Bleeding During Pregnancy
Abortion is the termination of pregnancy before the beginning of the perinatal period as defined by WHO ICD 10, from 22 completed weeks (154 days) of gestation (the time when the birth weight is normally 500 g). Abortion is usually classified as early when it occurs before 12 weeks and late from 13 to 21 weeks.
Clinical and differential diagnosis
The vaginal bleeding of a woman of reproductive age and activity, after a certain time of amenorrhea, suggests a pregnancy evolving into the clinical forms of abortion.
There are two possible complications to consider: bleeding from retained ovarian parts and infection.
In the analysis the date of the last menstruation should be specified and if small previous hemorrhages have occurred. In, the subjective symptoms that ectopic pregnancy may present (intense colic pain, loss of body stability, blurred vision, peripheral collapse, etc.) should be asked.
An attempt will be made to see the material expelled from the vagina if the patient refers it or brings it with her. Before continuing with the physical examination, the temperature and radial pulse should be taken. From 38 ºC, abortion should be septic or infected.
The examination should be continued by bimanual touch and palpation, with sterile gloves, and, like W. Pschyrembel (1958), follow the sequences of the following checks:
- 1. Whether the external os of the cervical canal is open or closed (open is normal in the multiparous).
- 2. If the cervical canal is only half-open or if it is already permeable.
- 3. Whether the internal os of the cervical canal is open.
- 4. If part of the egg is felt in the cervix
- 5. The size, position, and attitude of the uterus, and its consistency in particular
if its retroflex flex and look carefully:
- (a) If, by palpation, the adnexa on both sides are normal or show pathological changes (thickened in the form of a cord, swollen like a tumor, painful when pressed).
- (b) Whether the parametria, on the sides and towards the back, are free or infiltrated; if are palpated in these soft, pasty masses (retrouterine hematoma, ectopic pregnancy?) or tumorous masses (deep adnexal tumor, ectopic pregnancy?).
- c) If on physical examination, inflammatory signs, and fever of 38°C or more are found in the adnexa or parametria, the category of complicated abortion must be indicated.
Clinical forms :
Symptoms: The first symptom is bleeding; it appears after the lack of menstruation of several weeks, its appearance is frequent before 17 weeks. Bleeding is usually rare and bloody. Before the bleeding occurs
has pain that starts in the hypogastrium, which the woman compares to menstrual cramps. A physical examination shows that these pains coincide with a contracting uterus. The cervix is closed, long, without anatomical modifications.
-Imminent abortion in progress or in progress :
The pains intensify, they are more evident the more weeks the pregnant woman has. Bleeding increases, especially if the fetus is alive and the placental cotyledons are slowly detached.
During the physical examination, cervical modifications are checked (effacement and dilation), you can perceive the egg and if it has been detached: when you touch and feel you can see the bags, and further up the embryo and the placenta.
If the membranes are ruptured, the fetus will be seen in the vagina and the placenta will still be in the uterus. After the abortion, phenomena similar to the postpartum postpartum period occur, lochia is scarcer and lasts fewer days, the onset of lactation is scarce and the return of menstruation occurs between the fifth and sixth-week post-abortion.
The retention of ovarian attachments becomes effective when more than 6 hours after the expulsion of the fetus (Tarnier and Budin, 1945),
the bleeding in the the course of abortion can be so abundant as to endanger a woman’s life.
It’s less substantial if it’s due to retention of the placenta and membrane.
The most frequent and serious complication is infection (high fever, chills, tachycardia, hypotension). Late complications refer to genital inflammations and secondary sterility caused by bilateral tubal occlusion, all as sequelae of sepsis.
Infected or septic abortion can lead to serious complications of endometritis and even endomyometritis, when antibiotic treatment and instrumental evacuation are ineffective, total hysterectomy with double adnexectomy being indispensable. In complications due to sepsis, the joint administration of anticoagulant drugs (sodium heparin or better still fraxiheparin) is recommended.
Clinical forms and recommended behaviors :
The clinical evolution should be expected to be aided by ultrasonographic studies, although quantitative studies of the beta fraction of human chorionic gonadotropin hormone may also be indicated; and thus evaluate the survival of the embryonic sac.
You can act using:
- 1- The pharmacological method (misoprostol)
- 2- Instrumental curettage of the uterine cavity If bleeding is abundant, this surgical technique is used under general anesthesia; a vaginal examination is performed to determine the shape, size, and position of the uterus; the cervix is observed if it is not well dilated, Hegar‘s candles are used and the uterine cavity is gently and carefully checked: its front, back and lateral edges, as well as the uterine fundus until it is certain that there is no embryonic placental remains.
Reference is made to the clinical picture in which, dead in utero, the egg is not expelled to the outside. The doctor will act well with the pharmacological method
(misoprostol) or by aspiration with vacum or instrumental curettage of the cavity uterine.
A complete medical coagulation study will be indicated prior to the interventions blood. In pregnancies over 16-17 weeks, and even in Intermediate and late fetal death is very effective with misoprostol administration.
It is worth remembering that in Cuba there are favorable experiences of achieving the expulsion of The use of extra-ovulatory methods alone or by adding heavy oxytocin salt solutions to the treatment.
In the experience of the author of this work, it is infrequent and almost exceptional to dead fetus syndrome, before 22 weeks of amenorrhea.
-Abortion in progress
Expulsion of the egg in a dilated cervix, with bleeding, or leakage, or both, of amniotic fluid, will be facilitated: using heavy oxytocin salt solutions; misoprostol can also be used.
Once the fetus and placenta have been delivered, it is recommended that you evaluate whether it is a complete abortion (this is rare and there is always a possibility of incompleteness),
so it’s mandatory to have the uterine cavity checked. With the administration of misoprostol, complete expulsion of the product of pregnancy is frequent). However, if there is any doubt about the presence of ovarian remains an ultrasound study of the uterine cavity.
-Infected or septic abortion
It may be the result or consequence of an induced abortion or of abortive maneuvers. It should not be forgotten that a miscarriage, by delaying its treatment or ignoring its presence, can evolve into septic abortion and even severe septic shock.
In the presence of septic abortion, uterine evacuation should be performed.
In severe clinical forms of postabortion sepsis, it is necessary to assess the intervention radical total hysterectomy with double adnexectomy, since the ovary is an organ lacking in visceral peritoneum and very embolizing to distant organs such as the lung, heart and brain.
Bleeding During Pregnancy | Clinical and differential diagnosis
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