VAGINAL BLEEDING IN EARLY PREGNANCY

PRESENTED BY

INT. DR. AMIT POUDEL

INTRODUCTION

Bleeding occurring from the vagina of a pregnant women before the 22nd week of pregnancy

CASE NO 1

A 24-year-old nulliparous women, presented with 3 months amenorrhea to the ER with vaginal bleeding and severe abdominal pain particularly confined to the left iliac fossa.

Her UPT is (+).

Vaginal examination revealed• CMT (+)• normal-sized uterus.

USG and urine hCG levels were ordered.

The quantitative β-hCG is 2300 mIU/mL and TVS examination revealed

an adnexal mass (about 1 cm in size) and an empty uterus.

CASE NO 2• A 20 yr old primigravida female from Tansen Palpa presented to the Gopd of lmc on

2071/08/18 with c/o

Amenorrhoea x 4 months

vaginal bleeding for 2 days a/w clots

passage of grape like vesicles p/v for 2 days

Excessive vomiting

ON EXAMINATION• GC -fair P/v examination

GPE normal os – tip of the finger• P/A examination mass about 2x3 cm felt in the right

adnexa

Uterus 22 wk size CMT (-)

Fetal parts could not be felt.

FHS(-)

USG abdomen was ordered which showed the characteristic

‘’ Snow Storm ‘’ appearance.

CASE NO 3

A 35-year-old woman at 8 weeks’ gestation c/o • crampy lower abdominal pain and • vaginal bleeding. She states that the pain was intense last night, and that something that looked like liver passed per vagina. After that, the pain subsided tremendously as did the vaginal bleeding.

• O/E, her BP is 130/80 mm Hg,HR 90 bpm, and temp. is 98°FHer abdominal examination is unremarkable.

• The pelvic examinationreveals normal external female genitalia. The cervix is closed and nontender and no adnexal masses were appreciated

• Usg abdomen was ordered which revealed empty uterus with about 20 ml of RPOC

• Case 1 Ectopic pregnancy

• Case 2 Molar pregnancy

• Case 3 Complete abortion

ECTOPIC PREGNANCY

• An ectopic pregnancy is one in which implantation occurs outside the uterine cavity

UNRUPTURED VS RUPTURED ECTOPIC PREGNANCY

UNRUPTURED ECTOPIC RUPTURED ECTOPIC

Symptoms of early pregnancy Collapse and weakness

Abdominal and pelvic pain Fast, weak pulse (110 per minute ormore)

Hypotension

Hypovolemia

Acute abdominal and pelvic pain

Abdominal distension and rebound tenderness

Pallor

SYMPTOMS AND SIGNS

• The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding.• symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low

abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia.• pelvic tenderness• enlarged uterus• adnexal mass• Tenderness• Peritoneal irritation may produce muscle guarding, frequency of micturition, and later a

degree of fever

SEQUELAE OF ECTOPIC PREGNANCY

DIFFERENTIAL DIAGNOSIS• 1. Salpingitis.• 2. Miscarriage.• 3. Appendicitis.• 4. Torsion of pedicle of ovarian cyst.• 5. Rupture of corpus luteum or follicular cyst.• 6. Perforation of peptic ulcer.

AIDS TO DIAGNOSIS• Always take a careful history. Inquire in detail about supposed LMP• Always think of tubal pregnancy; a woman with lower abdominal pain in

whom there is a possibility of pregnancy should be regarded as having an ectopic until proved otherwise.

• Pregnancy test• β-hCG • Ultrasound• Laparoscopy• Culdocentesis

MANAGEMENTIf haemorrhage and shock are present, restore the blood volume by the transfusion of red cells or a volume expander and proceed with operation. The patient's condition will improve as soon as the bleeding is controlled.

MEDICAL MANAGEMENT• Methotrexate (mTX) folate antagonist that inactivates dihydrofolate reductase enzyme, leading to a fall in tetrahydrofolate

Dose50 mg/m2 (approximately 1 mg/kg body weight).

INDICATION• The women should be haemodynamically stable. • Ectopic pregnancy should be unruptured. • Serum β-hCG level should not exceed 6500-10,000 mIU/ml. • The size of the gestation sac should not exceed 3-5 cm in its longest diameter. • Fetal cardiac activity should be absent. • The patient should be willing to come for follow-up. • There should be no contraindication to mTX (liver disease, anaemia). • The patient should be desirous of future fertility.

CONTRAINDICATION• Serum creatinine level >1.3 mg%, liver function test serum SGOT and SGPT

>50 IU/L, low Hb and platelet count contraindicate its use. • Chronic alcoholism and liver disease • Pre-existing blood dyscrasia • Acute pulmonary disease • Peptic ulcer • Immunodeficiency disease • Breast feeding • Known drug sensitivity or presence of allergic diathesis • Gestational sac >3.5 cm • Presence of fetal cardiac activity

Other surgically administered medical (SAM) drugs • Mifepristone • Prostaglandins • 20% KCl solution • Glucose solution

all injected into the gestation sac under ultrasound/laparoscopic control.

Of all these, mTX has proved most effective.

Post-medication management :

•No alcohol •no folic acid. •Avoid pregnancy until ectopic pregnancy resolves and serum hCG is undetected. •Use barrier method consistently

The disadvantage of medical treatment lies in the prolonged follow-up and rarely resorting to surgery in failed cases

SURGICAL MANAGEMENT• Types of surgery

• Salpingectomy

if the gestation sac is >4 cm, most of the tube is damaged and the other tube is healthy

• Partial salpingectomy

if more than 6 cm of the tube can be preserved. Later, tubal anastomosis can be performed .

• SalpingostomyAntimesenteric border is incised, conceptus removed,

haemostasis secured and the wound left open for secondary healing.

• SalpingotomyThe wound is closed with Vicryl sutures.

• Milking of the tube

is possible with fimbrial pregnancy but prolonged bleeding and persistent trophoblastic tissue do not favour this technique.

SUBSEQUENT MANAGEMENT• Prior to discharge, provide counselling and advice on prognosis for fertility. • Given the increased risk of future ectopic pregnancy, family planning counselling and

provision of a family planning method, if desired, is especially important.

• Correct anaemia with ferrous sulfate or ferrous fumerate 60 mg by mouth daily for six months.

• Schedule a follow-up visit at four weeks

GESTATIONAL TROPHOBLASTIC DISEASE (GTD)

• Heterogeneous group of related lesions• Arise from abnormal proliferation of trophoblast of the placenta• Unique because the maternal lesions arise from fetal (not maternal) tissue• Most GTD lesions produce the beta subunit of human chorionic gonadotropin (B-hCG)

OVERVIEW

Hydatidiform Mole:• Complete • Partial

** Benign

Gestational Trophoblastic Neoplasia (GTN):• Persistent/Invasive Mole• Choriocarcinoma• Placental-Site Trophoblastic Tumor (PSTT)

** Malignant

HYDATIDIFORM MOLE

• North America: 0.6-1.1 per 1000 pregnancies• Asia: 2-10 per 1000 (3x Western countries)• Difference possibly related low dietary intake of carotene (vitamin A deficiency) and animal

fat • More common at reproductive extremes in age (>35y or <20y)

Risk Factors:• History of previous GTD

• If one previous mole, 1% chance of recurrence (vs. 0.1% in general population)• If 2 previous moles, risk of recurrence increases to 16-28%

• Smoking• Vitamin A deficiency

Clinical Manifestations:

• Vaginal bleeding/anemia• Enlarged uterus (size > dates)• Pelvic pain• Theca lutein cysts• Hyperemesis gravidarum• Hyperthyroidism• Preeclampsia <20 weeks gestation• Vaginal passage of hydropic vesicles• Fetal parts are not palpable

HYDATIDIFORM MOLE - DIAGNOSIS

• Evaluate for coexisting conditions:- History and physical examination- CBC, coagulation profile, serum biochemistry- thyroid function- blood type and crossmatch- chest radiography- pelvic ultrasonography

Pelvic USG• main method of diagnosing hydatidiform

mole• Extremely accurate provided that the mole is

sufficiently developed, as the echoes produced from the mass of vesicles produce a characteristic 'snowstorm' appearance.

HUMAN CHORIONIC GONADOTROPHIN• Since most of the trophoblast cells secrete HCG, its assay is a measure of the amount of• tumour tissue• Grossly elevated levels of HCG are found with hydatidiform moles.• Beta HCG is much more specific• Is useful during the follow up of the disease

MANAGEMENT

• Once hydatidiform mole is diagnosed, the uterus should be evacuated.• Risks before evacuation:• 1. Haemorrhage.• 2. Trophoblastic invasion and perforation of myometrium.• 3. Dissemination of possibly malignant cells.• Risks during evacuation:• 1. Haemorrhage.• 2. Perforation by instruments.• 3. Dissemination of possibly malignant cells.

The following plan of management is suggested.• 1. After miscarriage, the uterus should be completely emptied by

suction.• 2. If miscarriage does not occur, an attempt should be made to empty

the uterus by suction.• If bleeding becomes severe, oxytocics must be given, and on rare

occasions an emergency hysterectomy or hysterotomy may be unavoidable.

• 3. If the uterus is of such a size as to deter the obstetrician from attempting suctioncurettage, abortion should be induced using prostaglandin together with oxytocin if necessary. Subsequent surgical evacuation of the uterus may also be required.

• 4. In the case of the older woman whose family is complete, hysterectomy may be justified, especially as dissemination of trophoblast cells can be almost completely prevented by early clamping of the uterine vessels.

FOLLOW UP• Follow up is required because in about 10% of cases it will persist

and undergo malignant change invarying degrees• all patients must be followed up for prolonged periods by

radioimmune assays of serum or urinary HCG.• Normally, the test becomes negative in about 6-8 weeks' time

following evacuation of a molar pregnancy• Pelvic examination is done to rule out any vulval and vaginal

metastasis,• the uterine size is recorded. • The size of any ovarian cyst and reduction in its size are noted. • A radiograph of the chest is taken to detect lung metastasis. • Persistent uterine bleeding calls for a curettage, and the curettings

are sent for histopathological examination for choriocarcinoma. • Pelvic ultrasound scan can detect residual or locally invasive tumour

as well as an ovarian cyst.

PREGNANCY AND CONTRACEPTION• Pregnancy should be avoided preferably by barrier methods for at least 1 year as a fresh

pregnancy would interfere with the hCG levels.• Intrauterine device and progestogen-only pills cause irregular bleeding and are best

avoided.• Combined oral pills can be offered once the β-hCG level becomes undetected. • Oral combined pills lower the luteinizing hormone (LH) level and thereby hCG level and can

cause misinterpretation of the results.

PROPHYLACTIC CHEMOTHERAPY• indicated in the following conditions :• High-risk case, i.e. a very young woman and a multiparous woman above age 40 who

refuses hysterectomy. • A patient with an initial very high level of hCG or a patient in whom the level of hCG persists

or does not regress satisfactorily or there is a rise in the hormone. Patients with urine hCG level more than 30,000 IU/24 hours after 6 weeks or more than 24,000 IU/24 hours at 10 weeks after evacuation and patients with serum hCG level more than 20,000 mIU/ml if the serum β-hCG level plateaus over 4 weeks or rises over 3 consecutive weeks also need prophylactic therapy.

• If a woman cannot come for the follow-up, prophylactic chemotherapy is better than no follow-up.

PROPHYLACTIC CHEMOTHERAPY ….

• Prophylactic chemotherapy comprises administration of :

mTX 5 mg five times a day for 5 days, and three courses repeated at the interval of 7-10 days, provided hb % and WBC count remain above the critical level

• Subsequent Pregnancies:• Send placenta for pathology• Check B- hCG 6 weeks postpartum

MISCARRIAGE ( ABORTION )

Definition

• It is expulsion or extraction of products of conception before fetal viability i.e. before 24 weeks of gestation.

Incidence :

• Is the commonest gynaecological & obstetric disorder • About 15% of clinically recognized pregnancies end in abortion (this rise to 30% if

unrecognized pregnancies are included).• Most abortions occur between 8 and 12 weeks of pregnancy.

Miscarriage ( Abortion )

ETIOLOGY A. First trimester abortion :

1.  Fetal chromosomal abnormalities - particularly trisomy , triploidy & monosomy • is the commonest cause of abortion • 50– 70 % of the first trimester abortions are due to chromosomal abnormalities• the incidence of these abnormalities increased with the increase in the maternal age

2. Anembryonic pregnancy -  Blighted ovum

3. Multiple pregnancy

ETIOLOGY A. First trimester abortion :

3. Parental balanced translocation 

4. Infections:  genital tract infection , systemic infection with pyrexia & ToRCH  syndrome

5. Endocrine disorders :  Diabetes,  thyroid disorders , PCOS  &  corpus luteum  insufficiency

6. Uterine disorders:  Uterine anomalies , submucus fibroid &  Asherman’s syndrome

ETIOLOGY A. First trimester abortion :

8. Thrombophilia: Congenital deficiency of protein C & S, & anti-thrombin III

9. Immunological disorders : Anticardiolipin syndrome and SLE  

10. Cigarette smoking , anaesthetic agents & chemical agents . 

11. Psychological disorders

ETIOLOGY B. Second trimester abortion :

1. Multiple pregnancy

2. Cervical incompetence (congenital & acquired )

3. Uterine anomalies and submucous fibroid

4. Genital tract infection and PROM

TYPES1. Threatened abortion 

2. Inevitable abortion 

3.  Incomplete abortion 

4. Complete abortion 

5.  Missed abortion 

6. Septic abortion 

7.  Recurrent abortion  

THREATENED ABORTION(FEATURES)

1. History Mild vaginal bleeding.

No abdominal pain or mild abdominal pain

2. Examination Good general condition.

The cervix is closed

The uterus is usually the correct size for date

3. USG which is essential for the diagnosis shows the presence of fetal heart activity

THREATENED ABORTION(MANAGEMENT)

1. Reassurance If fetal heart activity is present, > 90% of cases will be progressed satisfactorily

2. Advice:  Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse

3. Hormones i.e. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of no proven value)

4. Anti- D:  An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients, whose husbands are Rh +ve

5. ANC as high risk patients  

Because those patients are liable to late pregnancy complications such as APH and preterm labour .

INEVITABLE AND INCOMPLETE ABORTIONS(FEATURES)1. History

Heavy vaginal bleeding. with no passage of products conception (inevitable) with the passage of products of conception

(incomplete abortion)Severe lower abdominal pain which follows the bleeding

INEVITABLE AND INCOMPLETE ABORTIONS(FEATURES)2. Examinations

Poor general condition. The cervix is dilating and products of conception may be

passing trough the os The uterus may be the correct size for date (inevitable

abortion) or small for date (incomplete abortion)

3. USG Fetal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in incomplete abortion

INEVITABLE AND INCOMPLETE ABORTIONS(MANAGEMENT)1. CBC , blood grouping , XM 2 units of blood

2. Resuscitation large IV line, fluids & blood transfusion

3. Oxytoxic drugs Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline)

4. Evacuation & curettage.

5. Post-abortion management.

COMPLETE ABORTION(FEATURES)

1. History Heavy vaginal bleeding which has been stopped. lower abdominal pain which follows the bleeding which has been

stopped.

2. Examination The cervix is closed

3. USG Shows empty uterine cavity or RPOC

COMPLETE ABORTION(MANAGEMENT)

1. Evacuation & curettage in the presence of RPOC.

2. Post-abortion management.

MISSED ABORTION(FEATURES)

1. Most of missed abortions are diagnosed accidentally during routine U/S in early pregnancy .

In some cases there may be a history of : Episodes of mild vaginal bleeding Regression of early symptoms of pregnancy . Stop of fetal movements after 20 weeks gestation.

2. Examination The uterus may be small for date

MISSED ABORTION(FEATURES)

3. USG (which is essential for diagnosis ) diagnosed if two ultrasound ( T/V or T/A) at least 7days apart showed an embryo of > 7 weeks gestation ( CRL > 6mm in diameter and gestational sac > 20 mm in diameter ) with no evidence of heart activity .

MISSED ABORTION(MANAGEMENT)

1. CBC , blood grouping , XM 2 units of blood

2. Platelets count, – to exclude the risk of DIC

NB : DIC does not occur before 5 weeks of missed abortion or IUFD and if occurred will be of mild grade

MISSED ABORTION(MANAGEMENT)

3. Options of treatment Conservative treatment: if left alone spontaneous expulsion will occur Surgical evacuation of the uterus; by D & C:

Indicated in 1st trimester missed abortionMedical termination of pregnancy: by Misoprostol (PGE1)

4. Post-abortion management.

ANEMBRYONIC PREGNANCY (BLIGHTED OVUM)

It is due to an early death and resorption of the embryo with the persistence of the placental tissue

It is diagnosed if two ultrasound ( T/V or T/A) at least 7 days apart showed after 7 weeks of gestation i.e. gestational sac > 20mm , an empty gestational sac with no fetal echoes seen .

It is treated in a similar way to missed abortion .

SEPTIC ABORTION

Definition : It is an incomplete abortion which complicated by infection of the uterine contents . This may be due to criminal interference

Features : Poor general condition Include the features of incomplete abortion i.e. severe vaginal bleeding with passage of

product of conception, with or without history of evacuation. Features of pelvic infection i.e. pyrexia , tachycardia , general malaise , lower abdominal

pain , pelvic tenderness & purulent vaginal discharge .

SEPTIC ABORTIONBacteriology : Mixed infection

The commonest organisms are :

1. Gram -ve : E.coli , strepto & staphylococcus

2. Anaerobics : Bacteroides Rarely Cl. tetani , which is potentially lethal if not treated adequately .

Types : Mild the infection is confined to decidua : 80% Moderate the infection extended to myometrium15% Severe the infection extended to pelvis + Endotoxic shock + DIC 5%

SEPTIC ABORTION

Management :

1. Investigations : CBC , blood grouping , XM 2 units of blood . Cervical swabs (not vaginal) for culture and sensivity Coagulation profile , serum electrolytes & blood culture if pyrexia > 38.5

2. Antibiotics : Cephalosporin I.V + Metronidazole I.V

3. Surgical evacuation of uterus usually 12 hrs after antibiotic therapy ( until a reasonable tissue levels of antibiotics have been achieved )

4. Post-abortion management.

 COMPLICATIONS OF ABORTION

1. Haemorrhage .

2.  Complication related to surgical evacuation ie E&C and D&C.• Uterine perforation- which may lead to rupture uterus in the subsequent pregnancy.• Cervical tear & excessive cervical dilatation – which may lead to cervical incompetence.• Infection – which may lead to infertility & Asherman's syndrome.• Excessive curettage – which may lead to Adenomyosis

3.  Rh- iso immunisation  if the anti –D is not given or if the dose is inadequate .

4. Psychological trauma .

POST - ABORTION MANAGEMENTIn cases of incomplete, inevitable, complete, missed & septic abortions

1.Support: from the husband, family& obstetric staff

2.Anti D – to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve

3. Counseling & explanation:

A.Contraception (Hormonal, IUCD, Barrier) Should start immediately after abortion if the patient choose to wait , because ovulation can occur 14 days after abortion and so pregnancy can occur before the expected next period .

POST - ABORTION MANAGEMENT

3. Counseling & explanation:

B.When to try again ?  Best to wait for 3 months before trying again . This time allow to regulate cycles and

to know the LMP, to give folic acid, and to allow the patient to be in the best shape (physically and emotionally) for the next pregnancy

C.Why has it happened ?In the fiIn the majority of cases there is no obvious causeIn the first trimester abortion , the most common cause is fetal chromosomal

abnormality

POST - ABORTION MANAGEMENT3. Counseling & explanation:

D. Can it happen again? As the commonest cause is the fetal chromosomal abnormality which is not a

recurrent cause , so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2 or 3 abortions

E. Not to feel guilty  as it is extremely unlikely that anything the patient did can cause abortion

No evidence that intercourse in early pregnancy is harmful No evidence that bed rest will prevent it ..

RECURRENT ABORTIONDefinition :

Is defined as 3 or more consecutive spontaneous abortions It may presented clinically as any of other types of abortions .

Types : Primary : All pregnancies have ended in loss Secondary : One pregnancy or more has proceeded to viability(>24 weeks gestation)

with all others ending in loss

Incidence : occurs in about 1% of women of reproductive age .

RECURRENT ABORTIONCauses• Idiopathic recurrent abortion, in about 50%, in

which no cause can be found . • The known causes include the followings :

1. Chromosomal disorders: Fetal chromosomal abnormalities & structural

abnormalities Parental balanced translocation

2. Anatomical disorders: Cervical incompetence: →congenital and aquiredUterine causes: → submucous fibroids, uterine anomalies &

Asherman’s syndrome

RECURRENT ABORTIONCauses

3. Medical disorders: Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus luteum

insufficiency . Immunological disorders : Anticardiolipin syndrome & SLE. Thrombophilia: congenital deficiency of Protein C&S and antithrombin III,

& presence of factor V leiden. Infections

ToRCH - CMV may be a cause of recurrent abortion, but ToRH are not causes of recurrent abortion.

Genital tract infection e.g Bacterial vaginosis Rh – isoimmunization

RECURRENT ABORTION

Diagnosis :

1. History : Previous abortions : gestational age and place of abortions & fetal

abnormalities. Medical history : DM , thyroid disorders, PCOS, autoimmune diseases &

thrombophilia.

2. Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine size.

RECURRENT ABORTIONDiagnosis :

3. investigations :

A. Investigations for medical disorders: Blood grouping & indirect Coomb’s test in Rh –ve women Endocrinal screening: Blood sugar , TFT & LH /FSH ratioImmunological screening: Anti anticardiolipine antibodies & lupus inhibitor.Thrombophilia screening: Protein C & S, antithrombin III levels, factor V leiden,

APTT and PT.Infection screening

High vaginal & cervical swabs ToRCH profile ( which scientifically is not necessary )

RECURRENT ABORTIONDiagnosis :

3. investigations :

B. Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS.Hysteroscopy or HSG, fibroids, cervical incompetence, uterine anomalies &

Asherman's syndrome

C. Investigations for chromosomal disorders: Parental karyotyping: Parental balanced translocation.Fetal karyotyping: Fetal chromosomal anomalies.

RECURRENT ABORTION

Management:

3. in idiopathic recurrent abortion.

With support and good antenatal care , the chance of successful spontaneous pregnancy is about 60-70% Support : from husband, family & obstetric staff. Advice : stop smoking & alcohol intake, decrease physical activity Tender loving care Drug therapy • Progesterone & hCG: start from the luteal phase & up to 12 weeks.• Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks • LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37 ws

RECURRENT ABORTIONManagement:

3. In the  presence of a cause treatment is directed to control the causeEndocrine disorders 

• Control DM and thyroid disorders before pregnancy• Ovulation induction drugs , ovarian drilling or IVF in PCOS.• Progesterone or hCG in corpus luteum insufficiency .

:In anti-cardiolipin syndrome: • Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg / day), starting when

pregnancy is diagnosed till 37 weeks.• These drugs are not teratogenic.

RECURRENT ABORTIONManagement:

In thrombophilia: • Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low

molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart activity diagnosed & to continue both till 37 weeks .

In uterine disorders • Cervical cerclage in cervical incompetence, best time at the 14 weeks of pregnancy.• Myomectomy in submucus fibroid, excision of uterine septum in septate &

subseptate uterus & adhesolysis in Asherman's syndrome.

RECURRENT ABORTION

Management: In infection:: treatment of the genital tract infection. In Rh isoimmunization: Repeated intrauterine transfusion In parental balanced translocation

• Explain the risk of fetal chromosomal disorders ( about 30% )• Encourage to try again or adoption.

SO TO SUM IT UP…….

Presenting Symptom and OtherSymptoms and Signs TypicallyPresent

Symptoms and SignsSometimes Present

Probable Diagnosis

• Light bleeding• Closed cervix• Uterus corresponds to dates

• Cramping/lower abdominalpain• Uterus softer than normal

Threatened abortion,

•Light bleeding• Abdominal pain• Closed cervix• Uterus slightly larger thannormal• Uterus softer than normal

• Fainting• Tender adnexal mass• Amenorrhoea• Cervical motion tenderness

Ectopic pregnancy

• Light bleeding• Closed cervix• Uterus smaller than dates• Uterus softer than normal

• Light cramping/lowerabdominal pain• History of expulsion ofproducts of conception

Complete abortion

Presenting Symptom and OtherSymptoms and Signs TypicallyPresent

Symptoms and SignsSometimes Present

Probable Diagnosis

• Heavy bleeding• Dilated cervix• Uterus corresponds to dates

• Cramping/lower abdominalpain• Tender uterus• No expulsion of products ofconception

Inevitable abortion,

• Heavy bleeding• Dilated cervix• Uterus smaller than dates

• Cramping/lower abdominalpain• Partial expulsion of productsof conception

Incomplete abortion,

• Heavy bleeding• Dilated cervix• Uterus larger than dates• Uterus softer than normal• Partial expulsion of products ofconception which resemblegrapes

• Nausea/vomiting• Spontaneous abortion• Cramping/lower abdominalpain• Ovarian cysts (easilyruptured)• Early onset pre-eclampsia• No evidence of a fetus

Molar pregnancy,

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