women s health issues
Vaginal Bleeding During Late Pregnancy
Evaluation of Vaginal Bleeding in Late Pregnancy
Doctors focus on ruling out potentially serious causes of bleeding (such as Placental Abruption Any vaginal bleeding late during pregnancy is considered a warning sign, except for the mucus plug or bloody show, which only has a small amount of blood and does not last long. Doctors are particularly concerned about women who have fainted, feel light-headed, or have a rapid heart rate—symptoms that suggest very low blood pressure. The following symptoms are also cause for concern: A tense, tender uterus No heartbeat or a slow heart rate in the fetus Labor that stops and loss of muscle tone in the uterus A woman with vaginal bleeding during late pregnancy should go to the hospital immediately. However, if she suspects that the bleeding is the bloody show, she should call the doctor first. The doctor can determine how quickly she needs to be seen based on the amount and duration of bleeding and the presence of signs of labor. Doctors first ask questions about the bleeding and other symptoms and about the medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and the tests that may need to be done (see table). Doctors ask about the bleeding: How long it lasts How severe it is What color the blood is Whether the woman has or has had other symptoms (such as abdominal pain, light-headedness, or fainting) The woman is asked about her pregnancies: how many times she has been pregnant, how many children she has had, and whether she has had any miscarriages or abortions or any problems in previous pregnancies. The woman is asked whether the membranes have ruptured (whether her water broke), usually a sign that labor is starting or has started. Doctors ask about conditions that increase the risk of the most common and serious causes of bleeding and about Risk factors , particularly a cesarean delivery in a previous pregnancy. During the physical examination, doctors first check for signs of substantial blood loss, such as a rapid heart rate and low blood pressure. They also check the heart rate of the fetus and, if possible, start monitoring the fetus’s heart rate constantly (with Fetal monitoring ). Doctors gently press on the abdomen to determine how large the uterus is, whether it is tender, and whether its muscle tone is normal. They then do a pelvic examination. They examine the cervix using an instrument that spreads the walls of the vagina apart (speculum). Normally when delivery is near, doctors examine the cervix with a gloved hand (digital cervical examination) to determine how dilated the cervix is and how the fetus is positioned (see Labor ). However, if bleeding occurs during late pregnancy, ultrasonography is done to check for placenta previa and vasa previa before this examination is done. If either disorder is present, the examination is not done because it may make the bleeding worse. Women who know they have placenta previa or vasa previa should feel empowered to remind clinicians of their diagnosis and refuse having a digital cervical examination. (Careful speculum examination can be done.) The following tests are done: Fetal heart rate monitoring Ultrasonography A complete blood cell count Sometimes, blood tests to determine whether blood is clotting normally Blood type and Rh status (positive or negative) When bleeding occurs in pregnancy, the doctor assesses maternal vital signs, does a physical examination, and evaluates the fetus with a fetal heart rate monitor or ultrasonography. Ultrasonography is also done to try to find the cause of the bleeding. An ultrasound device placed in the vagina (transvaginal ultrasonography) may be used to determine the location of the placenta, umbilical cord, and blood vessels. Thus, it can help doctors rule out or identify placenta previa and vasa previa. However, ultrasonography does not always detect a placental abruption. Doctors evaluate for placental abruption and uterine rupture based on results of the physical examination, including information about risk factors. A complete blood cell count is done. Blood type and Rh status are determined so that a donor with a compatible blood type can be identified in case the woman needs a transfusion. If the bleeding is heavy or if the doctor suspects a placental abruption, blood tests for Disseminated Intravascular Coagulation (DIC) are done. 