Bleeding in late pregnancy (? 20 weeks but before birth) occurs in 3-4% of pregnancies. Pathophysiology Some diseases can cause significant blood loss, sometimes so much that there is a hemorrhagic shock or disseminated intravascular coagulation. Etiology The most common cause of bleeding in late pregnancy is Bloody Draw birth Bloody drawing speaks for the onset of labor is mixed sparse and with mucus and is the result of tearing of small veins in the dilatation of the cervix and disappears with the onset of labor. More serious but less common causes (see Table: Causes of vaginal bleeding in late pregnancy) are Abruptio placenta (placental abruption) Placenta previa Vasa previa uterine rupture (rare) placentae as abortion refers to the early solution of a normally implanted placenta from the uterine wall. The mechanism is unclear, but it is likely to be a long-term consequence of chronic uteroplacental vascular insufficiency. Sometimes it happens after a trauma (eg. As personal injury, motor vehicle accident) to do so. Since some or most of the bleeding between the placenta and uterine wall may be hidden, does not correlate the quantity of external (i. E. Vaginal) bleeding necessarily with the amount of blood loss or placenta solution. A abruptio placentae is the most frequent cause of life-threatening hemorrhage in late pregnancy and represents about 30% of cases. It can occur at any time, but is most common in the third trimester. Placenta previa is the abnormal implantation of the placenta on the internal os or adjacent to him. It is a result of various risk factors. The bleeding can occur spontaneously or be triggered by manual examination or by the onset of labor. In placenta previa about 20% of bleeding omitted in late pregnancy; it is most common in the third trimester. In Vasa previa the fetal blood vessels that connect the umbilical cord and the placenta come above the internal os to lie and are in front of the presenting part of the fetus. Normally it comes to this abnormal connection when the vessels of the umbilical cord through parts of the chorionic membrane rather than lead directly into the placenta (Insertio velamentosa). By mechanical forces during childbirth these small blood vessels may be affected, causing them to tear. Due to the relatively small fetal blood volume a little loss of blood by vasa previa can even mean a catastrophic hemorrhage to the fetus and cause fetal death. A uterine rupture during labor can, almost always in women with a scarred uterus (eg., By caesarean section, uterine surgery or uterine infection), or occur after severe abdominal trauma. Causes of vaginal bleeding in late pregnancy cause Suspicion Results Diagnostic procedure birth departure of bloody Schleimpfropfes, no active bleeding Painful, regular uterine contractions with cervical dilation and exhaustion Normal fetal and maternal character diagnosis of exclusion Abruptio placenta Painful pressure sensitive uterus, often tense occasion with contractions Dark or clotted blood maternal hypotension signs of fetal Emergency situation (eg. As bradycardia or prolonged deceleration, repetitive late decelerations, sinusoidal pattern) Clinical suspicion Frequently ultrasound, although it is not very sensitive placenta previa sudden onset of painless vaginal bleeding with bright red blood and little or no pressure sensitivity of the uterus Occasionally suspected due to the findings of a routine ultrasound Transvaginal sonography Vasa previa Painless vaginal bleeding with fetal instability, but normal maternal characters often symptoms of birth Occasionally suspected due to the findings of a routine Ultra sound examination Transvaginal ultrasonography with color Doppler uterine rupture Severe abdominal pain, tenderness, end of contractions, frequent loss of uterine tone Mild to moderate vaginal bleeding Fetal bradycardia or loss of heart sounds Clinical suspicion, usually prior uterine surgery laparotomy clarification aims Clarification to the exclusion of potentially serious causes of blood flow (placental abruption, placenta previa, vasa praevia, uterine rupture). Bloody drawing the birth and placental abruption are diagnosis of exclusion. History to history of the current disease should the pregnancy (number of confirmed pregnancies), parity (number of births after 20 weeks) and the number of abortions (spontaneous or induced) as well as the duration of bleeding and quantity and color (bright red vs .) dark part of the blood. Important accompanying symptoms include abdominal pain and rupture of membranes. The physician should pay attention to these symptoms and they describe (eg. As whether the pain is intermittent and spasmodic as during labor or prolonged strong, indicating a placental abruption or uterine rupture). In reviewing the Organysteme all previous syncope or Beinahesynkopen should (which indicates a strong bleeding) are identified. The history should risk factors for major causes of bleeding (see Table: Risk factors for major causes of bleeding in late pregnancy), in particular a previous Caesarean section, capture. It should be determined whether a history of the patient’s hypertension, cigarette smoking, in vitro fertilization or illicit drug use (particularly cocaine) occurs. Risk factors for major causes of bleeding in late pregnancy cause risk factors Abruptio placenta hypertension Age> 35 Years Multi parity cigarette smoking cocaine Earlier Abruptio placenta injuries placenta previa Former cesarean multiparity multiple pregnancies Earlier placenta previa age> 35 years cigarette smoking Vasa previa deep-seated placenta bilobed or succenturiate-lobed placenta multiple pregnancies in vitro fertilization uterine rupture Former cesarean Any uterine surgery Age> 30 years Earlier uterine infection induction of labor trauma (eg. B. gunshot wound) Physical examination The examination begins with review of vital signs, especially blood pressure, signs of hypovolemia. The fetal heart rate is judged, and if possible a continuous monitoring of the fetus is started. The abdomen is with respect to the uterus size, pressure sensitivity and tone (normal, increased or decreased) keyed. A manual cervical examination is provided contraindicated in a blood flow in late pregnancy until a sonography a normal placenta and normal location of the vessels was confirmed (and placenta previa and vasa previa was excluded). A careful speculum examination can take place. If the ultrasound examination inconspicuous, can with a manual examination, the cervical dilation and depleting determined werden.Warnzeichen The following findings are of particular importance: hypotension Tense, pressure sensitive uterine fetal distress (loss of heart sounds, bradycardia, altered or late decelerations, during the monitoring be determined) decrease in the birth and atonic uterus interpretation of the findings, if more than a few drops of blood are observed or there are signs of fetal distress, the more serious causes must be excluded: placental abruption, placenta previa, vasa praevia and uterine rupture. However, some patients show placental abruption or uterine rupture with only a minimally visible bleeding despite strong intra-abdominal or intrauterine bleeding. Clinical findings help in finding the cause (see also causes of vaginal bleeding in late pregnancy). Slight bleeding with mucus suggests drawing a bloody birth. A sudden, painless bleeding with bright red blood previa is an indication of a placenta or vasa praevia. Dark clotted blood speaks for a placental abruption or uterine rupture. A tense, contracted, pressure-sensitive uterus is an indication of abruption placenta; an atonic or malformed uterus with abdominal tenderness leaves a uterine rupture vermuten.Tests following tests should be made: ultrasound blood count and type and screen if necessary Kleihauer-Betke test all women with bleeding in late pregnancy require a transvaginal ultrasound, which is performed in the unstable patient at the bedside. A normal placenta and umbilical cord and normal Gefäßinsertion exclude a placenta previa and vasa praevia. Although sonography occasionally shows a placental abruption, this study is not reliable enough to be a placental abruption be distinguished from a uterine rupture. These diagnoses are clinically based on risk factors and examination findings (a tense uterus is more common than a placental abruption, a loss of tone often than rupture) provided. A rupture is confirmed during a laparotomy. In addition, should blood count and “type and screen” done (blood typing and screening for abnormal antibodies). Is a strong bleeding before, is moderate degree to severe abruptio placentae suspected or is a maternal hypotension, are cross-tested several units of blood and tests for disseminated intravascular coagulation (PT / PTT, fibrinogen, D-dimer levels) is performed. The Kleihauer-Betke test can be used to measure the amount of blood in the fetal maternal circulation, and for determining the need for additional RhO (D) immunoglobulin-doses to prevent maternal sensitization are used. Treatment The treatment depends on the specific cause. Patients with signs of hypovolemia need i.v. Hydration, starting with 20 ml / kg physiological saline. Blood transfusion should be considered for patients considered, are not responsive to 2 L of brine. Summary All patients need an i.v. Access for the liquid or blood therapy and continuous maternal and fetal monitoring. Manual cervical examination is long contraindicated in the investigation of bleeding in late pregnancy until a placenta previa and vasa praevia were excluded. In placental abruption, vaginal bleeding may be missing if blood between the placenta and uterus remains hidden. A uterine rupture may be suspected in women with a history of cesarean section or other uterine surgery. Vaginal bleeding may be slightly despite maternal hypotension.


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