 50% of cases, vaginal bleeding is secondary to placental abruption or placenta previa.

I. Clinical evaluation of bleeding second half of pregnancy

A. History of trauma or pain and the amount and character of the bleeding should be assessed.

B. Physical examination

1. Vital signs and pulse pressure are measured. Hypotension and tachycardia are signs of serious hypovolemia.

2. Fetal heart rate pattern and uterine activity are assessed.

3. Ultrasound examination of the uterus, placenta and fetus should be completed.

4. Speculum and digital pelvic examination should not be done until placenta previa has been excluded.

C. Laboratory Evaluation

1. Hemoglobin and hematocrit.

2. INR, partial thromboplastin time, platelet count, fibrinogen level, and fibrin split products are checked when placental abruption is suspected or if there has been significant hemorrhage.

3. A red-top tube of blood is used to perform a bedside clot test.

4. Blood type and cross-match.

5. Urinalysis for hematuria and proteinuria.

6. The Apt test is used to distinguish maternal or fetal source of bleeding. (Vaginal blood is mixed with an equal part 0.25% sodium hydroxide. Fetal blood remains red; maternal blood turns brown.)

7. Kleihauer-Betke test of maternal blood is used to quantify fetal to maternal hemorrhage.

II. Placental abruption (abruptio placentae) is defined as complete or partial placental separation from the decidua basalis after 20 weeks gestation.

A. Placental abruption occurs in 1 in 100 deliveries.

B. Factors associated with placental abruption

1. Preeclampsia and hypertensive disorders

2. History of placental abruption

3. High multiparity

4. Increasing maternal age

5. Trauma

6. Cigarette smoking

7. Illicit drug use (especially cocaine)

8. Excessive alcohol consumption

9. Preterm premature rupture of the membranes

10. Rapid uterine decompression after delivery of the first fetus in a twin gestation or rupture of membranes with polyhydramnios

11. Uterine leiomyomas

C. Diagnosis of placental abruption

1. Abruption is characterized by vaginal bleeding, abdominal pain, uterine tenderness, and uterine contractions.

a. Vaginal bleeding is visible in 80%; bleeding is concealed in 20%.

b. Pain is usually of sudden onset, constant, and localized to the uterus and lower back.

c. Localized or generalized uterine tenderness and increased uterine tone are found with severe placental abruption.

d. An increase in uterine size may occur with placental abruption when the bleeding is concealed. Concealed bleeding may be detected by serial measurements of abdominal girth and fundal height.

e. Amniotic fluid may be bloody.

f. Fetal monitoring may detect distress.

g. Placental abruption may cause preterm labor.

2. Uterine contractions by tocodynamometry is the most sensitive indicator of abruption.

3. Laboratory findings include proteinuria and a consumptive coagulopathy, characterized by decreased fibrinogen, prothrombin, factors V and VIII, and platelets. Fibrin split products are elevated.

4. Ultrasonography has a sensitivity in detecting placental abruption of only 15%. D. Management of placental abruption

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