Clinicopathologic Correlations

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Bleeding during pregnancy is fairly common but is not considered to be normal. The causes may be benign or serious and vary according to the stage of pregnancy and the nature of the bleeding.

First trimester bleeding may be indicative of implantation of the ovum, or it may be indicative of cervicitis or vaginal varicosities. More seriously, it could be indicative of a threatened, inevitable, incomplete, or complete abortion.

A threatened abortion should always be considered when vaginal bleeding occurs in the first 20 weeks of pregnancy.

An inevitable abortion can be diagnosed if a patient presents during the first half of pregnancy with bleeding and crampy abdominal pain in association with a dilated cervix or a gush of fluid (rupture of membranes) without passing of the products of conception.

An incomplete or complete abortion occurs when part or all of the products of conception are extruded through the cervix and into the vagina and are passed out of the body.

Second or third trimester bleeding occurs in about 3% of all pregnancies. About 60% of these bleeding episodes result from placenta previa or abruptio placentae. Both of these conditions may gravely endanger the mother and fetus.

Fourth maneuver

Figure 23-17 Leopold's fourth maneuver. Relationship of clinician's hands and fetal presenting part. A, Position of clinician's hands on mother's abdomen. B, Illustration of relationship of clinician's hands and fetus. Note that the examiner's right hand is stopped higher by the fetus's cephalic prominence.

The incidence of placenta previa is about 1 per 250 deliveries and is more common among multiparas than among primigravidas. Placenta previa is characterized by painless vaginal bleeding in association with a soft, nontender uterus. The hemorrhage usually does not occur until the end of the second trimester or later. Although there are several types of placenta previa, the symptoms arise from the abnormal location of the placenta over or near the internal os of the cervix. Ninety percent of all patients with placenta previa have at least one antepartum hemorrhage. There is also a 20% incidence of premature delivery because of hemorrhage.

Abruptio placentae is the premature separation of a normally situated placenta. It also has an incidence of 1 per 75 to 225 deliveries. The symptoms include mild to severe pain with or without external bleeding in association with increasing uterine tone and tenderness. Fetal distress may or may not occur. The incidence of abruptio placentae is higher among women with high parity. It is also more common among African-American women than among white or Latino women. Hypertension is, by far, the most commonly associated condition. Cigarette smoking and cocaine abuse have also been linked to an increased risk of abruptio placentae. Women with a history of abruptio placentae are at significant risk of recurrence in subsequent pregnancies.

Vasa praevia is another serious but rare condition in which some of the fetal vessels in the membranes cross the region of the internal os. These vessels occupy a position in front of the presenting portion of the fetus. Rupture of the membranes may be accompanied by rupture of the fetal vessel, causing fetal blood loss and possible exsanguination.

Postpartum hemorrhage (PPH) is the most common cause of serious bleeding in obstetric patients and one of the leading causes of maternal death. It is sometimes defined as blood loss in excess of 500 mL during the first 24 hours after delivery, although the estimation of blood loss is notoriously inaccurate, and the loss of 500 mL after vaginal delivery or 1000 mL after cesarean delivery is quite common. The most common causes of PPH are uterine atony and laceration of the vagina or cervix. There are many causes for uterine atony: complications of general anesthesia, overdistention of the uterus by a large fetus or multiple fetuses, prolonged labor, rapid labor, augmented labor, high parity, retained products of conception, coagulation defects, sepsis, ruptured uterus, chorioamnionitis, and drugs such as aspirin, non-steroidal anti-inflammatory agents, and magnesium sulfate. It has been estimated that post-partum hemorrhage occurs in 1% to 5% of all deliveries, depending on the definition used.

Pseudocyesis, or false pregnancy, is said to occur in 1 per 5000 putative pregnancies. In this condition, nonpregnant women present with many of the classic symptoms of pregnancy and often report fetal movement. They may exhibit weight gain and amenorrhea. Many of these patients are psychotic and may be schizophrenic. They are fixated on their alleged pregnancies. Aggressive psychiatric help is usually required.

Useful Vocabulary

Listed here are the specific roots that are important for understanding the terminology related to the pregnant patient.


Pertaining to






A woman who has had two or more pregnancies that resulted in viable offspring




A woman pregnant for the first time




Giving birth; a woman in labor




A woman who has just given birth




False pregnancy




Abnormal labor




Before birth




Abnormally profuse discharge of vaginal lochia

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Pregnancy And Childbirth

Pregnancy And Childbirth

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