FIRST

TRIMESTER

BLEEDING

Aboubakr

Elnashar Benha university Hospital

Egypt

Aboubakr Elnashar

CONTENTS

1. INCIDENCE

2. CAUSES

3. DIAGNOSIS

Aboubakr Elnashar

1. INCIDENCE

Vaginal bleeding is common in 1st T

20-40% of pregnant women.

Source is virtually always maternal, rather than fetal. disruption of blood vessels in the decidua discrete cervical or vaginal lesions.

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2. CAUSES

Related to pregnancy:

Miscarriage (95%)

Ectopic pregnancy

Hydatidiform mole

Vanishing twin

Implantation bleeding.

Associated with

pregnancy: unrelated to pregnancy

pre-existing or aggravated

during pregnancy.

Cervico-vaginitis

Vascular erosion

Polyp, fibroid

Ruptured varicose veins

Malignancy.

Trauma

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1. Miscarriage:

most common

15 to 20% of pregnancies

±heavy:1%

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2. Ectopic pregnancy

much less common 2% of pregnancies most serious {rupture of the extrauterine pregnancy is a life threatening complication} must be excluded in every pregnant woman with bleeding.

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3. Trophoblastic disease

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4. Vanishing twin

Singleton pregnancy

{very early loss of one member of a multiple

gestation}.

often the product of ART

can be associated with vaginal bleeding

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5. Physiologic or implantation bleeding

small amount of spotting or bleeding

10-14 days after fertilization (at the time of the

missed menstrual period)

{implantation of the fertilized egg in the decidua}, although this hypothesis has been questioned

Diagnosis of exclusion.

No intervention is indicated.

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Vaginitis, trauma, tumor, warts, polyps, fibroids

Diagnosis

Visual inspection

Additional tests as indicated:

wet mount, pH of vaginal discharge,cytology

biopsy of mass lesions, US Ectropion: common and normal finding in pregnancy. The exposed columnar epithelium is prone to light bleeding when touched, such as during coitus, insertion of a speculum, bimanual examination, or when a cervical specimen is obtained for cytology or culture. Therapy is unnecessary

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3. DIAGNOSIS

History:

gestational age

character of bleeding:

light or heavy

associated with pain or painless

intermittent or constant

Examination

Laboratory:

TVS

confirm or revise the initial diagnosis.

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Speculum examination

:

1.3% change of management

4.2% change of diagnosis

: minority of management decisions.

The need for speculum examination

should be assessed on a case-by-case basis,

depending on whether the findings on bimanual

examination are conclusive.

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NICE, 2012

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TVS

Cornerstone of the evaluation of bleeding in 1st T.

Most useful

Intrauterine or extrauterine

Viable or nonviable.

Heterotopic pregnancy

Gestational trophoblastic disease

Loss of one fetus from a multiple gestation.

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It is vital to describe clinical and ultrasound

findings in early pregnancy using appropriate

terminology

Miscarriage

should replace ‘abortion’ in clinical practice.

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Pregnancy of unknown location: PUL

should replace pregnancy of indeterminate

location Positive pregnancy test but no signs of intra- or

extrauterine pregnancy or retained products of conception

Pregnancy of uncertain viability: PUV

Should replace pregnancy of indeterminate

viability IUGS 20 mm mean diameter with no obvious yolk sac or

fetus, or

fetal echo 6 mm CRL with no obvious fetal heart activity.

In these circumstances a repeat scan at a

minimum interval of 1 week.

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Clinical correlates of ultrasound appearances.

RCOG; 2006

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TAS:

most useful for assessing

free fluid in the abdomen

abnormalities beyond the field of view of a high

frequency vaginal probe

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U/S findings of threatened abortion

1. Viable IU pregnancy (50 % )

Bad signs: slow heart beat <85/min, subchorionic

bleeding and small sac

2. Non viable IU pregnancy

Missed miscarriage (25 %)

Delayed miscarriage Blighted ovum (20 %)

Incomplete miscarriage (3 %)

3. Ectopic pregnancy (2 %)

4. Hydatiform mole (< 1 %)

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1. PUL

Positive pregnancy test +

No IU pregnancy

No extrauterine pregnancy

No retained products of conception

NICE, 2012

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Condous, 2006 Aboubakr Elnashar

Most PULs are at low risk for an ectopic

pregnancy provided that US is sufficiently skilled

and uses US with acceptable image quality.

HCG at defined times in women with a PUL can

reliably predict immediately viability of a PUL, but

cannot predict its location.

An hCG ratio cut-off <0.87 can be used to identify

spontaneously resolving pregnancies in a PUL

population.

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2. BLIGHTED OVUM

(Anembryonic pregnancy)

No fetal parts with sac diameters > 20 mm (TV) 30 mm (TA)

No yolk sac

Irregular sac contour

If unsure repeat in 1 week

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3. MISSED ABORTION

CRL: 6 mm & no cardiac activity or

< 6 mm & no change at the time of repeat

scan 7 days later (embryonic growth rate is 1 mm/d)

Abnormal form of G S

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4. INCOMPLETE ABORTION

The endometrial midline echo:

distorted

>15 mm in the anteroposterior plane

Hetrogenous & irregular tissues.

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5. COMPLETE ABORTION

The endometrial thickness

<15 mm in the anteroposterior plane

No evidence of retained products of conception

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6. INEVITABLE ABORTION

GS situated low in uterus or cervix

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7. ECTOPIC PREGNANCY

A. Uterine

1. No IU gestational sac Normally BHCG doubles/48h Discrimination zone: BHCG increasing by >60% in 48 h if not and no considerable bleeding think of ectopic pregnancy if uterus Is empty on scan However 5% of normal pregnancies don’t behave like that

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2. Pseudo gestational sac (a fluid collection or

debris in the cavity)

10-20% of ectopic P.

No double decidual sac sign

No yolk sac or embryo

Not eccentric (within the cavity)

3. No yolk sac in a G. sac > 20 mm

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B. Adnexal

1. Non cystic mass:

(Blob sign) inhomogeneous small mass next to the

ovary with no sac or embryo.

By pressing the vaginal probe gently against the

ectopic it moves separately to the ovary.

The most appropriate sign. Sensitivity 84% & specificity

99%

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loop

Non cystic mass

D pouch

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complex mass.

The adjacent ovary is marked by the presence of

regular follicular structures in the ovarian

parenchyma.

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2. Cystic mass:

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3. Ring:

(Bagel sign) hyperechoic ring around the GS

Note the circular morphology and the strongly

echogenic appearance of the trophoblast.

The content is anechoic {accumulation of fluid in GS}

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Ring

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4.Sac & embryo.

Only seen in 10-20% of ectopic pregncncies

Ipsilateral side: Corpus luteum: 85% of cases

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C. D. pouch:

Fluid with or without blood clots

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Cervical

pregnancy

Abdominal

pregnancy

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8. HYDATIFORM MOLE

1. Placenta with multiple small sonolucent areas

(snowstorm)

2. Ovarian theca lutein cysts

D.D :

1.Missed abortion with hydropic degeneration

2 .Degenerating fibroid

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Definitive diagnosis is made by histological

examination.

U/S: Early detection reduced from 16 W (passage of

vesicles) to 12 w

βhCG levels > 2 multiples of the median

RCOG Guideline No. 38 ; 2010 Aboubakr Elnashar

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The characteristic snowstorm pattern representing the

hydropic chorionic villi

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Increased flow

Complete hydatidiform mole. The classic "snowstorm"

appearance is created by the multiple placental vesicles. Aboubakr Elnashar

Complete hydatidiform mole. The classic

"snowstorm" appearance is created by the

multiple placental vesicles. Aboubakr Elnashar

Color Doppler Scan In A Patient With A Molar Gestation

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In most patients

Cl and US diagnosis is usually

missed or incomplete abortion.

Thorough histopathologic evaluation of

all missed or incomplete abortions

Partial H .Mole

Disaia &Creasman Clinical Gynecological Oncologym 7th edd. 2007 Aboubakr Elnashar

Classically:

Placenta: Thickened, hydropic

Fetal or embryonic tissue

Multiple soft markers, including:

Cystic spaces in the placenta

Transverse to AP dimension a ratio of the GS of >

1.5, is required for the reliable diagnosis of a partial

molar pregnancy

RCOG Guideline No. 38 ; 2010 Aboubakr Elnashar

Partial molar pregnancy

The placenta shows multiple small cystic lesions, suggesting a

molar change.

a viable fetus

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Multicystic placenta

embryo

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Multicystic placenta

Yolk sac

Dead embryo

Partial Molar Pregnancy Aboubakr Elnashar

Theca lutein cysts

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246 lectures

3003 members

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