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