Page 292 - Learnwell EVS
P. 292
rorrhagia
Management
– Look for foreig n bod ies or v ag inal w ound consistent with ind uced abortion; rem ov e
foreig n bod ies, clean th e wound ; upd ate tetanus im m unization (pag e 170).
– T reat pain: paracetam ol or antispasm od ics.
– Depend ing on th e stag e of preg nancy:
Before 10 weeks of pregnancy: abortion is likely to be com plete. M onitor, only interv ene
in th e ev ent of h eav y bleed ing (aspiration).
Between 10 and 12 weeks of pregnancy: uterine ev acuation is often necessary.
• M anual v acuum aspiration is th e m eth od of ch oice (easier to perform , less
traum atic and less painful th an curettag e).
• Ad m inistration of misoprostol (600 µg P O as a sing le d ose) can be used to av oid
instrum ental ev acuation but carries a risk of failure. It is essential to ch eck if th e
uterus is em pty a few d ays after ad m inistration. If th e treatm ent h as failed ,
instrum ental ev acuation is unav oid able.
After 12 weeks of pregnancy: labour sh ould be allowed to prog ress, d o not rupture th e
m em branes. T h e placenta is usually ev acuated w ith th e foetus. If ev acuation is
incom plete or in th e ev ent of h aem orrh ag e, perform m anual rem ov al im m ed iately
after th e expulsion, before th e uterus retracts or th e cerv ix closes. If m anual rem ov al
is d elayed , curettag e m ust be perform ed w h ich carries a h ig h risk of uterine
perforation.
– In th e ev ent of post-abortion infection (pelv ic pain, uterine tend erness, foul-sm elling
v ag inal d isch arg e): antibiotic treatm ent, see Upper genital tract infections, pag e 241.
Bleeding during the second half of pregnancy
T h ree cond itions –placenta praev ia, abruptio placentae, and uterine rupture–can
quickly becom e life-th reatening to both m oth er and ch ild . T h ese cond itions m ust be
referred to surg ical facilities.
W h en no cause for th e bleed ing is found , consid er th e possibility of prem ature labour.
Placenta praevia
P lacenta th at cov ers eith er entirely or partially th e internal os of th e cerv ix. P lacenta
praev ia m ay g iv e rise to bleed ing d uring th e th ird trim ester and carries a h ig h risk of
h aem orrh ag e d uring d eliv ery.
Clinical features and diagnosis
– S ud d en, painless, slig h t or sig nificant brig h t red bleed ing .
– T h e v ag inal exam m ust be d one w ith extrem e care to av oid trig g ering m assiv e
bleed ing : uterus is soft; th e exam m ay rev eal d isplacem ent of th e cerv ix and
d eform ation of th e low er uterine seg m ent by th e placenta praev ia; if th e cerv ix is
d ilated , th e placenta can be felt in th e cerv ix. Do not repeat th e exam ination.
– If ultrasound is av ailable, v ag inal exam ination can be av oid ed .
Management
– If labour h as not yet started and bleed ing is lig h t: bed rest and m onitoring .
– If labour h as started and /or bleed ing is h eav y: refer to surg ical facility.
248
Management
– Look for foreig n bod ies or v ag inal w ound consistent with ind uced abortion; rem ov e
foreig n bod ies, clean th e wound ; upd ate tetanus im m unization (pag e 170).
– T reat pain: paracetam ol or antispasm od ics.
– Depend ing on th e stag e of preg nancy:
Before 10 weeks of pregnancy: abortion is likely to be com plete. M onitor, only interv ene
in th e ev ent of h eav y bleed ing (aspiration).
Between 10 and 12 weeks of pregnancy: uterine ev acuation is often necessary.
• M anual v acuum aspiration is th e m eth od of ch oice (easier to perform , less
traum atic and less painful th an curettag e).
• Ad m inistration of misoprostol (600 µg P O as a sing le d ose) can be used to av oid
instrum ental ev acuation but carries a risk of failure. It is essential to ch eck if th e
uterus is em pty a few d ays after ad m inistration. If th e treatm ent h as failed ,
instrum ental ev acuation is unav oid able.
After 12 weeks of pregnancy: labour sh ould be allowed to prog ress, d o not rupture th e
m em branes. T h e placenta is usually ev acuated w ith th e foetus. If ev acuation is
incom plete or in th e ev ent of h aem orrh ag e, perform m anual rem ov al im m ed iately
after th e expulsion, before th e uterus retracts or th e cerv ix closes. If m anual rem ov al
is d elayed , curettag e m ust be perform ed w h ich carries a h ig h risk of uterine
perforation.
– In th e ev ent of post-abortion infection (pelv ic pain, uterine tend erness, foul-sm elling
v ag inal d isch arg e): antibiotic treatm ent, see Upper genital tract infections, pag e 241.
Bleeding during the second half of pregnancy
T h ree cond itions –placenta praev ia, abruptio placentae, and uterine rupture–can
quickly becom e life-th reatening to both m oth er and ch ild . T h ese cond itions m ust be
referred to surg ical facilities.
W h en no cause for th e bleed ing is found , consid er th e possibility of prem ature labour.
Placenta praevia
P lacenta th at cov ers eith er entirely or partially th e internal os of th e cerv ix. P lacenta
praev ia m ay g iv e rise to bleed ing d uring th e th ird trim ester and carries a h ig h risk of
h aem orrh ag e d uring d eliv ery.
Clinical features and diagnosis
– S ud d en, painless, slig h t or sig nificant brig h t red bleed ing .
– T h e v ag inal exam m ust be d one w ith extrem e care to av oid trig g ering m assiv e
bleed ing : uterus is soft; th e exam m ay rev eal d isplacem ent of th e cerv ix and
d eform ation of th e low er uterine seg m ent by th e placenta praev ia; if th e cerv ix is
d ilated , th e placenta can be felt in th e cerv ix. Do not repeat th e exam ination.
– If ultrasound is av ailable, v ag inal exam ination can be av oid ed .
Management
– If labour h as not yet started and bleed ing is lig h t: bed rest and m onitoring .
– If labour h as started and /or bleed ing is h eav y: refer to surg ical facility.
248
