Outline the causes and management of bleeding in early pregnancy, and list causes of bleeding in late pregnancy.

i) Causes of bleeding in early pregnancy

• Implantation bleeding: Light spotting as the fertilized egg implants in the uterus.
• Miscarriage (spontaneous abortion): Loss of pregnancy before 20 weeks.
• Ectopic pregnancy: Fertilized egg implants outside the uterus, usually in a fallopian tube.
• Molar pregnancy: Abnormal growth of tissue in the uterus.
• Cervical polyps or infection: Non-pregnancy related causes of bleeding from the cervix.
• Subchorionic hemorrhage: Bleeding between the chorion and the uterine wall.

ii) Management of bleeding in early pregnancy

• Medical history and physical examination: To assess symptoms and determine the source of bleeding.
• Ultrasound: To confirm pregnancy location, viability, and rule out ectopic or molar pregnancy.
• Blood tests: Quantitative hCG levels, blood type, Rh status, and complete blood count (CBC).
• Rh immunoglobulin (RhoGAM): Administered to Rh-negative mothers to prevent Rh sensitization.
• Expectant management: For minor bleeding like implantation bleeding or small subchorionic hematomas.
• Surgical or medical intervention: For ectopic pregnancy (e.g., methotrexate, laparoscopy) or incomplete miscarriage (e.g., D&C, misoprostol).

iii) Causes of bleeding in late pregnancy

• Placenta previa: The placenta partially or completely covers the cervix.
• Placental abruption: The placenta separates prematurely from the uterine wall.
• Vasa previa: Fetal blood vessels cross or run near the internal opening of the cervix.
• Uterine rupture: A tear in the uterine wall, often in women with previous C-sections.
• Preterm labor: Cervical changes and contractions leading to early delivery.
• Bloody show: Mucus plug mixed with blood, indicating cervical changes before labor.

iv) Management of bleeding in late pregnancy

• Immediate assessment: Monitor maternal vital signs and fetal heart rate.
• Avoid vaginal examination: Until placenta previa is ruled out by ultrasound.
• Ultrasound: To determine placental location, assess for abruption, and evaluate fetal well-being.
• Blood tests: CBC, coagulation profile, blood type, Rh status, and cross-match.
• Hospitalization: For close monitoring and potential intervention.
• Fluid resuscitation/blood transfusion: If significant blood loss occurs.
• Tocolytics: Medications to stop contractions if preterm labor is suspected and delaying delivery is safe.
• Corticosteroids: Administered to promote fetal lung maturity if preterm delivery is likely.
• Delivery: May be necessary depending on the cause, severity of bleeding, and fetal status.

v) Diagnostic procedures that clarify bleeding in each case, be it early or late pregnancy

• History and Physical Examination: Detailed history of bleeding characteristics (onset, amount, color, associated pain) and a speculum examination to visualize the cervix. Digital vaginal examination is contraindicated in late pregnancy bleeding until placenta previa is ruled out.
• Ultrasound (Transvaginal and/or Transabdominal):
  • Early pregnancy: Confirms intrauterine pregnancy, fetal viability, gestational age, and rules out ectopic or molar pregnancy.
  • Late pregnancy: Determines placental location (ruling out placenta previa), assesses for placental abruption, and evaluates fetal well-being.
• Blood Tests:
  • Quantitative hCG: In early pregnancy, to monitor pregnancy progression.
  • Complete Blood Count (CBC): To assess for anemia.
  • Blood Type and Rh Status: Essential for Rh-negative mothers.
  • Coagulation Profile: In late pregnancy, to assess for coagulopathy, especially with suspected abruption.
• Fetal Monitoring:
  • Late pregnancy: Cardiotocography (CTG) to assess fetal heart rate patterns and uterine contractions for signs of fetal distress.