Bleeding in the II and III trimesters of pregnancy: causes, symptoms, diagnosis, treatment

Bleeding during pregnancy is observed in 2-3% of women. The most common causes of bleeding are placenta previa and premature detachment of the normally located placenta.

Placenta previa - abnormal attachment of the placenta in the uterus, its location in the region of the lower uterine segment, over the inner throat, which leads to partial or complete overlapping and placenta below the presenting part of the fetus, i.e. On the way of the fetus.

ICD-10:

• 046 Prenatal bleeding, not elsewhere classified.

[1], [2], [3], , [4], [5]

Epidemiology

Epidemiology of bleeding in the II and III trimesters of pregnancy

The frequency of placenta previa in relation to the total number of pregnancies is 0.2-0.6%. Approximately in 80% of cases, this pathology is observed in multi-genera (more than 2 births in the anamnesis). Maternal morbidity is 23%, premature births develop in 20% of cases. Maternal mortality with placenta previa varies from 0 to 0.9%. The main causes of death are shock and bleeding. Perinatal mortality is high and varies from 17 to 26%.

Screening

Conduction of ultrasound in 10-13, 16-24, 32-36 weeks of pregnancy. Placental localization is determined during each study, beginning with the 9th week of pregnancy.

[6], [7], [8], [9], [10], [11], [12]

Forms

Classification of bleeding in the II and III trimesters of pregnancy

By the degree of presentation of the placenta:

• full - the inner throat is completely blocked by the placenta;
• partial - the inner throat is partially blocked by the placenta;
• marginal - the edge of the placenta is located at the edge of the internal pharynx;
• low - the placenta is implanted in the lower segment of the uterus, but its edge does not reach the internal pharynx.

[13], [14], [15], [16], [17]

Diagnostics of the bleeding in the II and III trimesters of pregnancy

Diagnosis of bleeding in the II and III trimesters of pregnancy

Anamnesis and physical examination

In the anamnesis - a large number of births, abortions, postabortion and postpartum septic diseases, uterine fibroids, deformation of the uterine cavity (scars after cesarean section and other operations, anomalies of the development of the uterus), elderly primiparas, pregnancy as a result of stimulation of ovulation, in vitro fertilization.

Symptoms of placenta previa before bleeding are extremely scarce. The high standing of the presenting part of the fetus is noted, its unstable position, often oblique or transverse position, pelvic presentation, often there are symptoms of the threat of abortion, fetal hypotrophy.

The main clinical symptom for placenta previa is bleeding, characterized by the absence of pain syndrome ("painless bleeding"), frequent re-emergence and progressive anemization of the pregnant woman. Uterine bleeding with placenta previa is most often developed with a gestation period of 28-30 weeks, when the preparatory activity of the lower segment of the uterus is most pronounced. Diagnosis of the placenta is based on clinical data, mainly on bleeding with scarlet blood.

It is necessary to examine the cervix using vaginal mirrors and vaginal examination. When viewed in mirrors, bleeding is detected by scarlet blood from the cervical canal. When the vaginal examination behind the internal throat is determined by the placenta tissue, rough shells. If you have ultrasound data, do not perform a vaginal examination.

[18], [19], [20], [21], [22], [23]

Differential diagnosis of bleeding in the II and III trimesters of pregnancy

Differential diagnosis should be carried out with the following conditions:

• premature detachment of the normally located placenta;
• rupture of the marginal sinus of the placenta;
• rupture of the umbilical cord with their glandular attachment;
• rupture of the uterus;
• ectopia of the cervix;
• rupture of varicose-dilated veins of the vagina;
• bleeding ectopia;
• polyps;
• carcinoma of the cervix.

[24], [25]

Treatment of the bleeding in the II and III trimesters of pregnancy

Treatment of bleeding in the II and III trimesters of pregnancy

The purpose of treatment

Stop bleeding.

Indications for hospitalization

Full placenta previa even in the absence of clinical symptoms; the emergence of blood from the genital tract.

Non-drug treatment of bleeding in the II and III trimesters of pregnancy

Exclusion of physical activity, bed rest, sexual rest.

Drug therapy for bleeding in the II and III trimesters of pregnancy

Therapy is aimed at removing the excitability of the uterus, strengthening the vascular wall:

• drotaverina 2% solution (2 ml IM);
• hexoprenaline sulfate (500 μg - 1 tablet every 3 hours, then every 4-6 hours);
• fenoterol 10 ml IV drip in 400 ml of 5% glucose solution;
• menadione sodium bisulfite 1% solution (1.0 w / m);
• ethasylate 12.5% solution (2.0 w / w, IM) ⁱⁿ [5, 9].

In case of premature pregnancy (up to 34 weeks), in order to prevent respiratory distress syndrome of the fetus, the administration of large doses of glucocorticoids - dexamethasone 8-12 mg (4 mg twice daily for 2-3 days or per os at 2 mg 4 times on day 1, 2 mg 3 times on day 2, 2 mg 2 times on day 3) (see the article "Treatment of threatening premature birth").

[26], [27], [28], [29], [30]

Surgical treatment of bleeding in the II and III trimesters of pregnancy

The choice of method of therapy depends on the magnitude of blood loss, the general condition of the pregnant woman, the type of presentation of the placenta, the gestational age, the position of the fetus.

With a central presentation of the placenta without hemorrhage, delivery is shown by cesarean section at 37 weeks in a planned manner.

When bleeding in a volume of 250 ml or more, regardless of the degree of presentation of the placenta, emergency delivery is indicated by cesarean section at any time of pregnancy.

Due to the insufficient development of the decidua in the region of the lower segment of the uterus, dense attachment of the placenta often occurs, sometimes its true increment. In such cases, removal of the uterus is indicated.

With the marginal presentation of the placenta, one can use expectant tactics before the spontaneous onset of labor, and in labor the early amniotomy is indicated.

Patient education

Pregnant should be informed about the presence of her placenta presentation, the need for observance of sexual dormancy, bed rest and immediate hospitalization in case of even minor blood discharges from the genital tract.

Forecast

The prognosis regarding the life of the mother and fetus is mixed. The outcome of the disease depends on the etiologic factor, the nature and severity of the bleeding, the timing of the diagnosis, the choice of an adequate method of treatment, the state of the pregnant body, the degree of maturity of the fetus.

Prevention

Prevention of bleeding in the II and III trimesters of pregnancy

Reducing the number of conditions that cause abnormal implantation of the fetal egg - abortion, intrauterine interventions, inflammatory diseases of the internal genital organs.