Bleeding in Pregnancy

Question 1

Main causes

Answer 1

• 1st trimester
  
  • Spontaneous abortion
  • Ectopic pregnancy
  • Hydatiform mole
• 2nd trimester
  
  • Spontaneous abortion
  • Hydatiform mole
  • Placental abruption
• 3rd trimester
  
  • Bloody show
  • Placental abruption
  • Placenta praevia
  • Vasa praevia

Question 2

Spontaneous abortion

Answer 2

• Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
• Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
• Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled
• Incomplete miscarriage - heavy bleeding and crampy, lower abdominal pain
• Complete miscarriage - little bleeding

Question 3

Ectopic pregnancy

Answer 3

• Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later.
• Shoulder tip pain and cervical excitation may be present.

Question 4

Hydatiform mole

Answer 4

• Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy (i.e. hyperemesis).
• The uterus may be large for dates and serum hCG is very high.

Question 5

Placental abruption

Answer 5

• Constant lower abdominal pain and woman may be more shocked than is expected by visible blood loss.
• Tender, tense uterus with normal lie and presentation.
• Fetal heart may be distressed.

NB - Hard, woody uterus is classical description.

Question 6

Placental praevia

Answer 6

• Vaginal bleeding, no pain.
• Non-tender uterus but lie and presentation may be abnormal

Question 7

Vasa praevia

Answer 7

• Rupture of membranes followed immediately by vaginal bleeding.
• Fetal bradycardia is classically seen.