Haemorrhage In Early Pregnancy

ByMeenal PandeyBHMS 4th yearNehru Homeopathic Medical College

Cause may be

Related to pregnant state

AbortionEctopic pregnancyHydatidiform moleImplantation

bleeding

Associated with pregnancy

Cervical lesions likeVascular erosionPolypRuptured varicose

veinsMalignancy

Abortion: expulsion or extraction from its mother of embryo or fetus weighing 500g or less

when it is not capable of independent survival (WHO) i.e. at approximately 22 weeks(154

days) of gestation.

Abortion

Spontaneous (miscarriage) induced

isolated recurrent legal(MTP) illegal(unsafe)

Threatened inevitable complete incomplete missed septic

Spontaneous abortion(miscarriage)

Etiology(embryonic or fetal)

1.Genetic factors:autosomal trisomy,polyploidy,monosomy,structural chromosomal rearrangements.

2.Endocrine and metabolic factors:luteal phase defect, thyroid abnormalities, diabetes mellitus

3.Anatomical abnormalities: cervical incompetence,congenital malformation of uterus, intrauterine adhesions(synechiae).

4.Infections:toxoplasma,malaria,rubella,variola,cytomegalovirus,brucella.

5.Immunological disorders:

Autoimmune disease: Anti-nuclear antibodies, Anti DNA antibodies,Anti phospholipid antibodies.

Alloimmune disease

Antifetal antibodies:Rh-negative mother with anti-D antibodies

6.Premature rupture of membranes: sperm chromosomal anomaly(paternal factor),inherited thrombophilia, protein C resistance.

7.Environmental factors:cigarette smoking, alcohol consumption,contraceptive agents, anesthetic gases,arsenic,lead,aniline,formaldehyde.

8.Unexplained:in 40 to 60% of cases.

Threatened miscarriage: Is a clinical identity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible.

Clinical features: Bleeding per vaginum, pain following hemorrhage.

Investigations: blood for hemoglobin, hematocrit,ABO and Rh grouping;ultrasonography.

Treatment: rest and medicines. After 3-4weeks following indicate unfavourable outcome ,Falling serum hcg, decreasing size of fetus, irregular shape of gestational sac, decreasing fetal heart rate.

Prognosis: in about two-third pregnancy continues beyond 28 weeks,in the rest terminates either as inevitable or missed miscarriage.

Inevitable miscarriage: Is the clinical type of abortion where changes have progressed to a state from where continuation of pregnancy is impossible.

• Clinical features: patient having features of threatened miscarriage develops following -Increased vaginal bleeding,aggravation of lower abdomen pain,dilated internal os of uterus through which products of conception are felt on internal examination.

• Management: control excessive bleeding,correct blood loss.

• Treatment: before 12 weeks-D&C

after 12weeks-uterine contraction is accelerated by oxytocin drip.

THREATENED ABORTION INCOMPLETE ABORTION

Complete miscarriage: when the products of conception are expelled en masse.

Clinical features: expulsion of a complete fleshy mass per vaginum followed by; subsidence of abdominal pain, vaginal bleeding becomes trace or absent, on internal examination uterus is smaller than the period of amenorrhea.

Management: transvaginal sonography to see that uterine cavity is empty; if not uterine curettage should be done.

Incomplete miscarriage: when the entire products of conception are not expelled,instead a part of it is left inside uterine cavity.

Clinical features: history of expulsion of fleshy mass per vaginum followed by;

1.Continuation of lower abdominal pain.

2.Persistence of vaginal bleeding.

3.On internal examination:uterus smaller than period of amenorrhea,patulous cervical os admitting tip of finger, varying amount of bleeding.

4.Expelled mass found incomplete on examination.

Management:in recent cases evacuation of retained products of conception. She should be resuscitated before any active treatment is undertaken.

Missed miscarriage: when fetus is dead and retained inside uterus for a variable period.

Pathology:cause of prolonged retention of dead fetus unclear. Beyond 12weeks retained fetus becomes macerated or mummified,before 12weeks pathological process differs

when the ovum is more or less completely surrounded by chorionic villi.

Clinical features: patient presents with features of threatened miscarriage followed by;

1.Persistence of brownish vaginal discharge.

2.Subsidence of pregnancy symptoms.

3.Retrogression of breast changes.

4.Cessation of uterine growth which in fact becomes smaller in size.

5.Non audibility of fetal heart sound even with doppler USG if it had been audible before.

6.Cervix feels firm.

7.Immunological test for pregnancy becomes negative.

Management: expectant-many women expel conceptus spontaneously.

medical management

suction evacuation or dilation and evacuation.

Septic abortion: any abortion associated with clinical evidences of infection of uterus and its contents.

Abortion is septic when there are:

1.Rise of temperature to at least 100.4F for 24hours or more.

2.Offensive or purulent vaginal discharge.

3.Other evidences of pelvic infection such as lower abdominal pain and tenderness.

In majority of cases infection occurs following illegal induced abortion.

Microorganisms: bacteroides group, streptococci, Cl.welchii, tetanus bacillus, E.coli, klebsiella,staphylococcus.

Clinical features:

Pyrexia, pain abdomen, rising pulse rate, purulent vaginal discharge, tender uterus.

Investigation: cervical or high vaginal swab, blood for hemoglobin, urine analysis, USG pelvis abdomen.

Management:

Hospitalisation is essential.

investigations: cervical/high vaginal swab for culture. blood and urine examination

Line of treatment: control sepsis,remove source of infection, give supportive therapy.

Recurrent miscarriage: a sequence of 3 or more consecutive spontaneous abortion before 20 weeks.

Etiology: balanced translocation (genetic), poorly controlled diabetes, thyroid auto antibodies, luteal phase defect, hypersecretion of LH as seen in PCOS, infection , inherited thrombophilia, uterine fibroid, cervical incompetence, uncontrolled diabetes with arterioscletoric changes, hemoglobinopathies, syphilis, toxoplasmosis.

Management: Interconceptional periodCounsel the couple.should be assured that chance of successful pregnancy is high even after 3 consecutive miscarriages.Hysteroscopic resection of uterine septa,metroplasty for bicornuate uterus.Preimplantation genetic diagnosis for chromosomal anomaly.Control DM and thyroid disorders.

During pregnancy:Reassurance and tender loving care.Patient to take adequate rest,avoid strenuous activities.Mcdonald circlage operation to be performed for cervical incompetence at b14 weeks or atleast 2 weeks earlier than the lowest previous wastage.

Procedure reinforces the cervix by a non absorbable tape around cervix at level of internal os. Stitch removed at 37th week.

ECTOPIC PREGNANCY

Ectopic pregnancy: one in which the fertilized ovum is implanted and develops outside normal endometrial cavity.

Commonest 97% tubal.

Etiology: history of PID, history of tubal ligation, contraception failure, previous ectopic pregnancy, tubal reconstructive surgery, history of infertility, ART particularly if tubes are patent but damaged, IUD use, previous induced abortion, tubal endometriosis.

Clinical features :ACUTE-triad of abdominal pain, preceded by amenorrhea &lastly appearance of vaginal bleeding

signs; lies quiet &conscious, pallor, feeble& rapid pulse, cold clammy extremities, tender abdomen.

UNRUPTURED-delayed period or spotting, uneasiness on 1 side of flank continuous or colicky in nature.

signs; uterus soft showing evidence of early pregnancy, pulsatile small, well circumscribed tender mass may be felt through one fornix separated from uterus.

CHRONIC OR OLD-amenorrhea, low abdomen pain, vaginal bleeding.

signs: ill look, pallor, pulse persistently high, features of shock absent ,temperature slighlty elevated to 38C, tenderness & muscle guard on affected side, cullen’s sign, cervical movement tender, an ill defined, boggy, tender mass felt through posterolateral fornix extending to POD.

Investigations: blood examination, culdocentesis, UPT, sonography, laparoscopy, D&C, serum progesterone.

Management:

Acute:

Antishock measures with urgent laparotomy

Chronic:

Patient admitted as an emergency.put up for laparotomy at earliest convenient time.

HYDATIDIFORM

MOLE

Hydatidiform mole: an abnormal condition of placenta where there are partly degenerative & partly proliferative changes in the young chorionic villi. Regarded as benign neoplasia of chorion.( incidence:1 in 400 in India).

Etiology: teenage pregnancies& those in women over 35 years of age, faulty nutrition, disturbed maternal immune mechanisms, androgenesis.

Clinical features: vaginal bleeding, low abdomen pain, hyperemesis, breathlessness, thyrotoxic features, expulsion of grape like vesicles per vaginum.

Signs: patient looks more ill than can be accounted for, pallor, features of pre-eclampsia.

per abdomen-size of uterus more than that expected, feel elastic, fetal parts &fetal movement not felt,fetal heart

sound absent.

per vaginum-internal ballottement can not be elicited, unilateral or bilateral enlargement of the ovary, finding of

vesicles.

Investigation: blood examination, LFT,KFT, thyroid function test, sonography (snow storm appearance), serum hcg, X-ray abdomen.

Complications: hemorrhage & shock, sepsis, perforation of uterus, pre-eclampsia, acute pulmonary insufficiency, coagulation failure, development of choriocarcinoma.

Management: suction evacuation of the uterus, supportive therapy & counselling for regular follow up.

The end

Thank You