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VAGINAL BLEEDING IN

EARLY PREGNANCY

Fg Offr P K Dixit MBBS, AFMC 7 AF Hospital, Kanpur

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Care• Definition• Differential diagnosis• Definition of entities• Clinical approach to a patient• Brief management

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DEFINITION

Any vaginal bleeding before 20 wks period of gestation is defined as early pregnancy bleeding

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Causes of bleeding in early pregnancy

AbortionEctopic pregnancy

Hydatidiform mole

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Related to pregnant state

• Abortion

• Ectopic pregnancy

• Molar pregnancy

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Associated with the pregnant state

• Cervical lesions like

• Ruptured varicose veins

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CERVICAL EROSION

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CERVICAL POLYP

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CERVICAL MALIGNANCY

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Pathology

• Haemorrhage into the decidua basalis.• Necrotic changes in the tissue adjacent

to the bleeding.• Detachment of the conceptus.• The above will stimulate uterine

contractions resulting in expulsion.

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ABORTION-DEFINITIONTermination of pregnancy before the fetus is capable of extra-uterine survival i.e. 20 wks or 500gm birth wt

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Types of abortion

• Threatened abortion.• Incomplete abortion.

• Complete abortion.• Missed abortion

Septic abortion: Any type of abortion, which is complicated by infection

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MOLAR PREGNANCY

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CLINICAL APPROACH

• History

• Examination

• Special Investigations

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History

• VAGINAL BLEEDING• Slight and bright red• Associated with fleshy mass• Associated with fowl smell and discharge• Associated with grape like vesicle• Sanguinous or dark coloured and continuous• ‘White currant in red currant juice’

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Pain abdomen

• Minimal

• Acute , agonising or colicky

• Shoulder pain

• Fever

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Symptoms of early pregnancy

• Amenorrhoea

• Morning sickness

• Frequency of micturition

• Breast discomfort

• Fatigue

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Care• Hyperemesis

• Breathlessness

• Thyrotoxic features

• Syncopal attack

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Care• Careful menstrual history• Previous cycles• LMP

• Past history• Similar episodes• Infertility• Details of contraceptive use

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Care• Classical triad of ectopic pregnancy – Amenorrhoea

– Pain abdomen

– Irregular vaginal bleeding

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EXAMINATION

• General look

– Lies quiet and conscious, perspires and looks blanched

– Looks more ill than accounted for- molar pregnancy

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VITALS

• Temperature– Febrile/afebrile

• Pulse– Tachycardia/normal

• Blood pressure– Low/normal

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•Empty bladder

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GUARDING AND REBOUND TENDERNESS

Click icon to add picture

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Size of uterus

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Care• Trauma

• Cervical pathology

• Open cervical os- incomplete abortion

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Care• Bimanual examination

• Extreme tenderness on fornix palpation or rocking of cervix

• Palpation of bilateral or unilateral enlargement of ovary - molar pregnancy

• Palpation of adnexal mass- Ectopic pregnancy

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Urine pregnancy testpositive

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INVESTIGATIONS

• Hb• TLC• DLC• Platelet• PCV• ABO and Rh grouping• Thyroid function test

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ULTRASONOGRAPHY

• Routinely used

• Main modality of diagnosis

• Transvaginal and Transabdominal

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BLIGHTED OVUM

Click icon to add picture

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ECTOPIC PREGNANCY

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HYDATIFORM MOLE

(Snow storm appearance)

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DIAGNOSIS

• Threatened abortion– Positive UPT– Intrauterine pregnancy– Viable fetus

• Incomplete abortion• Positive UPT• Product of conception in-situ• Non viable fetus

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• Ectopic pregnancy– Positive UPT– USG confirmation– Product of conception absent in uterus

• Molar pregnancy– Positive UPT– Typical USG findings

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Management of Threatened Abortion

• Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary

• If bleeding stops, follow up in antenatal clinic. Reassess if bleeding recurs

• If bleeding persists, assess for fetal viability.

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Incomplete Abortion

• If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix

• If bleeding heavy, evacuate uterus:

– Manual vacuum aspiration (MVA) is preferred method

– If evacuation not immediately possible, give ergometrine OR misoprostol

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Incomplete Abortion

• Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of products of conception occurs

• Evacuate any remaining products of conception from uterus by dilatation and curettage

• If necessary, give misoprostol 200 µg vaginally every 4 hours until expulsion

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Management of Complete Abortion

• Evacuation of the uterus usually not necessary

• Observe for heavy bleeding

• Ensure followup of woman after treatment

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Follow up After Abortion

• Tell woman that spontaneous abortion is common

• Reassure woman that chances for subsequent successful pregnancy are good

• Encourage her to delay next pregnancy until completely recovered

• Advise on contraception

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Immediate Management of Molar Pregnancy

• If diagnosis is certain, evacuate uterus:

– If cervical dilatation is needed, use a paracervical block– Use vacuum aspiration (MVA preferred)

• Infuse oxytocin 20 units in I L IV fluids at 60 drops per min.

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ECTOPIC PREGNANCY

• Expectant

• Medical

• Surgical

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THANK YOU

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THANK YOU