1. Bleeding during pregnancy

2. Assessment of the patient
Scene size up
Primary assessment
History taking
Secondary assessment
reassessment

3. Points in history taking
determine nature of bleeding :
Amount ?
Was patient active or resting at time of bleeding ?
When did the bleeding started ?
Painful or painless ?
If painful ask OPQRST to determine pain nature and character ?
Stress on type of pain : colicy , sharp , dull aching .
Dull aching pain occurs in septic abortion
Sharp pain in rupture ectopic
Colicy pain in abortion.

4. Important points in examination
Orthostatic changes in vital signs , in case of compensated shock ( both indicates significant blood loss ).
Abdominal examination for grey turner signs and Cullen sign of internal hemorrhage .
Avoid vaginal examination .
examination of female with vaginal bleeding underestimates amount of blood loss due to physiological changes

5. Signs of internal hemorrhage
A . Cullen sign : bluish discoloration around umbilicus.
B . Grey turner line :
Bluish discoloration in the flanks.
Signs of internal hemorrhage in abdominal examination are …………………….. And …………………………
Grey turner sign is …………………………….. While Cullen sign is ………………. And both are signs of ……………………………………..

6. General lines of treatment
Address ABC :
Administer 100% supplemental oxygen via non rebreathing mask at 15 L/min.
Start an IV line of normal saline with a large-bore IV catheter.
Infuse at the rate necessary to maintain blood pressure.
Use loosely placed trauma pads over the vagina to try to stop the blood flow.
Give short account on prehospital management of vaginal bleeding case.?

7. Provide rapid transport :
Notify the facility of the patient’s condition while en route
Keep the woman recumbent and lying on her left side
Obtain an ECG and baseline vital signs and continuously reassess while en route , watch out for signs of shock.
fetal monitoring continuously throughout the management .
Complete the following :
Women with vaginal bleeding is transported lying …………………..
True or false . : transport of vaginal bleeding case is not urgent and could be done slowly.

8. Causes of vaginal bleeding during pregnancy
Abortion .
Ectopic pregnancy .
Placental abnormalities .
Bleeding during third trimester .
What are the most common causes of vaginal bleeding during pregnancy?

9. Abortion
Definition : expulsion of the fetus and uterine contents before the 20th week of gestation.
Mostly occur during the first trimester before the placenta is matured.
classification :
1- Spontaneous abortion
5- Missed abortion
2- Induced abortion
6- Incomplete abortion
3- Habitual abortion
7- Septic abortion
4- Inevitable abortion
Define abortion ?
Enumerate types of abortion and give short account on one ?

10. Spontaneous abortion
Spontaneous abortion (miscarriage) : is an abortion which occurs naturally.
Causes include:
Acute or chronic illness in the pregnant woman.
Maternal exposure to toxic substances.
Fetal abnormalities.
Abnormal attachment of the placenta.
Can be
avoided
Give short account on spontaneous abortion ? Answer : def. and causes
Define spontaneous abortion?
Answer : expulsion of the fetus which occurs before 20 weeks of pregnancy naturally.

11. You are in the business of saving people not lecturing them
Induced abortion
Intentional , criminal or elective abortion : abortion that is induced either for criminal or medical causes.
as paramedics , care must be given to the patient as usual despite of your ethical or religious believes , you should show empathy and compassion .
You are in the business of saving people not lecturing them
True or false :
criminal abortion is expulsion of uterine content in first trimester which occurs naturally.

12. Habitual abortion
Definition : three or more consecutive pregnancies that end in miscarriage .
Causes include:
Chromosomal and endocrine disorders.
Ovarian issues.
Uterine malformations.
Cervical conditions.
Infections.
Lifestyle factors.
Define habitual abortion ?
Enumerate causes of habitual abortion ?

13. Threatened abortion
Definition : any vaginal bleeding in the first half ( 20 weeks ) of pregnancy (usually first trimester).
Usually associated with mild abdominal cramping.
It differs from inevitable abortion that cervix is closed and bleeding is minimal .
Can progress to an complete abortion or may subside.
Treatment : complete bed rest so the condition can be monitored.
Prehospital treatment : transport and support.
Define threatened abortion?
Complete : in threatened abortion the cervix is …………………. And bleeding ……………………. , it either progress to ……………………… or subsides .
True or false and correct the false:
Threatened abortion is any bleeding that occurs in first trimester.
Cervix is dilated in threatened abortion and thus it can be prevented.
Abdominal pain is usually sever in patient with threatened abortion.

14. Inevitable ( imminent ) abortion
Definition : an abortion that has progressed to a stage where termination of the pregnancy cannot be avoided , ( abortion can not be avoided ).
Signs and symptoms :
Severe abdominal pain from strong uterine contractions
Vaginal bleeding, often massive
Cervical dilation.
Short account on imminent abortion?
Signs and symptoms of inevitable abortion ?
True or false :
In inevitable abortion abdominal pain is sever and bleeding is massive.
Unlike threatened abortion , cervix is closed and pain is mild in inevitable abortion.
In evitable abortion could be prevented by drugs and bed rest.
Complete :
Inevitable abortion is characterized by ……………… cervix , …………. Pain and ………………

15. Prehospital management of inevitable abortion aims at :
Maintain blood pressure.
Prevent hypovolemia.
Watch for signs of shock
Treatment of inevitable abortion : mention general guidelines + aims of Prehospital management .

16. Inevitable abortion

17. Incomplete abortion
Definition : abortion where parts of product of conception remains inside uterus.
Complication : vaginal bleeding will continue increasing risk of shock .
Management : as general guidelines plus
Consult medical control if products of conception are protruding from the vagina.
Collect all products of conception and give to the receiving facility.
Allow the patient to view the fetus if she wishes.
Be prepared for strong emotions.
Define incomplete abortion/?

18. Missed abortion
Definition : retention of product of conception in uterus after abortion for 2 months or more .
The fetus dies during the first 20 weeks of gestation but remains in utero.
Diagnosis :
History : history of threatened abortion, with cessation of vaginal bleeding and a gradual diminishing of signs of pregnancy.
Examination : ♠ Uterus feels like a hard mass.
♠ Fetal heartbeat cannot be heard.
Management : provide emotional support and transport , address ABCs .
True or false :
missed abortion is death of the fetus after 20 weeks which remains inside uterus .
( false ) → death before 20 weeks .

19. Septic abortion
Definition : uterus becomes infected during or shortly ( within hours) after abortion.
Diagnosis :
History : fever and bad-smelling vaginal discharge.
Physical examination : Fever and abdominal tenderness.
Hypotension may indicate septic shock.
Complication : can progress to septicemia and septic shock in severe cases.
Give short account on abortion?
hypotension in patient with septic shock indicates ……………………
Complication of septic abortion are ………………….. And …………………………

20. Ectopic pregnancy

21. Ectopic pregnancy
Definition : life threatening condition in which the fertilized ovum is implanted outside normal site of implantation.
pathology :
Fetus can develop to term .
Normal signs and symptoms of pregnancy are present .
Sites include : fallopian tube ( commonest ) , cervix , ovary and abdominal cavity.
Complication : rupture leading to internal hemorrhage .
Define ectopic pregnancy
Complication of ectopic pregnancy include……………………….

22. Sites of ectopic pregnancy
Tubal (commonest )
Cervical .
Ovarian .
Intraabdominal.
Site of ectopic pregnancy are ………………..
Commonest site of ectopic pregnancy is ……………………

23. Clinical presentation : Symptoms :
Symptoms of pregnancy ( amenorrhea , morning sickness )
Abdominal pain , which is sever with rupture ectopic
Syncope in case of shock
Signs :
Abdominal tenderness
Signs of acute abdomen and internal hemorrhage in case of rupture.
Management : general guidelines + rapid transport + emotional support.
Define ectopic pregnancy ?
Short essay on ectopic pregnancy ?
Enumerate sites of ectopic pregnancy and what is the commonest?
Tubal ectopic pregnancy is the commonest ( true or false ) → true .
Management of ectopic pregnancy

24. Abdominal pain in female in child bearing period is ectopic pregnancy until proved other wise
Ectopic pregnancy must be considered on any female in child bearing period with signs of acute abdomen ( true or false ) , true.

25. Placental causes of vaginal bleeding
Definition : Premature separation of the placenta from the uterine wall.
incidence
Most common in the last trimester, but can happen in the second as well.
Causes :
Maternal hypertension ( commonest ).
Trauma , assault and falls .
Drug abuse , alcohol and smoking .
More common with previous history of abruptio placenta.
Abruptio placenta , placental abruption
Placental causes of vaginal hemorrhage are : ………………….. And ……………………….
Preeclampsia and eclampsia is the commonest cause of abruptioplacenta ( true or false ).

26. Clinical presentation : Symptoms :
Vaginal bleeding with bright red blood.
( Sometimes the blood does not reach the vagina, so doesn't appear).
Sudden onset of severe abdominal pain
No longer feeling the fetus moving.
Physical examination
Signs of shock, often out of proportion of apparent blood loss.
Tender abdomen and rigid uterus on palpation.
Fetal heart sounds may be absent.
You and your team has been called to school where one of the teacher which is 30 weeks pregnant and known to have gestational hypertension has collapsed , her colleagues states that she has been complaining of sever abdominal pain before her collapse , what is most probable diagnosis and appropriate approach for this case.?

27. Abruptio placenta

28. Management :
General outlines + careful and rapid transport + reassess continuously for shock + fetal monitoring .

29. Placenta previa
Definition : Placenta that is implanted low in the uterus and partially or fully covers the cervical canal.
Chief complaint is usually painless vaginal bleeding with bright red blood.
Leading cause of vaginal bleeding in the second and third trimesters.
Complications include:
Disseminated intravascular coagulation .
Hemorrhage .
Low fetal birth weight .
Definition?
Presentation :
Painless vaginal bleeding with bright red blood
Signs
Complication.

30. signs :
The uterus is soft and non tender.
Do not palpate deeply in any woman with third-trimester bleeding.
May induce heavy bleeding if she does have placenta previa.

32. Third trimester bleeding
Bleeding during third trimester is of the greatest danger due to :
Large volume of blood present
Compensatory mechanisms present as a result of pregnancy.
pregnant woman can lose 40% of circulating volume before hypovolemia is apparent.

33. Summary
Bleeding in obstetric patient require good assessment , rapid transport and continuous reassessment for signs of shock.
Vaginal examination is better avoided in patient with vaginal bleeding .
Abortion is expulsion of product of conception before 2o weeks of gestation.
Tubal pregnancy is most common type of ectopic pregnancy.
Placenta previa is leading cause of bleeding in third trimester.
Hypotension in patient with septic abortion is grave and means septic shock.

34. Any questions ?