Bleeding in Pregnancy & Abortion

Clinical presentation 

• Mild vaginal bleeding
• Mild/no lower abdominal pain
• Cervix is closed on digital examination

Investigation  Check Hb level 

Management of threatened abortion in Dispensary & Health Centre 

• Adequate bed rest at home
• Avoid strenuous activities and sexual intercourse until all the symptoms have subsided
• Schedule a follow up within 7 days
• Tell the woman to come immediately if;
  • Bleeding becomes heavy
  • Experiences offensive discharge
  • Severe abdominal pain

Referral 

Refer to higher-level health facility with adequate expertise and diagnostics if: 

• Bleeding recurs
• Experiences fever
• Experiences offensive discharge
• Experience severe abdominal pain

In higher level health facilities: 

• Take thorough history and perform investigations to establish the causes
• Perform  ultrasound  to  confirm  pregnancy,  gestational  age,  foetal  viability  and  potential causes of abortion.
• Admit the patient and manage appropriately
• Encourage bed rest
• For  unexplained  recurrent  miscarriage  (3  consecutive  abortions)  or  PRL  due to luteal phase defect manage with

Pharmacological Treatment 

S:  dydrogesterone  (PO)  40mg  stat  then  10mg  24hourly  until  the  bleeding  stops  for threatening abortion 

OR

10mg 24hourly from conception up to 20weeks for luteal phase defect. 

Abortion is said to be inevitable when it is not possible for the pregnancy to continue and the cervix  is dilated, but all the products of conception are in situ. 

Clinical presentation 

• Moderate or severe per vaginal bleeding
• Moderate or severe lower abdominal pain
• Membranes may be intact or ruptured with leakage of
• The uterine fundal height may correspond with gestational age
• The cervix is dilated

Management of inevitable abortion in Dispensary & Health Centre (B-EMONC facilities) 

• Apply Airway, Breathing, Circulation and Dehydration (ABCD) principles of resuscitation
• A: compound sodium lactate (IV) OR 0.9% sodium chloride (IV) depending of amount of blood loss. 
• Perform Manual Vacuum Aspiration (MVA) if gestation age is below 12 weeks
• Augment  the  process  by  administering  A:  oxytocin  20  IU  in  500mls  RL/NS  at  40–60 drops/minute if gestation age is above 12 weeks
• Manage as incomplete abortion if after augmentation some products of conception remain in the uterus
• Manage as complete abortion if all products of conception are expelled

Referral:  Refer  to  hospital  if  MVA  is  not  possible  and/or  bleeding  is  persisting  or  severe  to  necessitate blood transfusion. 

Management of inevitable Abortion in the Hospital 

• Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
• Obtain blood samples for Hb, grouping and cross–matching
• Give compound sodium lactate (IV)OR 0.9% sodium chloride aim at replacing 3 times the amount of estimated blood loss.
• Give blood transfusion if indicated
• Perform Manual Vacuum Aspiration (MVA) if gestation age is below 12 weeks
• Augment  the  process  by  administering  oxytocin  20IU  in  500mls  RL/NS  at  40–60 drops/minute if gestation age is above 12 weeks
• Manage as incomplete abortion if after augmentation some products of conception remain in the uterus
• Manage as complete abortion if all products of conception are expelled

Abortion  is  said  to  be  incomplete  when  after  expulsion  some  of  the  products  of  conception  get  retained in the uterine cavity. 

Clinical presentation 

• Severe Cramping lower abdominal pain
• moderate to severe PV bleeding
• Fundus smaller than dates
• The cervix is dilated and products of conception may be felt on or through the cervix on digital examination

Management of incomplete abortion in dispensary & health centre (B-EMONC facilities) 

• Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
• Check hemoglobin level
• A: compound sodium lactate (IV) OR 0.9% sodium chloride depending on amount of blood loss
• If feasible Perform digital evacuation of products of conception to miminize the PV bleeding Perform MVA if gestation age is below 12 weeks

Pharmacological treatment in place 

In place where uterine evacuation is accessible give; 

A: oxytocin (IM) 10 IU 

OR 

A: misoprostol (sublingual) 600µg 

After evacuation give: 

A: erythromycin (PO) 500mg 8hourly for 5days 

OR 

B: amoxicillin + clavulanic acid (FDC) (PO) 625mg 8 hourly for 5days 

AND 

A: metronidazole (PO) 400mg 8hourly for 5days 

AND 

A: paracetamol (PO) 1g 8hourly for 5 days 

Referral: Resuscitate the patient and to hospital level with an escort of a nurse if bleeding continues 

Management in a Hospital 

• If patient is in shock, shout for help, mobilize resources
• Apply ABCD principles of resuscitation
• Obtain blood for HB, grouping and cross–matching
• Blood transfusion if indicated
• Give compound sodium lactate (IV) OR 0.9% sodium chloride aim at replacing 3times the amount of estimated blood loss
• Digital evacuation of products of conception if feasible to minimize the PV bleeding
• MVA if gestation age is below 12 weeks
• Evacuate uterus in theatre with sharp curette under general anesthesia if pregnancy was more than 12 weeks

Pharmacological Treatment  After evacuation give: 

A: erythomycin (PO) 500mg 8hourly for 5days 

OR 

B: amoxicillin + clavulanic acid (FDC) (PO) 625mg 8hourly for 5 days 

AND 

A: metronidazole (PO) 400mg 8hourly for 5 days 

AND 

A: paracetamol (PO) 1g 8hourly for 5days. 

AND 

A: ferrous sulfate + folic acid (FDC) (PO) 1 tab 24hourly for 4 weeks 

Patient education. 

• Counsel and educate the patient on possible reasons for abortion and future fertility
• Provide family planning counseling and give appropriate contraceptive method before the patient leaves the facility premises.
• Provide linkage to other reproductive and non reproductive health services depending on patient needs

Abortion is said to be complete when the Products of conception are completely expelled 

Clinical presentation 

• Minimal or no PV bleeding
• Uterus smaller than dates and often well contracted.
• Cervix may or may not be closed
• The patient may be in Shock due to severe bleeding

Pharmacological Treatment 

A: erythromycin (PO) 500mg 8hourly for 5days 

OR 

B: amoxicillin + clavulanic acid (FDC) (PO) 625mg 8hourly for 5days 

AND 

A: metronidazole (PO) 400mg 8hourly for 5days 

AND 

A: ferrous sulfate + folic acid (FDC) (PO) 1 tablet 24hourly for 4weeks 

If patient is in shock

• Shout for help and mobilize resources
• Apply ABCD principles of resuscitation
• Give compound sodium lactate (IV) OR 0.9%sodium chloride (IV) 3litres or more in the first hour  
• Insert an indwelling urethral catheter  
• Give ampicillin (IV) 1g and metronidazole (IV) 500mg stat  
• Obtain blood for HB, 

Referral: Resuscitate the patient and refer to hospital with an escort of a nurse 

Management in a hospital   

• If patient is stable continue as above; 
• If patient is in shock, perform as above and give blood transfusion if indicated  

Patient Education 

• Provide counseling, education and FP services as in incomplete abortion above 

Abortion is said to be septic when It is complicated by infections. 

Clinical presentation 

• Moderate to severe Abdominal pain following abortion  
• Fever may be present  
• Foul smelling PV discharge which may be mixed with blood.      May be in shock  
• Tender uterus with or without rebound tenderness  
• Cervix is usually open  

Management of septic abortion in dispensary & health centre 

• Apply ABCD principles of resuscitation  
• Give compound sodium lactate (IV) OR sodium chloride (IV) 0.9% in case of hypotension or shock. Avoid IV fluid in case of chronic anaemia. 
• Insert an indwelling urethral catheter  
• Obtain blood for Hb or FBC 
• Perform Ultrasound if feasible 

Pharmacological Treatment 

C: amoxycillin + clavulanic acid (FDC) (IV) 1.2g 8hourly for 24-48hours 

AND  

B: metronidazole (IV) 500mg 8hourly for 24–48hours      

Referral: Resuscitate and immediatelyrefer the patient to hospital with an escort of a nurse.  

Management in the Hospital: 

• Full Blood Count (FBC) 
• Draw Blood for culture and susceptibility testing 
• Check abdominal pelvic ultrasound as appropriate 
• IV RL/NS depending on individual patient needs 
• Give blood transfusion if indicated  
• Evacuate the uterus with sharp wide curette under general anesthesia 

Pharmacological Treatment 

Treat as above and when the patient is stable continue with;  

B: amoxicillin+ clavulanic acid (FDC) (PO) 625mg 8hourly for 7days                    

A: metronidazole (PO) 400mg 8hourly for 7days  

If no response with the above antibiotics within 3 days; adjust according to culture and sensitivity  results or switch to  

D: ceftriaxone + sulbactam (FDC) (IV) 1.5g 12hourly for 5days  

AND 

B: metronidazole 500mg (IV) 8hourly for 5days 

AND 

A: ferrous sulfate +folic acid (FDC) (PO) 1tablet daily for 4weeks then reassess. 

Patient Education 

• Counsel educate and provide appropriate contraceptive method.

A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that  has  swollen  chorionic  villi.  These  villi  grow  in  clusters  that  resemble  bunches  of  grapes.  Once  diagnosed it should be treated right away. 

Clinical presentation 

• Vaginal bleeding
• Uterus that is bigger than gestational age.
• Exaggerated pregnancy symptoms (Severe nausea and vomiting)
• Vaginal discharge of tissue that resemble grapes
• Heavy PV bleeding when the mole abort spontaneously

Management of Molar pregnancy at the dispensary and Health centers 

• Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
• Check hemoglobin level
• If the patient is actively bleeding, catheterize, Establish Iv line and Give IV RL/NS 2lts at a rapid rate

Referral: Resuscitate and refer the patient to higher level facility with a nurse escort for appropriate  management 

Management of molar pregnancy at the Hospital 

• Apply Airway, Breathing, Circulation and Dehydration principles of resuscitation
• If  the  patient  is  patient  is  actively  bleeding  or  in  shock  shout  for  help  and  mobilize resources
• Cheek HB, Blood grouping and Cross matching
• Perform quantitative serum Beta Human Chorionic Gonadotropin (bHCG)
• Check abdominal pelvic Ultrasound to confirm the diagnosis (Snowstorm appearance)
• Infuse compound sodium lactate (IV) OR 0.9% sodium chloride (IV) as needed
• Initiate blood transfusion if indicated
• Perform suction curettage in operating theatre
• Perform other investigations as appropriate (chest X ray, RFT, LFT, Chemistry panel)

Follow up for Molar pregnancy after Molar Evacuation 

• Check weekly bHCG until when it becomes normal(5-10mIU/ml) for 3 weeks consecutively
• Then check monthly bHCG and pelvic ultrasound for 12 months
• Advice the patient to use effective contraception during follow up (preferably COCs)

This happens when a Fetus less than 24weeks die in utero, but it’s not expelled out 

Clinical presentation

• History of amenorrhea
• Regression of the pregnancy symptoms
• Uterine size smaller than dates
• Mild of no PV bleeding

Management of a missed abortion at the dispensary and Health center 

Referral: Referto higher level health facility with adequate expertise and diagnostics/equipment 

Management of missed abortion at the hospital Investigations 

• Abdominal pelvic ultrasound
• Full blood count, Blood Grouping and cross matching
• Clotting indices (PT, APTT, INR)

Pharmacological Treatment 

Induce abortion with misoprostol if it is more than 12 weeks 

A:  misoprostol  (PV)  100mcg  8hourly  to  max.  400mcg  followed  by  sharp  curettage  in  case  of  incomplete abortion 

Note: Avoid misoprostol in case of previous uterine scar 

Evacuate by Dilatation and Curettage (D&C) if the GA is less than 12weeks  

After evacuation give 

A: metronidazole (PO) 400mg 8 hourly for 7days 

AND 

B: amoxicillin+ clavulanic acid (FDC) (PO) 625mg 8hourly for 7days 

Patient education. 

Counsel and provide appropriate contraception.