bleeding in early pregnancy slide world

8/2/2019 Bleeding in Early Pregnancy Slide World

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ABNORMAL MIDWIFERY

(Bleeding in early Pregnancy)

by: Florence Wambua


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First Trimester

Any bleeding in pregnancy is abnormal andis of concern to any mother.

To the midwife, this is something to betaken very seriously even if there has notbeen any history of previous fetal loss.

The midwife should establish the followingthrough history taking:


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Cont.

At what obstetrical age the bleedingoccurred.

How much blood was lost.

The color of the blood.

Was it associated with any pain?

Have the symptoms subsided sincethen.


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Cont.

After taking history, the next stepshould be to do fetal assessment todetermine the condition of the baby.

The best method to do this would beultrasound because even in veryyoung pregnancies, the viability offetus can be determined even before

the establishment of fetal heartsounds loud enough to be heard overthe fetal-scope.


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Causes of bleeding in earlypregnancy

Implantation bleeding

Cervical eversion

Carcinoma of the cervix

Abortions/Miscarriages

Ectopic pregnancy

Hydatidiform mole (gestational

trophoblastic disease.)Retroversion of the uterus


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Implantation bleeding

This bleeding occurs as part of thenormal implantation process.

It is not a cause of alarm, the bleedingis small and occurs around the time ofexpected menstruation and may bemistaken for a period and makes

calculation of the EDD false.


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Cervical Eversion

This is not the same as cervicalerosion and requires no treatment inpregnancy.

The cervix is composed of 2 types ofcells: columnar epithelium in the canalreaching the external os and stratified

squamous cells that cover the vaginalside of the cervix.


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High levels of oestrogen in pregnancycause the junction to be everted intothe vagina and bleeding may occur

especially after intercourse.This is because this cells at thejunction are highly vascularised andmay cause intermittent blood loss inaddition to the spontaneous bloodloss after sexual acts.


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Carcinoma of the cervix

This is the most diagnosed cancer inpregnancy.

Most are discovered in the first andsecond trimesters.

This condition is treatable ifdiscovered early in pregnancy.

It is caused by HPV type 16(humanpapillomavirus).


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Risk factors

Sexual behaviour: women who becomesexually active at an early age, manypartners and unprotected sex.

Smoking: women smokers are 2 times atrisk.

Pregnancy: women with a late 1stpregnancy have a lower risk. Risk also

increases with parity.Social class: women in manual socialclass have an increased risk.


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Clinical Signs and investigations

Bleeding is the most commonsymptom.

Investigation is mostly through apapanicolaou smear test (pap smear).

When changes are detected throughthe pap smear then colposcopy isdone and a cone biopsy taken forsubsequent tests.


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Treatment

This depends on the stage of thedisease and gestation.

Laser treatment or cryotherapy

following colposcopy can be carriedout as outpatient.

Cone biopsy is done under general

anasthesia and may be dangerous tothe mother. There is risk of severehemorrhage and miscarriage.


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Delaying treatment until the end ofpregnancy is an option for women

with early changes in cervicalcytology.

If the changes are advanced anddiagnosis is done in the 1st or 2ndtrimester, the mother may have tochoose between treatment andkeeping the baby. In later pregnancy,

the decision to deliver the fetus maybe taken to allow mother to starttreatment.


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Abortion/ Miscarriage

a.) Spontaneous miscarriage

This is the involuntary loss of theproducts of conception before 26weeks.

Loss before 12 weeks is earlymiscarriage whereas after 13 weeksits called late miscarriage.


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Causes

Fetal causes: chromosomnalabnormalities.

Maternal causes: advanced maternalage, structural abnormalities of thegenital tact, infections, maternalmedical conditions, excessive use of

alcohol, coffee and cigarette smoking.


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Types of Spontaneous miscarriages

Spontaneous abortion

Threatened Inevitable

Missed Incomplete

Septic

CompletePregnancy progress

Birth of viable infant Blood mole


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Threatened Miscarriage

Any vaginal bleeding duringpregnancy should be treated asthreatened miscarriage until proven

otherwise.Blood loss may be little with or withoutback pain and cramp like pains.

The cervix remains closed and theuterus soft. symptoms may continuefor sometime then stop. Out come?


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Inevitable Miscarriage

Patient is usually admitted in the hospital.

A urine sample is taken for a pregnancytest and vital signs taken.

Blood taken to confirm Rhesus factor andanti-D given within 72 hours if she isnegative.

A transvaginal ultrasound is taken toconfirm if any products of conceptionremain.


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Vaginal bleeding may be heavy withclots or gestational sac containing the

embryo or fetus.The uterus if palpable may be smallerthan expected.

The membranes can rupture at thistime, and amniotic fluid will be seem.The cervix dilates and tissue or clots

may be seen in the vagina or cervicalos. Blood loss may be excessive andoxytocin 20 units IV may be given.


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Dilatation and curretage are now notthe only method for treating this formmiscarriage.

some patients may present withshock that is inconsistent with theblood loss because some of the

POCs may be trapped in the cervixand will resolve with their removal.


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Pain may be a lot and adequateanalgesia should be provided to the

mother.The mother and partner should beinformed of the outcome of theabortion and proper support, dignityand care accorded to them.Sometimes a live fetus is bornespecially in the 2nd trimester, in that

case the baby should be resuscitatedand a pediatrician informed. Mothershould hold this baby.


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Incomplete Miscarriage

In this case POCs remain within theuterine cavity making bleeding heavyand profuse.

Oxytocin may be given to control thebleeding, evacuation should be doneunder General anasthesia.

Blood loss estimates is poor so treathypovolemia before anasthesia.


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Complete Miscarriage

In this case, all the POCs have beenexpelled completely from the uterus.

The pain stops and signs of

pregnancy regress.On palpation, the uterus is contractedand firm and on ultrasound an empty

uterus is seen.No further treatment is needed unlesspatient develops pyrexia or bleeding.


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Missed Miscarriage

Also known as silent or delayed.

In this case the fetus dies despite thepresence of a viable placenta but is

not expelled from the uterus.Death occurs at 8wks gestation butthe body does not recognise it. A

brown loss is seen as the placentadegenerates. Symptoms of pregnancycease and uterine growth stops.


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Management

Administration of prostagladins isdone and in some cases that is all theintervention required.

Evacuation of the uterus undergeneral anasthesia.

Use of prostaglandins before surgery

help to dilate the cervix gently.

Blighted ovum should be avoided.


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Septic Abortion

This is a complication of missedabortion or induced abortion becauseof ascending infection.

In addition to the signs of miscarriage,mother reports feeling unwell mayhave a headache, nausea and hightemperature.

Blood culture and vaginal swabsidentify the bacteria and its antibiotics.


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b.) Induced Abortion

This is termination of pregnancy as achoice of the mother up to 12 weeksgestation.

It may be legal or illegal depending onthe laws of ones country orcircumstances surrounding the

pregnancy.


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Assignment 2

Is induced abortion legal in Rwanda?

What is the role of the midwife inRwanda if he/she encounters a caseof induced abortion?

Research and write a report.


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Risk Factors for Ectopic pregnancy

Previous history of ectopic pregnancy.

Previous surgery on the uterine tube.

Exposure to diethylstilboestrol in utero.

Congenital abnormalities of the tube.Previous infection including chlamydia,gonorrhea, and pelvic inflammatorydisease.

Use of intrauterine contraceptivedevices.

Assisted reproductive techniques.


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Physiology of ectopic pregnancy

The blastocyst embeds in the deciduaand the trophoblast erodes thematernal tissue anchoring the

developing embryo.

It rapidly grows distending the tube,exposing the maternal vessels and

the pressure caused by the resultantblood flow can destroy the embryo.


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outcomes

Tubal abortion the developingconceptus is expelled through thefimbriated end of the tube, especially

in ampullary implantation.Tubal mole bleeding around theembryo results in its death. The bloodclots around the conceptus enclosingit. Products are retained in the tubeand may need to be removed.


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Tubal rupture

the wall is distendedby the pregnancy and penetrated bythe trophoblast to such an extent thatit raptures.

Abdominal pregnancy.

Maternal death.


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Clinical Picture

Rarely remains asymptomatic formore than 5 weeks.

It may be difficult to diagnose but with

each delay, the risk to losing themother increases.

Mother presents with vaginal spotting

following a short period ofamenorrhea, abdominal pain,dizzines, nausea and shoulder pain.


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Pelvic pain when present is severe.

N/B Acute symptoms are the result of

tubal rupture and relate to the degreeof hemorrhage there has been.

Atypical signs such as unexplained

abdominal pain due to bleeding intothe peritoneal cavity causingdistension can delay diagnosis fatally.

Pleuritic chest pain can be a sign ofdiaphragmatic irritation.

Vomiting with or without diarrhea.


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Diagnosis and Treatment

Ultrasound is an accurate diagnosis.

In a case of uterine rupture, shockmay ensue therefore resuscitationwould be followed by a laparatomy totry and stem the bleeding and repairthe damaged tube as well as remove

the products of conception.


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Gestational trophoblastic disease

This term covers hydatidiform mole,trophoblastic tumor andchoriocarcinoma.

a.) Hydatidiform moleThis is a malformation of the

trophoblast in which the chorionic villi

proliferate and become avascular.Found mostly in the uterus and rarelyin the tubes.


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Risk factors

Women who have had a molarpregnancy.

Women under the age of 20 and overthe age of 40.

Women of Asian origin.

NB. Accurate diagnosis is important asit can lead to the development ofcancer; choriocarcinoma.


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Types

There are 2 types of moles:

a.) complete hydatidiform mole

In this instance there is no evidence

of embryo, cord or membranes. Deathoccurs prior to the development of theplacental circulation.

The chorionic villi change to formclear, hydropic vesicles which hang inclusters from pedicles like grapes.


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Hyperplasia occurs and the growthcan mimic that of an advancedgestation.

The trophoblast as usual willpenetrate the myometrium to anchorthe conceptus and can penetrateeven beyond the uterus.

Rupture of the uterus with massivehemorrhage is a possible outcome.


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Complete moles have 46chromosomes of paternal origin only.This happens because a sperm

fertilises an empty egg, the maternalchromosomes being lost.

Choriocarcinoma can develop from

this type.


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b.) Partial mole

In this case there is the evidence ofan embryo, fetus or amniotic sac asdeath has occurred on the 8th or 9th

week.Analysis reveal this to have 69chromosomes; one maternal and 2

paternal. Risk to developchoriocarcinoma is slight.


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Clinical presentation

Symptoms vary according to the typeof mole:

Exagerrated signs of pregnancy by 6 8

weeks is due to a complete mole.

Partial mole signs are less obvious.

Vaginal bleeding after amenorrhea of

light pink or brown.Sometimes a vesicle may detach and isthen passed out allowing for diagnosis.


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Anemia as a complication of thebleeding.

Excessive nausea and vomiting due tohigh levels of Hcg lead to hyperemesisgravidarum.

Pre-eclampsia early in pregnancy issuggestive of hydatidiform mole.

On palpation, uterus exceeds expecteddate and feels doughy.

Diagnosis is by ultrasound and Hcg level


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Treatment

The aim is to remove all trophoblasttissue. This may occur as aspontaneous abortion or vacuum

aspiration or dilatation and curettagemay be necessary.

Due to the risk of carcinomadevelopment, suspected cases havea 2 year follow up program.IUCD family planning and hormonals


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Method are contraindicated.

In addition, women should avoidpregnancies over the 2 year period.

Choriocarcinoma:It is a malignant neoplasm. Aside from

hemorrhage, patient risks developing lung,hepatic and cerebral metastases ifundetected. Can also occur after a normalpregnancy, an ectopic or abortion.


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Retroversion of the uterus

This is when the long axis of theuterus is directed backwards duringpregnancy.

Normally it would rise out of the pelviccavity by the 14th week spontaneously

but when it remains confined to thepelvis, pressure symptoms ensue.


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Abdominal discomfort

A feeling of pelvic fullness

Low abdominal pain

Back pain

frequency of micturation, dysuria orparadoxical incontinence or retention.

Urinary tract infectionsRectal pressure and constipation withimpacted faeces.


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On examination

Bladder will be palpable abdominally.

Fetal heart difficult to auscultate if therectum is full.

Way forward:midwife should referpatient to a gynecologist and gainconsent for catheterization to drainurine and an indwelling to keepbladder empty, enabling the uterus torise out of the pelvic cavity.


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If untreated.

The lower portion of the uteruscontinues to expand and extend,forming a pouch to accommodate the

growing fetus.Uterine rupture can result (leading tovaginal bleeding) and bladder rupturedue to overextension or from necrosis

of the bladder wall during manualcorrection.


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Fibroids (Leiomyomas)

These are firm, benign tumors ofmuscular and fibrous tissue varying insize.

Types of fibroidIntramural: they are embedded in theuterus separated from themyometrium by a capsule ofconnective tissue. They imitate agravid uterus.


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Subserosal: These lie below theperimetrium and may be irregular inshape and may become peduculated.

Submucosal: these are found withinthe endometrium or decidua. Difficultto detect on examination, can cause

bleeding and become both infectedand necrotic.


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Effect of pregnancy on fibroids

There is no evidence of increasedfibroid growth during pregnancy.

Most changes occur during the first

10 weeks of pregnancy.

In pregnancy, the fibroids becomesofter, more vascular and edematous

making it difficult to detect duringpregnancy.


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Effect of fibroids on pregnancy

Sub-mucosal fibroids are likely tocause early pregnancy loss.

Mild abdominal pain that resolves

spontaneously.Outcome of pregnancy is dependenton the position of the fibroids. Thosesituated in the lower uterine segmentcause obstruction, so delivery shouldbe by caesarian section.


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THE END!

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