Any bleeding in late pregnancy should never be ignored.

IF you bleed during the late stages of your pregnancy, consult the hospital doctor without any delay. Continuous bleeding might endanger the life of both mother and foetus.

The causes of bleeding in late pregnancy include:

●Cervical erosion (ectropion) is the commonest cause in the second half of pregnancy. Sometimes, it may follow sexual intercourse.

●Abruptio placentae, a condition in which there is premature separation of the placenta from its attachment to the uterine cavity,

●Placenta praevia in which the placenta is attached too low in the uterus and covers all or part of the cervix. If it covers the entire cervix, it is called major placenta praevia. A low-lying placenta may be suspected during a routine scan at 18 to 20 weeks. The majority of women with this diagnosis will not develop placenta praevia. Only about 10% of these women will develop placenta praevia later in pregnancy.

●Placenta accreta, a rare condition in which the placenta is markedly adherent to the uterine wall, leading to difficulty in separation of the placenta from the uterine wall after the baby is born.

Risk factors

Note that it is not uncommon for many women to have bloody mucus just before labour starts. The factors that increase the risk of abruptio placenta include smoking, cocaine abuse, abdominal trauma, pre-eclampsia/hypertension, prolonged rupture of membranes (24 hours or more), previous placental abruption and low socio-economic status.

Placenta praevia accreta is more common in women with placenta praevia who have had a previous Caesarean section.

The clinical features of abruption include vaginal bleeding, contractions, abdominal pain and tenderness, and decreased foetal movements. Vaginal bleeding occurs in about 80% of abruptio placentae. The bleeding is concealed in the other 20%. Painful uterine contractions are associated with the abruption. The uterine tone is increased and there may be little or no break in uterine activity between contractions. Decreased foetal movements may be due to foetal jeopardy and impending death.

The classical clinical feature of placenta praevia is painless vaginal bleeding. There may or may not be uterine contractions and decreased foetal movements. When there is vaginal bleeding in late pregnancy, a diagnosis will have to be made and an assessment made of the patient’s physical and the foetus’ conditions.

The foetus may lie in a position with its buttocks first (breech) or across the uterus (transverse lie) when there is placenta praevia or the expected date of delivery is far away in abruptio placentae.

Pelvic ultrasound enables a rapid diagnosis of placenta praevia. However, it is not a sensitive tool for diagnosing abruptio placentae. A significant abruption will show as a clot between the placenta and uterine cavity wall in the ultrasound image but not all abruptions are ultrasonically detectable.

Management

Hospitalisation will be necessary in abruptio placentae. It will be usually advised after 34 weeks in major placenta praevia or when placenta praevia accreta is suspected even if there are no symptoms. The reason is that bleeding may occur suddenly and/or severely, necessitating urgent attention.

A patient can stay at home if there is placenta praevia and no bleeding. However, one should know what to do in an emergency and have ready access to a hospital. It is advisable to abstain from sexual intercourse as it may precipitate bleeding. A discussion with the obstetrician about what to do and what not to do will be essential.

The management is influenced by several factors including maternal age, previous obstetric history, other pregnancy problems like pre-eclamptic toxaemia, diabetes, foetal and maternal condition, duration of pregnancy and the presence of any complications.

Apart from diagnosis and assessment of mother and foetus, blood will be taken for cross matching and an intravenous line established. If there is a need, intravenous fluids and/or blood or blood products will be given. Any clotting disorder will be corrected. If the mother has had an abruption and is of rhesus negative blood group, Rh immune globulin will be given.

In patients with abruptio placentae and certain types of minor placenta praevia and whose foetuses are at or near maturity, the obstetrician will do a vaginal examination and then break the waterbag (amniotic sac) surrounding the foetus and induce labour. The ability to undergo vaginal delivery is dependent on the patient’s haemodynamic stability. Labour is usually rapid in such patients.

Caesarean section is carried out whenever there is maternal or foetal distress or major placenta praevia. The patient’s coagulation status may complicate the operation. The vertical incision is often used if the patient appears to have clotting disorders or there is severe foetal distress. The reasons are less blood loss in the case of the former and the facilitation of a rapid delivery in the case of the latter. The transverse incision is made on the uterus on most occasions but the vertical, classical incision may be necessary if the foetus is pre-term.

The complications of Caesarean section include infection, bleeding, need for transfusion of blood and/or blood products, injury to adjacent organs, and/or hysterectomy for uncontrollable bleeding as well as anaesthetic complications.

If there is severe bleeding, administration of medicines to make the uterus contract, ligation of the uterine artery, packing of the uterus or insertion of special sutures will be carried. If the bleeding is still uncontrollable, a hysterectomy may have to be carried out to save life.

The patient who has a severe abruptio placentae or major placenta praevia or who has developed complications may have to be nursed in the intensive care unit. Hospital stay may be longer in such situations.

In patients with placenta praevia, whose pregnancies are not near maturity, conservative treatment will be carried out provided there is no maternal and foetal compromise. The objective is to get the pregnancy to as near maturity as possible. Medicines to prevent pre-term labour (tocolytics) and corticosteroids to accelerate foetal lung maturity may be prescribed.

The use of tocolytics in abruptio placentae is controversial. It may be prescribed in those who are haemodynamically stable, there is no foetal compromise and when corticosteroids are prescribed. Tocolytic use is cautious as maternal or foetal distress can develop quickly. The cardiovascular side effects of tocolytics may mask the signs of significant blood loss.

Bleeding in late pregnancy should not be ignored as it is potentially life threatening for mother and foetus. When it happens, one should proceed to the hospital without delay.

Source: Dr Milton Lum