Bleeding during pregnancy is common, especially during the first trimester. Bleeding can sometimes be a sign of something serious, therefore it is important to know the possible causes and take adequate measures.
Abortion
It is a spontaneous loss of a fetus before it is viable (has the potential to survive outside the womb). The World Health Organization (WHO) defines it as expulsion or extraction of an embryo or fetus weighing 500mg or less, aproximately 24 weeks of gestation. Clinical features will depend on the types of abortion.
11.1.1 Threatened Abortion
Diagnostic criteria
- Mild vaginal bleeding
- Mild/no lower abdominal pain or back ache
- Cervix closed on digital examination
Management of threatened abortion in Dispensary & Health Centre
- Adequate bed rest at home
- Avoid strenuous activities and sexual intercourse until all the symptoms have subsided
- Schedule a follow up within 7 days
- Tell the woman to come immediately if;
-
- Bleeding becomes heavy
- Experiences offensive discharge
- Severe abdominal pain
Referral Refer to higher-level health facility with adequate expertise and diagnostics if:
- Bleeding recurs
- Experiences fever
- Experiences offensive discharge
- Experience severe abdominal pain
In the Hospital:
- Perform ultrasound to confirm gestational age and foetal viability
- Admit the patient and manage appropriately if;
- The foetus is dead
- Bleeding recurs
- Fever
- Foul smelling vaginal discharge o Severe abdominal pain
11.1.2 Inevitable Abortion
Abortion is said to be inevitable when it is not possible for the pregnancy to continue and the cervix is dilated, but all the products of conception are in situ.
Diagnostic Criteria
- Moderate or severe per vaginal bleeding which may be accompanied with clots
- Severe lower abdominal pain
- Significant draining of liquor if membranes have ruptured or the membranes may be intact.
- The cervix is dilated with evidence of imminent expulsion of products of conception.
- Fundal height may correspond with gestational age
- Presence of uterine contractions
Management of inevitable abortion in Dispensary & Health Centre
- Apply Airway, Breathing, Circulation and Dehydration (ABCD) principles of resuscitation
- Check Hb level.
- Give IV Ringers Lactate (RL)/Normal Saline (NS) 2litres
- Perform Manual Vacuum Aspiration (MVA) in health centre if gestation age is below 12 weeks
- Augment the process by administering oxytocin 20 IU in 500mls RL/NS at 40– 60 drops/minute if gestation age is above 12 weeks
- Manage as incomplete abortion if after augmentation some products of conception remain in the uterus
- Manage as complete abortion if all product of conception are expelled
Referral
Refer to hospital if MVA is not possible and/or bleeding is persisting.
In the Hospital
- Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
- Obtain blood for Hb , grouping and cross–matching
- Give IV RL/NS 2liters
- Give blood transfusion if indicated
- Perform Manual Vacuum Aspiration (MVA) if gestation age is below 12 weeks
- Augment the process by administering oxytocin 20 IU in 500mls RL/NS at 40– 60 drops/minute if gestation age is above 12 weeks
- Manage as incomplete abortion if after augmentation some products of conception remain in the uterus
- Manage as complete abortion if all product of conception are expelled
11.1.3 Incomplete abortion
Some of the products of conception have been retained in the uterine cavity and there is persistent lower abdominal pain, continuing per vaginum bleeding and open cervix.
Diagnostic Criteria
- Cramping lower abdominal pain
- Slight to profuse per vaginal (PV) bleeding accompanied with clots/products of conception
- Clots/ products of conception protruding through the cervical
- Fundus smaller than dates
- The cervix is dilated and products of conception may be felt in the cervix on digital examination
Management of incomplete abortion in dispensary & health centre
- Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
- Check hemoglobin level
- Give IV RL/NS 2lts
- Perform digital evacuation of products of conception
- Perform MVA in health centre if gestation age is below 12 weeks
Pharmacological Treatment
A: Oxytocin 10 IU IM
OR
A: Misoprostol 600μg PO start
After evacuation give:
A: Amoxicillin PO 500mg 8 hourly for 5 days
AND
A: Metronidazole PO 400mg 8hourly for 5 days
AND
A: Paracetamol 1g 8 hourly for 5 days
Referral
Refer patient to hospital level with an escort of a nurse if bleeding continues
Management in a Hospital
- Apply ABCD principles of resuscitation
- Obtain blood for HB, grouping and cross–matching
- blood transfusion if indicated
- Give IV RL/NS 2lts
- Digital evacuation of products of conception
- MVA if gestation age is below 12 weeks
- Evacuate uterus in theatre with sharp curette under general anesthesia if pregnancy is more than 12 weeks
Pharmacological Treatment
Continue as above
Patient education.
Counsel and provide appropriate contraception.
11.1.4 Complete Abortion
Products of conception are completely expelled
Diagnostic Criteria
- Minimal or no PV bleeding
- Uterus smaller than dates and often well contracted. Cervix may or may not be closed
Pharmacological treatment
A: Amoxicillin PO 500 mg 8 hourly for 5 days
AND
A: Metronidazole PO 400mg 8 hourly for 5 days
AND
A: Iron + folate (FeFol) one tablet twice daily for 3 months and reassess after every
4 weeks
If patient is in shock;
- Shout for help and mobilize resources
- Apply ABCD principles of resuscitation
- Give IV RL/NS 3liters or more in the first hour
- Insert an indwelling urethral catheter
- Give IV ampicillin 1g and metronidazole 500mg start Obtain blood for HB, grouping and cross match.
Referral: Refer patient to hospital with an escort of a nurse
Management in a hospital 16
If patient is stable continue as above; if patient is in shock, perform as above and give blood transfusion if indicated
Pharmacological treatment
A: Start or continue with IV Ampicillin 1g 6 hourly for 24–48 hours
AND
A: Metronidazole (IV) 500mg 8 hourly for 24–48 hours
Then change to:
A: Amoxicillin (PO) 500mg 8hly for 5 days
AND
A: Metronidazole (PO) 400mg 8hly for 5 days
AND
A: Iron + Folic acid (Fefol) one table twice daily for 3 months and reassess after every 4 weeks Patient Education.
Counsell and provide appropriate contraception.
11.1.5 Septic Abortion
It is an abortion complicated with infections.
Diagnostic Criteria
- Abdominal pain following history of abortion
- Fever may be present
- Foul smelling PV discharge which may be mixed with blood.
- May be in shock or/and jaundiced
- Tender uterus, there may be rebound tenderness
- Cervix is usually open
Management of septic abortion in dispensary & health centre
- Apply ABCD principles of resuscitation
- Give IV RL/NS 3liters or more in the first hour
- Insert an indwelling urethral catheter
- Obtain blood for Hb
Pharmacological Treatment
A: Ampicillin 1g IV 6 hourly for 24–48 hours
AND
C: Metronidazole IV 500mg 8 hourly for 24–48 hours
AND
A: Gentamicin 80mg IV 12 hourly for 7 days
Referral: Refer patient to hospital with an escort of a nurse.
Management in the Hospital:
- Full Blood Count ? (FBC)
- Give blood transfusion if indicated
- Perform endocervical swab for culture and sensitivity
- Evacuate the uterus with sharp wide curette under general anesthesia
Pharmacological Treatment
Treat as above and when the patient is stable continue with; A: Amoxicillin 500mg 6 hourly for 7 days
A: Metronidazole (PO) 400mg 8 hourly for 7 days
If no response with the above antibiotics within 3 days;
- Adjust according to culture and sensitivity results. if no culture sensitivity services switch to
A: Ceftriaxone IV 1g 12 hourly for 5 days
AND
A: FeFol one tablet twice a day for 3 months and review after every 4 weeks
Patient Education
- Counsel and provide appropriate contraception.
11.1.6 Molar Pregnancy /Abortion
It happens when tissue that normally becomes a fetus instead became an abnormal growth in the uterus. Once diagnosed it should be treated right away.
Diagnostic Criteria
- Vaginal bleeding
- Uterus that is larger than gestational age? (GA) and fetal parts not palpable.
- Severe nausea and vomiting
- Vaginal discharge of tissue that is grape like
- Very heavy vagianal bleeding when the mole abort spontenously
Referral: Resuscitate and refer the patient to higher level facility for appropriate management.
11.1.7 Missed Abortion
Fetus die in utero but it’s not expelled out
Diagnostic criteria
- History of amenorrhea
- Regression of the pregnancy symptoms
- Uterine size smaller than dates
- Mild per vaginum bleeding
Investigations
- Abdominal pelvic ultrasound
- FPC?
Pharmacological Treatment
- Induce abortion with misoprostol if it is more than 12 weeks
- Evacuate if it is less than 12 weeks
After evacuation give;
A: Amoxicillin (PO) 500mg 8hly for 5 days
AND
A: Metronidazole (PO) 400mg 8hly for 5 days
Patient education.
Counsell and provide appropriate contraception.
| NOTE:Refer to higher level health facility with adequate expertise and diagnostics/equipment |