Our subject is emergencies in pregnancy. We discussed
bleeding, but why does bleeding occur?
A small amount of bleeding in the first trimester does not
worry us too much, but bleeding with pain does. One of the
most feared complications of pregnancy is an ectopic
pregnancy, where the fetus implants in the wrong place. The
most common place is in the tubes. Should the tube tear,
massive internal bleeding can occur with death a possibility.
The usual presentation is severe abdominal pain, which may
mimic appendicitis. This could even happen before the woman
is aware that she is pregnant. An astute emergency physician
does a pregnancy test on all females of child-bearing age to
consider this diagnosis. A ruptured tube is an indication for
immediate surgery. Nowadays tube sparing surgeries and even
non-surgical treatment of tubal pregnancies (before rupture
of course) is the rule.
Ectopic pregnancy usually gives pain before bleeding, while
miscarriage is the opposite: bleeding and then pain. Risks
for ectopic are any scarring in the area, such as from a
surgical procedure, infection or endometriosis.
Miscarriage also presents with bleeding. A simple exam will
tell us if the pregnancy is lost or not.
Third trimester bleeding is particularly worrisome, because
of something called placenta previa. Here the placenta
implants right over the uterine opening, and when birth
begins, the placenta will be ripped by the opening uterus,
with massive bleeding. Here is one of the indications for C-
section, a procedure being done a lot less today. This
condition should never be a surprise. As ultrasounds are done
routinely, the condition should be picked up much earlier in
the pregnancy.
Having used ultrasound both in my past as an engineer and as
a physician, and having a sister who did a fellowship in
ultrasound, I believe it to be entirely safe. With the
millions of ultrasounds that have been done in pregnancy--we
have yet to find a problem with them. The information they
give both for ectopic pregnancy, and placenta previa can save
lives, as well as letting us know if any other procedures
need be done.
Many women in the past died from post partum bleeding, but
this is becoming rare, as we have medications and if that
doesn't help, we can pack to stop the bleeding. Uterine
massage, use of radiology to find the bleeding vessel and
close it or even surgery can be done to prevent this tragic
problem. People who have home births must be ready to treat
this problem, as it can occur. Write me in care of the
Yated.
A message from Glaxo, sponsor of this column. It is
comforting to know that the dangerous drugs of the past for
depression have been replaced by a safer group called the
SSRls. Seroxat is Glaxo's representative in this group and it
is one of the best-selling antidepressants in Israel, which
is a tribute to it's effectiveness and low side effect
profile.
