Bleeding in early pregnancy

• 25%bleeding before 20 weeks gestation

• -implantation bleed :

• spot of blood occur 5-7 days after blast cyst implantation .

Causes of bleeding in early pregnancy

• 1-miscarriage

• 2 –ectopic pregnancy

• 3–benign lesion lower genital tract

• 4 –hyditidform mole

• 5-cervical pregnancy

Spontaneous miscarriage

• Definition :• -termination of pregnancy prior to 24 weeks gestation • ,fetal weight less than 500 gm• N.B:• -survival rate 50%• - extremely premature less than 26 weeks infant )• -incidence 15-20 % end by miscarriage • -most of miscarriage occur prior to 13 weeks • -1-2 %miscarriage occur between 13-24 weeks

– 1-genetic abnormalities 50%– - chromosomal abnormalities failure to develop embryo – -trisomy 21 down syndrome {Mongol} – -polyploidy monosomy – 2-endocrinefactors – -early failure of corpus luteum due to progesterone

deficiency – -PCOS (poly cystic ovarian syndrome)– –poor un-controlled DM– -untreated thyroid disease – Lead to miscarriage ,fetal malformation

Etiology :

• 3-maternal illness : maternal cardio-vascular , hepatic , renal problem

• 4-maternal infections • -syphilis ,listeria,toxoplasmosis,maternal febrile

illness ( influenza,pyelitis ) ,malaria, bacterial vaginosis

• 5- abnormalities of uterus • -uterine anomalies :-• 1-bicornuate• 2- –subseptate 15-30% causes of miscarriage• 3 –sub mucosal fibroid

Anatomical defect:

4 –asherman syndrome :adhesion between endometrium & inner uterine walls 6-cervical incompetence : painless dilatation of the cervix ,lead to SORM (spontaneous rupture of membrane), miscarriage ,or PTL(preterm labor)Dx:history of recurrent miscarriage -u\s (TVS) –funnel internal cervical os ,shortening of the cervical canal less 2 .5 mm.

• Causes of cervical incompetence

• 1-congenital anomalies of genital tract

• 2-physical damage after ( D&C,E&C )

• 3-birth trauma

• 7-auto immune disease:• -antiphospholipid syndrome{ APS}• - lupus anticoagulant {LA}• - anticardiolipin antibody {ACL}• 8-thrombophilic defect • -defect antithromin III• -protein C,S deficiency • -defect factor V Leiden

• Action:-• formation of thrombosis ,uteroplacental

blood vessels ,defect trophoblast function ,lead to

• 1-miscarriage 2-IUGR 3-pre-eclampsia 4-DVT

• 9-alloiummuno factors • Immune defect cytotrophoblast reject fetal

allograft

Types of miscarriage

• 1-threatened miscarriage • -bleeding in early pregnancy • -uterine size normal corresponding with

gestational age • -cervix closed .• -minimal lower abdominal pain .• -80%will continue pregnancy .• -no specific treatment reassurance & support • -bed rest??

• 2-inevitable / incomplete :

• - more abdominal pain

• -heavy vaginal bleeding .

• -cervix open

• -product of conception ,passed through vagina

3-incomplete ;

• -heavy bleeding .• -cervix open • -sever abdominal pain • -part of conception remain in the

uterus • Treatment: medical management • Surgical evacuation E&C

under local or general anesthesia to curette the retained tissue

• 4-complete miscarriage :

• All of conception expel out of uterus cervix closed ,involution of the uterus

• treated by blood replacement

• 5-septic miscarriage :

• Any type of miscarriage with infection

• -infection presented in the uterus

Clinical Findings

Amenorrhea

Bleeding

Pain

• Incomplete miscarriage • -adenxial pain • -tenderness of abdomen.• -purulent vaginal discharge • -pyrexia• -sepsis ,endotoxic shock {septic shock }renal

failure, DIC , petechial Hge .• - Types of micro-organism ,Ecoli, staphili

coccus facalis, staphylucous albus , aures , kllebsella, clostrdium welchi & c. perfringens.

Clinical picture :

• - fetal demise , ultrasound no fetal heart rate.

• - fetal pole presence of gestational sac by uls.

• - regress of abdominal Size.

• -regress signs of pregnancy .

• - blighted ovum

6- Missed or silent miscarriage :

• - Three or more successive miscarriage, prior to viability

• Diagnosis:• 1-karyotype of both parents { geneticist}• 2-fetal product.• 3-maternal blood sample for LA,

aCA{ during 6 weeks of miscarriage }done twice to be sure of the result .

• 4-u\s for @ ovarian morphology { PCOS}• @ uterine cavity

7- Recurrent miscarriage :

Threatened Abortion Inevitable

Incomplete Missed

Laboratory Findings

Ultrasonography

Pregnancy tests

Blood count

Gestational sac and viable embryo with heart motion

HCG

Anemic

• Treatment :-aspirin or heparin

• -cervical cerclage {shourtkhar } done on 14-16 weeks gestation under general anesthesia, & remove at 38 weeks gestation or at the onset of labor .

DX : as general for all types of miscarriage

• clinical assessment.• Haemodynamic stability.• Assessment of blood loss.• Distension of cervical canal by conception.• Hypotension – Brady cardia "cervical shock" • Rupture ectopic pregnancy need abd,

examination .• V. E is open to distinguish the type.

• TVS to confirm the DX.

• Gestational sac less than 20 mm, fetal pole less than 6 mm

• No evidence of cardiac activity.

• Urine BHCG positive 9-10 days of conception.

• HCG level double every 48 hrs [4-6 weeks]

Indication for E & C :

• Persistent excessive bleeding .

• haemmodynamic instability.

• infected retained tissue give A/ B(antibiotics) 12- 24 hrs before E&C .

• suspicion gestational trophablastic disease

preoperative management :-

• treat infection if present by A\B.• Give prostaglandin to dilate cx.• Consent form.• CBC & blood group ,canula IV fluid .• V/E & uls.• Emptying bladder.• Wearing gowns ,v/S.• PCR, endo- cervical swabs for STIS.

Complications of E & C :

• Cervical / uterine Trauma, Tears.• uterine perforation.• Intra abd. Trauma .• Intra. uterine adhesion.• Internal bleeding.• death increase Mortality rate.• increase a chance to develop of PID who has

syphilis ,gonorrhea, & or BV(bacterial vaginosis).

DILATATION & EVACUATION (D and E) ABORTION

-Used for 2nd trimester abortions, at which point in fetal development the fetal bones become calcified.

Over all management :• history• passage of conception.• • Medical Management :• PG " Antiprogesrone ".prostaglandin dose according to • size of Gestational sac.• type of Miscarriage .• gestational weeks.• Anti- D Immune globulin:• -Mother RH –ve should take Anti D after 12 weeks gestation .• -Indication to give Anti- D before 12 weeks gestation• heavy bleeding.• pain.• Don’t forget to document Anti D.

* psychological aspect of miscarriage :

• anger ,grief ,guilt feeling continue up to six weeks after miscarriage .

• loss in the second trimester liable to mood disorder ,like post partum depression .

• grief up to 6 months .