Bleeding in Pregnancy

By Clare Di Bona

Early Pregnancy Loss

  Defined as pregnancy loss before 20 weeks gestation

  Approximately 20% of pregnancies miscarry   Approximately 1 in 200-500 pregnancies are

ectopic   Miscarriages and ectopic pregnancy can

cause considerable distress   Women should have the opportunity to make

informed decisions about their care and treatment

Objectives

  How to take an obstetric/gynaecological history, investigations, examination in pregnancy

  Understand the principles of diagnosis and management of miscarriage

  Understand the principle of diagnosis and management of ectopic pregnancy

  Understand the distress caused by miscarriage and ectopic and how you can support women that present to the ED

O&G History Taking

Investigations

Examination

Miscarriage

  Definition   Early pregnancy loss is defined as a loss before 20

weeks of pregnancy   US criteria

  Gestational sac ≥25mm diameter does not contain a yolk sac or embryo

  Embryo with CRL >7mm that does not have cardiac activity

  Risk Factors:   Advanced maternal age, previous miscarriage and

maternal smoking

Normal Fetal Development

 During normal fetal development the gestational sac develops, followed by the yold sac then the embryo

 Gestational sac >25mm without a yolk sac or embryo criteria for failed pregnancy

 CRL >7mm with no cardiac activity meets criteria for a failed pregnancy

Miscarriages

  Causes:   Most commonly caused by structural or chromosomal

abnormalities of the embryo   Accounts for 50% miscarriages   Most common chromosomal abnormality aneuploidy (missing

or additional chromosome)   Extrinsic factors: amniotic band, chorionic villus sampling,

amniocentesis, trauma   Uterine issues: uterine septum, submucosal leiomyoma,

intrauterine adhesions   Exposure to teratogens: thalidomide   Maternal Disease: infection (Listeria, parvovirus B19, rubella..)

poorly controlled diabetes, endocrinopathies (thyroid, Cushing’s syndrome, PCOS), thrombophilias (SLE, antiphospholipid)

Miscarriages

  Classification   Threatened

  Vaginal bleeding +/- abdo pain, closed cervix and presence FHR. Often attributed to marginal separation of the placenta

  Managed expectantly, weekly US if bleeding stops go back to routine care.   Missed

  Non-viable pregnancy (embryo >7mm no cardiac acitvity) that has not passed. Cervix is closed. Or can an anembryonic pregnancy (gestation sac >25mm without embryonic tissue (yolk sac or embryo)).

  Complete/incomplete   Incomplete; some products have passed but placental/fetal tissue remains in uterus   Complete: all tissues and placenta have passed from uterus

  Inevitable   Vaginal bleeding +/- pelvic pain with a dilated cervix +/- products at the os

  Septic   Miscarriage associated with intrauterine infection

Miscarriage-ED treatment

  In unstable patient   2 large IV lines (BHCG, G&H, FBP, U&E, VBG(Hb))   In patients with heavy bleeding need urgent

speculum exam and possible removal of tissue from cervix

  If active heavy bleeding from os +/- unstable patient urgently discuss with O&G reg directly

  IVH and possible blood products may be needed for BP

  Arrange theatre promptly via O&G reg is necessary   DO NOT CONSIDER A PRIVATE ADMISSION

FOR UNSTABLE O&G PATIENTS AS THIS LEADS TO DELAYS IN TREATMENT

Miscarriages

  Treatment Options:   1) Expectant   2) Medical   3) Surgical

Good success rates with expectant and medical treatment   success rates incomplete miscarriage 74-94% expectant vs

96-100% medical   For missed miscarriage lower success rates expectant 14-50% vs

medical 80-90%   More outpatient visits expectant>medical>surgical   More bleeding medical treatment vs surgical but less pain   Misoprostol is the medication of choice and is prescribed only by

the O&G team.

Miscarriage

 Expectant Management   Means waiting for the natural loss of the

pregnancy-this occurs in about 50% of miscarriages

  It take some time before the bleeding starts and can take up 3-4 weeks

  If bleeding doesn’t start or miscarriage isn’t completed, offered medical or surgical treatment

Miscarriage

  Medical Management   Misoprostol tablets are placed into vagina and help

open the cervix and pass the pregnancy   Takes a few hrs to start and can cause pain,

bleeding or clotting   May continue to bleed for up to 3 weeks   Sometimes more than 1 dose is needed 1 week

apart   80-90% success rate   If treatment doesn’t work need surgical

management

Medical Treatment Miscarriage

Medical Management Miscarriage

Surgical Management of Miscarriage

  Dilatation and curretage   Success rate 95-100%   Necessary in cases of heavy ongoing bleeding,

infection or used in women who don’t want to wait for products to pass or sick of bleeding

  Risks   Endometritis   Cervical trauma   Small risk of perforation of uterus   Retained products   Adhesions

Support and Information Giving

  Throughout the woman’s care give her and her partner appropriate support and information including:   When and how to seek help is symptoms worsen   What to expect in the time she is waiting for

treatment ie length and extent of pain/or bleeding and possible side effects

  What to expect in recover-when to resume sexual activity and/or try to conceive again

  Information on impact of her treatment on future fertility

  Where to access support and counselling services including leaflets, web addresses, help lines

Post Management Counselling

  When to start trying again?   After next normal period BUT no absolute right or wrong

answer.   Recommended have at least 2 weeks rest (no sex, tampons,

heavy lifting   Why did this happen to me?

  50% time chromosomal abnormality   A lot of the time we can’t give an answer

  What are the risks of miscarriage in future pregnancies?   FUTURE REPRODUCTIVE OUTCOMES — The predicted

risk of miscarriage in future pregnancy is approximately 14 percent after one miscarriage, 26 percent after two miscarriages, and 28 percent after three miscarriages [66].

Ectopic

 Occurs when the developing blastocyst implants in a site other than the endometrium of the uterine cavity

 Diagnostic Criteria:   Positive pregnancy test   Empty intrauterine cavity   Complex adnexal mass +/- extrauterine

gestational sac

Ectopic

 Symptoms of ectopic   Common: abdo/pelvic pain, amenorrhoea or

missed period, vaginal bleeding with or without clots

  Other: breast tenderness, GIT symptoms, dizziness/fainting or syncope, shoulder tip pain, urinary symptoms, passage of tissue, rectal pressure or pain on defecation

Ectopic

  Signs:   Pelvic/adnexal tenderness   Cervical motion tenderness   Rebound tenderness or peritoneal signs   Pallor   Abdominal distention   Enlarged uterus   Tachycardia (>100bpm) or hypotension (<100/60)   Shock or collapse   Orthostatic hypotension

Ectopic

 Most common site of ectopic is the fallopian tube (98%)   Other: ovarian, cornual (junction uterus and

fallopian tube), C-section scar, abdominal, cervical, heterotopic (multiple pregnancy intra and extrauterine).

Ectopic

 Diagnostic Algorithm   BHCG >1500 perform TV Ultrasound

  no intrauterine gestational sac strongly suggests ectopic

  BHCG <1500 repeat BHCG in 72hrs

Ectopic ED Management

  2 large bore IV lines (G&H, FBP, U&E, BHCG)   Immediately discuss with O&G reg possible

ectopic in unstable patients   IVH to maintain BP if required (low Hb and

unstable may need blood product)   Urgently arrange US (transvaginal)   Urgently arrange for theatre in unstable

patients

Ectopic

  Management   Expectant   BHCG days 3,7 and follow up US day 7 looking

for looking for drop 50% in BHCG and reduction in size of ectopic mass

  BHCG performed weekly until <15 Only can be offered if the following criteria can be met: 1)  No sign of rupture 2)  Pelvic free fluid <100ml 3)  Tubal mass <2cm 4)  No yolk sac or fetal pole seen on ultrasound 5)  BHCG <1000 IU/L

Ectopic

  Management   Medical: Methotrexate   Folic acid antagonist (anti-metabolite) prevents

growth of rapidly dividing cells including trophoblastic and fetal cells by interfering with DNA synthesis

  Inclusion Criteria   Haemodynamically stable   Unruptured   BHCG <5000IU/L   Size <3.5cm   Normal LFT, U&E, FBP   Patient compliant with regular follow-up

Ectopic

  Medical Management   Given as an IM injection   Cytotoxic precautions needed

Ectopic Medical Management

Ectopic Medical Management

 Side effects   Commonly: stomatitis, conjunctivitis   Rarely: gastritis, enteritis, dermatitis,

pneumonitis, alopecia, elevated liver enzymes, bone marrow suppression

  Separation pain 2-7 days after the injection   No negative effect on future fertility medical

management vs other treatments.

Ectopic

  Surgical Management   First line treatment when the patient is unstable   With health tubes no evidence that salphingostomy

should be used vs salphingectomy   Risk salpingostomy is persisting trophoblast and

small increase risk of bleeding   Fertility rates are similar providing the contralateral

tube is normal   Pregnancy rates not significantly different surgery

vs medical treatment

Ectopic

 Salpingectomy vs salpingotomy   Offer salpingectomy for women undergoing

surgery for ectopic pregnancy unless have issues infertility (contralateral tube damage)

  Inform women that having a salpingotomy up to 1 in 5 women may need further treatment. This may include methotrexate and or salpingectomy

  Women have salpingotomy need weekly BHCGs

Ectopic

  Indications for surgery   Haemodynamically unstable   Ruptured   Co-existing intrauterine pregnancy   Contraindication of medical treatment

Ectopic

 Follow-up   All women should be counselled re the risk

of recurrence   Anti-D needs to given to all Rhesus negative

women   If histology shows no fetal tissue the case

must reviewed by a consultant   BHCG needs to monitored weekly post

surgery (may take up to 10 weeks to normalise)

References

  KEMH guidelines (via JEDO)   Early pregnancy complications-Assessment and diagnosis   Early Pregnancy Failure-Management of Miscarriage   Diagnosis of Ectopic Pregnancy   Medical Management using Methotrexate   Surgical   Expectant Management   Pregnancy Loss in the First 13 Weeks of Pregnancy (patient pamphlet)

  NICE Guidelines   Ectopic pregnancy and miscarriage: Diagnosis and initial management in early

pregnancy of ectopic pregnancy and miscarriage   Uptodate

  Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation

  Spontaneous abortion: Management   Ectopic pregnancy: clinical manifestations and diagnosis   Ectopic pregnancy: Choosing a treatment and methotrexate therapy   Ectopic pregnancy: Incidence, risk factors, and pathology   Ectopic pregnancy: Surgical treatment