3.4 Diagnosis of bleeding during the second half of pregnancy (summary)

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    Table 3.1 - Aetiological diagnosis

     

     

    Placenta praevia

    Abruptio placenta

    Uterine rupture

    History

     

    • Twin pregnancy
    • Caesarean section
    • Bleeding during a previous pregnancy
    • Pre-eclampsia
    • Primipara
    • Trauma
    • Long labour
    • Primipara
    • Dystocia
    • Grand multipara (≥ 5)
    • Caesarean section
    • Overuse of uterotonic
    Clinical signs

    Bleeding

    • Bright red blood
    • Painless bleeding, spontaneous or after vaginal exam or sexual intercourse
    • Bleeding without warning sign
    • Light flow of blackish blood, or sudden bright red bleeding
    • Bleeding with severe, constant uterine and lower back pain

    Variable

    Haemorrhagic shock

    • Blood loss visible
    • Shock proportional to amount of bleeding
    • Blood loss not always visible
    • Shock out of proportion to the amount of visible bleeding (intra-abdominal or retroplacental bleeding)
    • Diffuse haemorrhage
    • Blood loss not always visible
    • Shock out of proportion to the amount of visible bleeding (intra-abdominal bleeding)

    Uterus

    • Soft uterus
    • Contractions, if present, are intermittent
    • Foetus high and mobile
    • Painful, continuous contraction ("woody uterus")
    • Foetal position hard to determine (hard uterus and haematoma)

    Foetus sometimes expelled into the abdominal cavity: uterus is retracted into a ball, the foetus felt under the skin

    Vaginal exam

    Soft, spongy placenta

    Perform only one, very cautious, vaginal exam if ultrasound is not available.

    Cervix often closed

    Vaginal exam not helpful in diagnosis of abruptio placenta.

     

    Foetal heart tones

    Normal in the absence of maternal shock

    Absent or weak

    Absent or weak