Genital bleeding after week 20 is called Hemorrhage of the Second Half of Pregnancy or Bleeding of the Second and Third Trimester. There are three elements of clinical importance that move away from Abortion and early pregnancy loss (1) the fetus is viable, (2) the bleeding is more severe and the maternal complications are more dangerous, potentially catastrophic, and (3) it is indicated to employ measures that try to control the situation and prolong the pregnancy even when this involves exposing the mother to some risks in an attempt to improve fetal survival.

Whenever there is a late hemorrhage there is the possibility of termination of pregnancy before the term and obtain a premature baby, the causes quite limited but potentially fatal for the life of the mother and her baby. It is never taken lightly a bleeding of this type and with some exceptions, I could say that the more severe the more severe bleeding is the cause that gives rise to it and the greater the risk of having Maternal-fetal complications.

I Non-Obstetric Causes

• Changes of the Uterine Neck of Pregnancy
• Infectious Lesions of the Uterine Neck
• Endocervical polyps
• Urinary infection
• Expulsion of the Mucosal Stopper due to the start of Labor
• Gynecological touch
• Sampling of the sample for Cytology and bacterial cultures in the Cervix
• Cervical cancer

These conditions cause genital bleeding without having a direct relationship with the baby and its placenta. Bleeding may originate in the cervix, vagina, or urinary tract and is rarely abundant. With the exception of the unusual case of Cervical Cancer, it usually has a very good prognosis and its control is quite easy.

II Obstetric Causes: Late Obstetric Hemorrhage

• Placenta Previous: frequent
• Placental Premature Detachment: Unusual
• Uterine rupture: rare
• Previous Rate: very rare

Placenta Previa

It is the best known and most frequent of all, and also the most diagnosed sonographically although it is not present. It consists in the implantation of the placenta very close to or over the internal orifice of the cervix in a way that partially or totally obstructs the way out of the baby during delivery, so the placenta is exposed to local trauma producing a bright, painless red bleeding of the placenta. variable amount and with a tendency to repeat in days or weeks. Bleeding is of maternal origin and can lead to acute anemia that requires transfusions. The condition can become so severe as to compromise the oxygenation of the baby, and may, among others, cause premature labor or interruption of pregnancy by emergency cesarean section. When I mentioned that more previous placentas are diagnosed than there really are, it is because in the early stages of many pregnancies the placenta is seen as “Low” or “Previous” but as the uterus grows as a result of fetal growth, it is observed as the most part of these move away from the cervix leaving the criterion of Placenta Previa. Finally, the frequency is reduced to 5 cases per 1000 live births (0.5%). More information?  Placenta Previa.

Placental Premature Detachment (DPP)

Normally the placenta is detached and is expelled after the birth of the baby (this is called Childbirth); If the placenta falls off prematurely during pregnancy, the exchange of oxygen between the mother and the baby ceases and the latter may die as a result of suffocation. The diagnosis of this dangerous condition is considerably more difficult than that of the Placenta Previa and the ecosonogram does not easily detect areas of placental detachment with certainty. The prognosis is related to the area of ??placental detachment and the bleeding it causes: if the detachment occurs in small areas and bleeding is scarce, the exchange surface is maintained and the baby is able to oxygenate; if the detachment is considerable (typically greater than 50%), the exchange between the baby and its mother is lost and severe bleeding occurs that can quickly threaten the life of both, with the baby being the first victim.

In severe cases, fetal mortality is close to 30% and maternal mortality around 5% in centers with adequate resources. Unlike the clinical presentation of the Placenta Previa, Placenta Premature Detachment of significant severity does not allow expectant management (observation of evolution) but implies the induction of labor or emergency caesarean section; classic cases present with very abundant bright red vaginal bleeding that is accompanied by severe abdominal pain menstrual type with pelvic and lumbar discomfort (lower back) and evidence of sustained uterine contractions detected by palpation of the abdomen , this may be accompanied by dizziness, thirst , tachycardia, weakness and respiratory distress, symptoms that indicate the presence of a severe hemorrhage.

Vasa Previa

This cause is the most infrequent of all, occurs when some blood vessels of the baby’s umbilical cord are located at the level of the cervix and are exposed to vascular injury when the neck begins to dilate due to labor. The case is so rare that it becomes difficult to diagnose and usually appears as something unexpected during the labor of a normal pregnancy: at the moment of rupturing the membranes (Water Bag) either spontaneously or the obstetrician with a “break”. membranes “, there is a painless vaginal bleeding of fetal origin that quickly leads to acute fetal distress and fetal death in more than 50% of cases, which is why when practicing the rupture of membranes (amniorrhexis) we are very aware if there is bleeding genitalia beyond that existing during labor. Fortunately, Vasa Previa is extremely rare (0.1%, 1 case in 1000 pregnancies).

Uterine rupture

Extremely rare, occurs almost exclusively during labor in association with previous uterine surgery, adenomyosis (a form of endometriosis), previous caesarean sections and uterine overdistension (multiple pregnancy)

Prevention

This chapter offers a devastating picture, but remember: the severe cases in each of the bleeding problems are quite rare and most of these can be prevented following the instructions of your obstetrician:

• • Regularly attend your gynecological consultation.
  • Plan your pregnancies ahead of time so that risk factors can be detected
  • Start your Prenatal Control early and do not miss your appointments
  • Provide all the possible data during when they take your Medical History
  • Avoid getting pregnant during the first 6-12 months after the last delivery or cesarean
  • Do not smoke, do not use Cocaine, Crack, Meth and avoid alcohol during your pregnancies
  • If you suffer from chronic diseases, check them well before getting pregnant.
  • Avoid direct hits on your abdomen
  • Use the seat belt when driving or being a passenger in cars: place the straps on your waist and shoulder, never crossing the abdomen.
  • Eat properly
  • Tell your obstetrician immediately if genital bleeding has occurred
  • If you have been diagnosed with Placenta Previa, stay at all costs, do not have sex and notify the doctors so they do not perform vaginal digital exams.