Bleeding in Early

Pregnancy
Dr.Raedah Al-Fadhli
 Causes
• Miscarriages
• Ectopic pregnancy
• Trophoblastic disease
• Lesions of cervix or vagina.
•
 Miscarriage
• Definition: loss of pregnancy before
viability. i.e. before 24 weeks
gestation or < 500gm (WHO
criteria).
• Miscarriage is either:
– Spontaneous (Miscarriage)
OR


– Induced (Therapeutic/illegal)

 Miscarriage

• Miscarriage may occur at any

gestational age from 5 to 24 weeks.
v<12 weeks: first trimester
Miscarriage.
v12-24 weeks: second trimester
Miscarriage.
• Commonest complication of
pregnancy affecting up to 20% of
women.
• Etiology is multifactorial. So, no
PRESENTATION :


• Supra pubic pain.

• Vaginal bleeding.
• Extrusion of products of conception.
• Dilatation of cervix.
• Ultrasound findings.
• ß HCG levels.
• Disappearance of pregnancy signs and symptoms.


 CLINICAL PRESENTATION
• Bleeding per vagina.
• Pain and discomfort.
• Fever and infection signs (septic abortion).
• History of trauma.
 LABORATORY FINDINGS
• Complete blood picture.
• Pregnancy test.
• Blood type and Rh.
• Serum progesterone levels.
• Ultrasound.
  
 DEFFERENTIAL DIAGNOSIS
• Ectopic pregnancy.
• Dysmenorrhoea.
• Hydatiform mole.
• Pedunculated myoma.
• Cervical neoplasm.
• Ruptured F. Tube or ovarian abscess.
 Types of Miscarriage
1.Threatened Miscarriage:
• On Hx: - minimal vaginal bleeding:
Red
 (fresh) or Dark (old).
 - minimal or no abdominal
pain
 (mild period-type pelvic
pain).
• O/E:
Ø Uterus size corresponds to GA.
 Threatened Miscarriage

• U/S: viable fetus.

• Management:
vReassurance that pregnancy should
continue satisfactorily once the
bleeding settles.
vBed rest. Avoidance of strenuous
activity & sexual intercourse.
vIf bleeding continues, repeat U/S
(within week) to confirm viability.
v

 Miscarriage

2.Inevitable Miscarriage:
• O/H: - lower abdominal pain similar
to
 dysmenorrhea that vary
from mild
 to severe.
 - passage of clots.
• O/E: Cx is open.
• Management: as incomplete
 Miscarriage
3.Incomplete Miscarriage:
• O/H: - as inevitable i.e. abdominal
pain.
 - passage of clots & tissues.
• O/E:
Ø If bleeding is severe, pt. may be
shocked.
Ø Uterus size corresponds to GA.
Ø POC may be felt in the os or in the
vagina.
 Incomplete Miscarriage

• U/S: remnant of conception in the

uterus.
• Management:
vTreatment of shock.
vEvacuation of retained products
under general anaesthesia.
•
 Miscarriage
4.Complete Miscarriage.
• O/H: - Abdominal pain.
 - vaginal bleeding
 - passage of clots & tissues.
• O/E:
Ø Uterus size is smaller than expected
for GA.
Ø Cx closed.
• U/S: empty uterus.
• Management: pt. well & fit to go
home.
Threatene Incomplet
d Inevitable e Complete

preg. cont.
(majority)
 Miscarriage
5.Septic Miscarriage:
• If Miscarriage is associated with
infection, it is called septic
Miscarriage.
• It is usually associated with
incomplete induced Miscarriage.
• O/H: - Abdominal pain
 - vaginal bleeding
 - foul vaginal discharge
 Septic Miscarriage

• O/E:
Ø Pt. looks unwell, pyrexia with
tachycardia.
Ø If severe, pt. might have septic
shock.
Ø Lowe abdominal tenderness &
enlarged tender uterus on bimanual
exam.

 Septic Miscarriage
 Management:


v Admission to hospital.
v CBC to look for anemia & leukocytosis.
v HVS for C/S to identify the causative organism
(commonest organism E.coli & Strept. faecalis)
v If pt. hypovolemic, monitor BP, CVP, cardiac output
& renal output. IVF for rehydration.
v For infection: give broad spectrum antibiotics to
cover all organisms then adjust the Rx according
to HVS results.
v Evacuation of uterus under general anaesthesia
(when?) using suction evacuation (why?).
v This is a serious problem & may lead to renal failure,
respiratory failure & even maternal death.
 Miscarriage
6.Missed Miscarriage:
• Failure to expel a dead/non viable
fetus from the uterus.
• Loss of pregnancy symptoms.
• Uterus is smaller than expected for
date.
• U/S: absence of fetal heart activity &
fetus size is smaller than expected
for GA.
 Missed Miscarriage
• Management:
vIf uterine size <12 weeks
evacuation under general
anaesthesia (suction)
vIf uterine size >12 weeks extra-
amniotic PG
 Abortion
7.Therapeutic Abortion:
• Medical termination of pregnancy.
• Indications:
Ø To save mother’s life.
Ø To preserve mother’s health.
Ø To prevent the birth of severely congenital
abnormal child.
• In Kuwait:TOP is indicated if pregnancy
constitutes a risk to the mother’s life or
fetal abnormality is incompatible with
life (anencephaly?)
 Therapeutic Abortion

• Methods of TOP:
vIf uterine size <12 weeks 
evacuation under general
anaesthesia (suction)
vIf uterine size >12 weeks  extra-
amniotic PG

 Recurrent Miscarriage
 CAMBRIDGE MISCARRIAGE STUDY:
• Principal Predictor of Pregnancy Failure in
Previous Miscarriage:
 After 1 miscarriage 20%
 After 2 miscarriage 28%
 After 3 miscarriage 43%
• This study showed that there is no significant
difference in chance of having a successful
pregnancy in a woman with one or two
miscarriages; however there is a significant
drop in the chance of having a successful
pregnancy after third miscarriage.
• Therefore we investigate after 3 consecutive
miscarriage
 Recurrent Miscarriage
• Definition: 3 or more consecutive
pregnancy loss before viability.
• Incidence: 1%
• Etiology:
ØGenetic
ØAnatomical
ØInfective
ØSystemic
ØImmunological
Øendocrine
 Genetic
• Rare (3-5% of recurrent Miscarriage will
have paternal abnormal chromosomes).
• Usually cause early trimester Miscarriage.
• Parentral karyotyping:
Ø Robertsonian translocation
Ø Balanced reciprocal translocation
Ø Inversions & mosaics
• Management:
vGenetic counseling
vKaryotyping the POC
vPrenatal diagnosis ?
vPreimplantation diagnosis ?
 Anatomical
• Congenital uterine abnormalities.
Abnormal mullerian development
(bicornuate uterus, septate uterus,
unicornuate uterus)
• Uterine fibroid (submucous)
• Uterine synechiae (intrauterine
adhesion due to previous
curettage)
• Cervical incompetence.
 Cont. Anatomical
• Usually lead to midtrimester
miscarriages/preterm deliveries.
• Diagnosis:
ØHSG (Hysterosalpingography)
ØU/S
ØLaparoscopy/hysteroscopy
• Management: according to the
cause.
vBicornuate uterus: Strassman’s
metroplasty. Complication of
surgery: adhesion formations which
may lead to infertility.
 Cont. Management
v Septate uterus: Hysteroscopic resection of
septum
v Cervical incompetence: cx cerclage (how?
& when?) Types: Mckdonald suture &
shirodkar suture. Complications:
infection, rupture of membranes,
bleeding.
v Submucous fibroid: hysteroscopic
resection
v Uterine synechiae: hysteroscopic division
of adhesions & prevent adhesion (IUCD,
Intra-uterine folly's catheter, estrogen)
 Infective
• Rare
• TORCH (Toxoplasmosis, Rubella,
Cytomegalovirus,Herpes)screen
unhelpful (reinfection rare in these
cases)
• Bacterial vaginosis may lead to
recurrent late losses & preterm
labour.
• Chlamydia Trachomatis, Ureplasma
urealyticum, Mycoplasma hominis,
Brucella.
 Immunological
Antiphospholipid syndrome (APL):


• Definition: presence of antibodies

to pt. own phospholipids &
associated with thrombosis,
thrombocytopenia & recurrent
Miscarriages.
• Incidence: up to 40% of recurrent
Miscarriage
 Complications
• Obstetric:
ØFetal loss (early & late)
ØAbruptio placenta
ØIntrauterine growth restriction.
• Vascular:
ØArterial thrombosis
ØVenous thrombosis
• Neurological:
ØTIA
Diagnosis:
Ø Prolonged APTT
Ø Lupus anticoagulant (LA): +ve
Ø Anticardiolipin antibodies: +ve
Treatment:

vBaby aspirin
vHeparin
vImmunoglobulins

 Endocrine
• Diabetes/Hypothyroidism:
 In asymptomatic pts GTT & TFT are non-
informative.
• Luteal phase deficiency:
 Low progesterone level reflect a failing
pregnancy.
• PCO (Polycystic Ovarian disease):
ü -Common, 56% of recurrent Miscarriage.
ü -High secretion of LH is associated with
poor pregnancy outcome (fertilization) &
poor implantation (rate of miscarriage) .
ü Treatment by insulin lowering drugs
sensitizers (Glucophage), Ovarian
 In Conclusion
• Pt with recurrent Miscarriage needs to
be investigated by the following
tests
Ø For all:Chromosomal analysis of both
partners

Serum LH (day 2-5 ) for PCO

Antiphospholipid Antibodies (LA,
ACA)

Pelvic U/S
 Rubella antibodies (if –ve,
vaccine)
 Causes
• Miscarriages
• Ectopic pregnancy
• Trophoblastic disease
• Lesions of cervix or vagina.
 Ectopic Pregnancy
• Ectopic pregnancy is implantation occurring
outside the uterine cavity.
• The sites:
 Abdominal (peritoneum)
 Ovarian
 Cervical
 Tubal: 95-98% (corneal, isthmal(20%),
ampullary(50%), fimbrial(12))
Ø 2% of all pregnancies each year in the Unites States
Ø Increasing incidence due to:
 Increasing prevalence of STIs

 Early diagnosis

 Contraception that predisposes failures to be

ectopic
 Use of tubal sterilization techniques

 Use of assisted reproductive techniques

 Tubal surgery (salpingotomy, tuboplasty)

Ø Commonest cause of maternal mortality within the

1st trimester
Ø Overall incidence in non-white women is 1.4 times
higher than in Caucasian women
Ø 2% of all pregnancies each year in the Unites States

 Risk Factors

High:
 Tubal corrective surgery, tubal
sterilization, previous ectopic, in utero DES
exposure, Intrauterine device, tubal
pathology


Moderate: Infertility, previous genital



infection, multiple partners



Slight:
 Previous pelvic/abdominal
surgery, smoking, douching, intercourse
prior to 18 years of age
•
 Differential Diagnosis
Ø Appendicitis
Ø Threatened Abortion
Ø Ruptured ovarian cyst
Ø PID
Ø Salpingitis
Ø Endometritis
Ø Nephrolithiasis
Ø Ovarian torsion
Ø Intrauterine pregnancy

Alternative diagnoses :
•Dysmenorrhea
•Dysfunctional uterine bleed
•UTI
•Diverticulitis
•Mesenteric lymphadenitis
•
 Presentation
• Tubal rupture (esp. isthmal?)  shock &
tender abdomen with guarding.
• Acute abdomen, amenorrhea &
haemodynamic compromise.
• Gradual leak of little blood into peritoneal
cavity causing shoulder tip discomfort.
• Vague abd. pain due to irritation of pelvic
peritoneum (pain on defecation or
micturition).
• Vaginal bleeding from shedding of decidual
lining of the uterus rather than bleeding
from ectopic itself.
 Differentiate between ectopic &
Miscarriage from history

• PV bleeding from ectopic is usually

lighter than that seen with
miscarriage.
• PV bleeding from ectopic occurs after
the onset of abd. pain, whereas
that from miscarriage tends to
precede abd. pain.
• Abd. pain with ectopic tends to be
more unilateral than that seen with
 Examination
• General appearance: comfortable, no pallor
• Vitals signs: within normal limits
– BP 95/60mmHg
• CVS exam: heart sounds 1 and 2 present, no
added sounds or murmurs
• Resp exam: normal vesicular breath sounds
• Abdominal:
• Normal on inspection, no visible swellings,
scars, etc.
• No pain on palpation
• Bowel sounds present
 Initial Investigations
 Monitor βhCG levels
• βhCG- hormone produced by the placenta (and fetal
kidney)
• Detectable in plasma and urine following blastocyst
implantation
• Blood levels rise rapidly, doubling every 2d and
plateaus at 8-10 weeks gestation
• Serum βHCG levels correlate with the size and
gestational age in normal embryonic growth


• βHCG with inadequate increase may

suggest ectopic pregnancy
• Sensitivity: 36%
• Specificity: 65%
•

**βhCG level does not predict ruptured
 Other Labs :
• Complete blood count
– Leukocytosis


• Urinalysis with microscopic exam



• Blood Type and Rhesus

– A negative
• Therefore, must give anti-D (RhoGAM)
prior to surgery
 Imaging Studies
• US imaging confirms the clinical
diagnosis of suspected ectopic,
location,
Findings and
suggestive of size
ectopic pregnancy:

•Absence of gestational sac at

βHCG 1800 IU/L
•Free fluid present (71%
likelihood of ectopic)
•Echogenic mass at adnexa (85%
likelihood)
•Echogenic mass with free fluid
(100% likelihood)

Transvaginal vs. Transabdominal

 Transabdominal Ultrasound
( on admission )
• Empty Uterus
• Free fluid
• Distended portion of left
Fallopian tube
• No evidence of rupture
• Adenexal mass:
– 1.7 x 1.6cm
adjacent and
anterior to
left ovary
• Cervical excitation
• Tenderness over left
iliac fossa on deep
palpation with the
probe
 Management Options
• Expectant Management Indications
– Minimal pain or bleeding in reliable patient
– bHCG less than 1000 IU/L and falling
– No signs of tubal rupture
– Adnexal mass <3 cm
– No embryonic heart beat


• Medical Management : Methotrexate (anti-metabolite)

– Stable vital signs with normal LFTs, CBC, platelets
– Unruptured ectopic pregnancy without cardiac activity
– Ectopic mass <4 cm
– βHCG <5000 IU/L


• Surgical Management Indications

– Failed or contraindicated non-surgical management
– Nondiagnostic Transvaginal US and βHCG >1500
– Hemoperitoneum
– Diagnosis unclear
– Advanced ectopic pregnancy
– Non-compliant patient
– Unstable vital signs
 Surgical Options

1 . Laparoscopy
• “Key hole” surgery
• Recommended
approach

Advantages :
Le ss b lo o d lo ss, d e cre a se d n u m b e r o f tra n sfu sio n s, le ss re co ve ry tim e ,
le ss p o st- o p a n a lg e sia , co st e ffe ctive
Contraindications :
Absolute : ruptured EP , haemodynamic instabilitysurgeon
, ’ s lack of
experience Relative : previous multiple pelvic surgeries, unruptured
interstitial EP, morbid obesity
Surgical options ( cont ’ d )

2 . Laparotomy


– Surgical incision
through the
abdominal wall
– Pfannensteil incision
– Mainly used for cases
involving
haemodynamic
instability
 Radical vs . Conservative
Surgery
Salpingostomy (Conservative)
• Small pregnancy (<2cm) located
in distal fallopian tube
• Maximizes preservation of
affected tube
• Associated with a 5% risk or
recurrence
• Risk of tubal scarring due to
incision
Salpingotomy

• Same as above only incision is

sutured closed


Salpingectomy (Radical)


• Tubal resection



 Prognosis for Subsequent Fertility

§ Overall subsequent pregnancy rate is 60%,
other 40% are infertile.
§ One-third of pregnancies after an ectopic
pregnancy are another ectopic pregnancy,
one-sixth are spontaneous abortions
§ Only 33% of women with ectopic pregnancy
will have a subsequent live birth
Unusual Variants
Heterotopic Pregnancy

üSimultaneous IUP and ectopic

gestations
üRare- 1 in 30,000 pregnancies
Abdominal Pregnancy-can occur

anywhere in peritoneal cavity (1 in

3000)
Cervical Pregnancy (1 in 10,000) May

need hysterectomy
Ovarian Pregnancy (1 in 7,000)

Oophorectomy usually required

 Clinical case
Presenting Complaint:


• 23 year old female at 8 weeks gestation

admitted for observation following a 2
week history of abnormal serum βhCG
levels
– βhCG = 858U/L (normal= 7000-20000 U/L)
•
• Positive pregnancy test 20/12/05
• LMP 12/11/05
• EDD 19/08/06
• Para 0, gravida 5
• Please write short Essay about this case.