Case 64: Bleeding in pregnancy

 

Case 64: Bleeding in pregnancy

CASE 64: BLEEDING IN PREGNANCY

History

You are asked to review a nulliparous woman who has presented with vaginal bleeding at 39

weeks 5 days’ gestation. Booking blood pressure was 123/72 mmHg. Her last midwife visit

was 10 days ago when blood pressure was 130/76 mmHg.

This evening she noticed a small ‘gush’ of blood and discovered a bright red stain in her

underclothes. She denies actual abdominal pain but reports some intermittent lower abdominal discomfort. The baby has been moving normally during the day.

Examination

She is warm and well perfused. Her blood pressure is 158/87 mmHg and heart rate 84/min.

The symphysiofundal height is 36 cm and the fetus is cephalic with 3/5 palpable abdominally.

Moderate uterine tenderness is noted. The uterus is soft but during the palpation two moderate uterine tightenings are noted. On speculum examination the cervical os is closed and

there is a moderate amount of vaginal blood.

INVESTIGATIONS

Urinalysis: protein +; blood ++; leucocytes negative; nitrites negative

The cardiotocograph (CTG) is shown in Fig. 64.1.

Questions

• What is the diagnosis?

• How should this woman be managed?

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Figure 64.1 Cardiotocograph.100 Cases in Obstetrics and Gynaecology

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ANSWER 64

The diagnosis is of placental abruption in view of the bleeding, uterine tenderness and irritability. CTG is reassuring at present with baseline 130/min, normal variability, several accelerations and no decelerations. Regular uterine activity is demonstrated on the tocograph.

! Common causes of antepartum haemorrhage (APH) at term

• Maternal blood:

• blood-stained show

• bleeding placenta praevia

• placental abruption

• cervical ectropion

• infection (e.g. candida)

• Fetal blood:

• vasa praevia

A ‘show’ can be ruled out, as the blood is fresh rather than mucus-like and dark. Placenta

praevia would have been detected at the anomaly scan, and bleeding placenta praevia is typically painless. She has no features suggesting infection, and vasa praevia bleeding would

normally occur with rupture of membranes. Placental abruption is supported by the history

of fresh bleeding and uterine irritability with the associated high blood pressure and proteinuria (pre-eclampsia is a cause of abruption).

Placental abruption may be major with catastrophic haemorrhage or, as in this case, be less

dramatic. However caution should be maintained for two reasons: first, a small bleed may

herald a larger bleed. Second, although some bleeding is revealed, there may be a more significant concealed bleed. Pregnant women may not show any signs of hypovolaemic shock

until a large amount of blood has been lost.

Management

Women with APH should always be admitted for observation. Initial management for this

woman includes intravenous access, group and save, full blood count and clotting profile.

Urea, electrolytes and urate should be sent, looking for abnormalities associated with preeclampsia. Urine collection for over 24-h for proteinuria is not indicated in this case as induction of labour is already indicated on clinical grounds. Blood pressure should be repeated at

regular intervals and antihypertensives commenced if indicated.

Induction of labour may increase the chance of operative intervention, but the risk of expectant management is that sudden and catastrophic further haemorrhage may occur. As the

woman is over 37 weeks, there is little risk to the fetus of prematurity from induction.

KEY POINTS

• Placental abruption is a clinical diagnosis based on symptoms and examination.

• Blood loss caused by placental abruption may be concealed or revealed.

• A woman may not show signs of hypovolaemia until she has lost a large proportion

of her blood volume.