Vaginal Bleeding in the Pregnant Patient

Prehospital treatment of abruptio placentae centers on correcting hypovolemic shock. In a hemodynamically stable patient with no signs or symptoms of shock, BLS care is appropriate. If the patient has active vaginal bleeding, place a feminine pad over the vagina. The patient in this case shows numerous signs and symptoms of shock. She is tachycardic, hypotensive (especially when you consider she has chronic hypertension and is not taking her medications), her skin is cool and slightly pale with delayed capillary refill, and she experiences dizziness when she stands and walks around. All of this indicates that she has experienced significant blood loss and is in decompensated hypovolemic shock. This patient should receive supplemental oxygen via nasal cannula, be placed on the cardiac monitor and have a large-bore IV catheter placed. Administer an isotonic crystalloid such as normal saline to help correct hypotension.

Another cause of bleeding in the second half of pregnancy is placenta previa. Placenta previa occurs when the placenta either partially or completely covers the internal cervical os, the opening between the uterus and vaginal canal. A marginal placenta previa occurs when the placenta approaches the border of the os but does not touch it. During childbirth, the delivering fetus can damage the placenta, resulting in bleeding that can be significant and lead to hypovolemic shock. The exact cause of placenta previa is unknown, and risk factors include multiparity, multiple gestation, advanced maternal age, previous cesarean delivery or other uterine surgery, and smoking.¹⁷ Bleeding from a torn placenta is particularly dangerous because the placenta has no ability to contract to tamponade bleeding. Thus, when the placenta begins to bleed, it essentially bleeds uncontrollably. The patient in this case would be considered to have an advanced maternal age, a history of smoking and previous uterine surgery in the form of cesarean sections and elective abortions.

Placenta previa occurs in about 0.3%–0.5% of all pregnancies, and mortality associated with it is as high as 1%. Of all placenta previas, about 20%–45% are complete, 30% partial, and the remaining 25%–50% marginal.¹⁸

The classic presentation for placenta previa is painless bright-red bleeding. The first bleed tends to occur at 27–32 weeks’ gestation, and the onset is usually acute and may accompany uterine contractions. Bleeding often resolves spontaneously but may recur with contractions. This patient’s episode of vaginal bleeding is accompanied by abdominal pain and hypotension, making placenta previa less likely than abruptio placentae.

The prehospital treatment for placenta previa is mostly supportive. Place a feminine pad over the vagina if there is active bleeding. For patients with severe bleeding that leads to hypovolemic shock, ALS intervention and volume resuscitation with an isotonic crystalloid is necessary.

Conclusion

Remembering some general principles can help the EMT and paramedic in making decisions regarding the care and transport of the pregnant patient with vaginal bleeding:

• Light vaginal bleeding is not uncommon in pregnancy, but heavy bleeding or bleeding accompanied by abdominal pain is and requires evaluation in the emergency department.

• The development of hypovolemic shock from uncontrolled internal bleeding should always be a concern in the patient with vaginal bleeding. Assess and treat accordingly.

• Transport pregnant patients with greater than 20 weeks’ gestation to a hospital with OB capability. Those under 20 weeks’ gestation may be able to be evaluated in an ED in a hospital without OB capability. Consult with medical control regarding a destination.

Documenting a Woman’s Reproductive History

Common nomenclature for documenting a woman’s reproductive history is with an abbreviation listing the patient’s GPA:

G—Gravida (number of pregnancies)

P—Para (number of live births)

A—Abortus (number of abortions)

For the purposes of history taking, abortions are defined as any spontaneous abortions prior to the 20th week of pregnancy and any planned abortions the patient has had. These are then documented in order, such as: G2P2A0. This would mean gravida 2, para 2, abortus 0. Put in colloquial terms, this woman has had two pregnancies that produced two children, and no abortions.

Table 1: Risk Factors for Ectopic Pregnancy

• History of pelvic inflammatory disease

• History of tubal ligation or other tubal surgery

• Use of intrauterine device

• History of ectopic pregnancy

• History of smoking

• Advanced age

• History of spontaneous or medically induced abortion

Table 2: Risk Factors for Abruptio Placentae

• Advanced maternal age

• History of cesarean section or other uterine surgery

• History of smoking

• History of cocaine abuse

• History of hypertension (chronic or pregnancy-induced)

• Previous abruptio placentae