Early pregnancy bleeding

Dr. Muhabat Salih Saeid

MRCOG-London-UK

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Goals of the talk:

• Differential diagnosis/work up for first trimester bleeding

• Different types of first trimester pregnancy loss

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Bleeding in Early Pregnancy

• Abortion

• Ectopic Pregnancy

• Trophoblastic disease

• Lesions of cervix or vagina

•Placentation

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HistoryExamination

InvestigationsDiagnosis

Management

Assessment

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History and examination

LMP

Duration of amenorrhea

Menstrual history

Contraceptive history

Planned?

Nature of bleeding

pain

Observations ? Haemodynamically stable

Abdominal palpation

Speculum examination- look for lacerations, warts, vaginitis, cervical polyps, fibroids, ectropion, cervicitis, neoplastic process

Vaginal examination-assess adnexal/cervical tenderness, adnexal masses, uterine enlargement

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Cornerstone of evaluationMost useful with positive preg test where IUP not previously seen

Uses: location of pregnancy (intra- or extrauterine), viability (+/- FCA), other rare findings (GTD, partial loss of multiple gestation)

TransvaginalLook for pregnancy within the uterus

Presence of fetal heartShould be present 6 weeksIf CRL< 6mm or MSD<20mm with no yolk sac/fetus – rescanUncertain viability and unknown location

Presence of yolk sac

Adnexal masses

Free fluid/ endometrial thickness

USS findings

Subserosal Fibroid

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Pregnancy hormone

Should approximately double in the first trimester every 48 hours

Usually see something in the uterus on TV scan at 1000 (1500 TA)

Ectopics usually visible at this level

Serial measurements are important – every 48 hoursRising, falling, stable, suboptimal rise

βHCG

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FBC - can indicate volumes of blood loss

Progesterone - <25 mmmol/l is associated with a non viable pregnancy.

Absolute levels here>60 v.strongly associated with viable pregnancy

Blood group – need for anti D

Other investigations

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Abortion:• Definition: Loss of pregnancy before viability. i.e. before 24 weeks gestation or <500 grams (WHO criteria)

• Abortion is either: Spontaneous (Miscarriage) or induced (Therapeutic / illegal)

• Abortion may occur at any gestational age from 5 to 24 weeks

* <12 weeks – first trimester abortion* 12-14 weeks _ second trimester abortion

•Commonest complication of pregnancy affecting up to 20% of women• Etiology is multifactorial• No single Rx can be applicable to all cases

threatened inevitable

incomplete missed

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Types of abortions:1. Threatened Abortion• On history : a. Minimal vaginal bleeding: Red(fresh)

or dark(old) b. Minimal or no abdominal pain

• On examination:

a. The size of uterus is equivalent to that of expected for gestational age b. Cervix is closed c. Positive fetal heart sounds

*Ultrasound : Viable fetus.* Management:

* Bed rest (though there is no evidence that rest will alleviate the course of pregnancy

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2-Inevitable Abortion:

O/H :lower abdominal pain similar to dysmenorrhoea which persist/worse

O/E:Cervix is open

Abortion will take its course

Management: as incomplete abortion

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3. Incomplete abortion:

* OH: as inevitable i,.e. abdominal pain and passage of clots and tissues

* O.E: Cervical os open- If bleeding is severe, the patient may be shocked- Suprapubic tenderness, the uterine size is corresponding to expected gestational age- Bimanual examination: products of conception may be left in the os or in vagina

* Ultrasound : remnant of conception in the uterus * Management:

- Treatment of shock (plasma expanders and blood transfusion)- Evacuation of retained products under general anaesthesia

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4. Complete abortion: * History of abdominal pain and vaginal bleeding as well as passage of clots and tissues

* On examination: The uterine size is smaller than expected for gestational; the cervical os is closed (the uterus expelled its contents)

* Ultrasound shows empty uterus

* Management : Patient usually well and fit to go home

Threatened - Inevitable Incomplete Complete ※ ※ ※Preg. Continues (majority)

Complete miscarriage

Bleeding and cramps which are usually settling

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5. Septic abortion: * If abortion is associated with infection, it is called septic abortion* It is usually associated with incomplete induced abortion

* History of abdominal pain, vaginal bleeding and may have foul vaginal discharge

* On examination: the patient usually looks unwell; pyrexia with tachycardia

If severe; the patient might have septic (endotoxic) shock

Lower abdominal tenderness and enlarged tender uterus on bimanual examination

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* Management:

-Admission to hospital

-Check CBC (anaemia, leukocytosis)

-vaginal swab for cs to identify the causative organism (commonest organism is Escherichia coli and streptococcus faecalis)

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* Treatment

Hypovolemia:

Monitor: BP, CVP, cardiac output, renal output

Treatment: intravenous rehydration

* Infection:

• Broad spectrum antibiotics to cover all organisms then adjust the treatment according to vaginal

swab C/S results

• Evacuation of uterus under general anaethesia (suction evacuation)

• This is a serious problem and may lead to renal failure, respiratory failure and even maternal death

Missed miscarriage

Spotting only usually. Expected to be 6-12 weeks by LMP.

Fetal pole seen

Missed Miscarriage

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6. Missed abortion

- Embryo dies and the uterus does not expel its contents

- Loss of pregnancy symptoms

- Uterine size is smaller than expected

- Ultrasound showed: *no fetal heart

* Embryo / Fetus size is smaller than expected for gestational age

Management:

If uterus size <12 weeks

- evacuation under general anaethesia (suction currtage) bec. Risk of perforation if use sharp one as the uterus in this condition is soft.

If uterine size >12 weeks

- Extra-amniotic prostaglandins

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7. Therapeutic Abortion: - Medical termination of pregnancy - Indication

* To save the mother’s life* To preserve the mother’s health* To prevent the birth of a severely congenital abnormal child

T.O.P is indicated if the pregnancy constitutes a risk to the mother’s life or the fetal abnormality is incompatable with life (anecephaly)

Methods of T.O.P: * If uterine size <12 weeks - Evacuation under general anaethesia (suction currtage) * If uterine size >12 weeks - Extra amniotic prostaglandins

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RECURRENT MISCARRIAGEDefinition:Three or more consecutive pregnancy loss before viability

Incidence 1%

Etiology:* Genetic* Anatomical* Infective* Systemic* Immunological* Endocrine

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1. Genetic:- Rare (5% of recurrent abortion will have paternal abnormal chromosomes)- usually cause early trimester abortion- Parental karyotyping:

* Balanced reciprocal translocation* Invertions & mosaisms

Management:Genetic counselingKaryotyping the product of conceptionPrenatal diagnosisPreimplantation diagnosis

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2. Anatomical Causes:

- Abnormal mullerian development (Bicorneate uterus, septate uterus, unicorneate uterus)

- Uterine Fibroid (submuscous fibroid)

- Uterine Synechae (intrauterine adhesion due to previous curettage

- Cervical incompetence

These causes usually lead to midtrimester

miscarriages/preterm deliveries

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- Diagnosis: HSG

Ultrasound scan

Laparoscopy/hysterscopy

- Management according to the cause:

Bicorneate uterus: Strassman’s Metroplasty.

Complication of surgery: Adhesion formation which may lead to infertility.

Septate uterus: Hysteroscopic resection of septum

Cervical incompetence cervical cerclage (Mckdonald suture, Shirodkar suture).

Complications of surgery: Infection, rupture of membranes, bleeding.

Submucus bibroid: Hysteroscopic resection

Uterine Synechia:Hysteroscopic division of adhesions

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3. Infective causes:

- Rare

- TORCH screen unhelpful (reinfection rare in these cases)

- Bacterial Vaginosis may lead to recurrent late losses and preterm labour

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*Normal uterus at laparoscopy

*Normal HSG

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4. Immunological causes:Antiphospholipid syndrome (API)Definition: Presence of antibodies to patient`s own phospholipids and associated with thrombosis,

thrombocytopenia and recurrent abortions.

Incidence upto 40%of recurrent abortion.Theory:Disordered platelet function: release of

thromboxane.

Disordered endothelial function: reduce prostacyclin release

Altered ratio of thromboxane /prostacycline ratio

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Complications:Obstetrics complications : Fetal losses (early and late); Abruptio placentae; intrauterine growth restrictionVascular complications: arterial and venous thrombosis.Neurological: TIA

DiagnosisLupus Anticoagulant (LA) Positive prolonged APTT

Positive anticardiolipin antibodies (ACA)

Treatment: Baby AspirinHeparinImmunoglobulins (under investigations)

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5. Endocrine causes :

* Diabetes/Hypothyroidism: In asymptomatic patients GTT and TFT are non-informative.

•Luteal phase defeciency: Low progesterone level reflects a failing pregnancy (not a cause but a consequence). Therefore exogenous progesterone/hcg in early pregnancy is of no benefit.

• PCO (polycystic ovarian disease): Common (56% of recurrent abortion) High secretion of LH is associated with poor pregnancy outcome:

* Fertilization* Poor implantation* Rate of miscarriage

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In Conclusion: Patients with recurrent abortion needs to be investigated by the following tests

For all: * Chromosomal analysis of both partners* Serum LH (day 5) for PCO* Antiphospholipid Antibodies (LA, ACA)* Pelvic ultrasound* Rubella antibodies (if negative, vaccinate)

For selected patients:* Hysteroscopy/hysterosalpingography

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Thank youQuestions?