BLEEDING IN EARLY PREGNANCY

PRESENTED BY ELIAS
 INTRODUCTION
• Common causes include:
– Abortions(miscarriage)-95%
– Ectopic gestations-1%
– Gestational trophoblastic disease-0.1%
– Cervical eversion-1%
– Endocervical polyp-1%
– Cervical carcinoma-0.05%
 ABORTIONS(MISCARRIAGES)
• Definition
– Foetal expulsion/loss before it reaches
viability
– A foetus is viable after 22/40
gestation(WHO)
– In Malawi 28/40 is practical
– Commonest cause of bleeding in early
pregnancy (95%)
Threatened Abortion Inevitable

Incomplete Missed
 Causes
• Ovofoetal causes
– Defective ovum that fails to develop
– Malformed foetus (before or after
conception)
– Chromosomal abnormalities
• Maternal causes
– General maternal diseases
• Febrile illness(malaria, infections):
lead to transplacental passage of
viruses, bacteria; metabolic
disturbances; hypoxia
– Hormonal:corpus luteum
insufficiencylow progesterone levels
• Maternal causes cont…
– Metabolic/ endocrine causes:
• Nutritional deficiencies--fefol
– Malformations of the genital tract
• Submucus/deep intramural myomas
• Bicornute uterus
• Cervical incompetence
anatomic defects
• ABO +Rhesus incompatibility
• Exposure to toxic substances
– Drugs
– Effects of Hiroshima/Nagasaki bomb
• Psychosomatic causes
– Stress
• Paternal causes
– Chromosomal defects
 Varieties of abortions
• Threatened
• Missed
• Inevitable
• Incomplete
• Complete
• Septic
 Threatened abortion
• Clinical presentation:
– Confirming the patient is pregnant
– Slight/light per vaginal bleeding: r/o other
possible causes of bleeding in early
pregectopic gestations
– Mild uterine contractions(lower abd
painshx)
Threatened abortion clinical pres cont…
• V/E:
– Bulky uterus
– Determining source of bleeding- being
inside the cervix(by speculum)
– Cervix is closed(not dilatedbimanual)
• Ultrasound:
– Normal size amniotic sac & foetus with
positive foetal heart
– Empty amniotic sac no life
• Outcome:
– May proceed to term
– Foetal expulsion
– Missed abortion
• Management:
– Bed rest. Even at homeavoid strenuous
activities
– Psychological support on course of
condition
– Drugs, hormones or sedatives will not save
the pregnancynot effective
– U/S @8/40 after resolutionfoetal viability
• Differential diagnosis:
• Ectopic pregnancymass in adnexa
• Missed abortiondirty muddy malodourous
discharge
 Inevitable abortion
• Diagnosis:
– Increasingly painful and strong contractions
– Dilatation/opening of cervix
– Some POCs bulging through the open cervix
– Vaginal bleeding with clots
• Management:
– Accelerate the process by augmenting with oxytocin drip
(under close observation!!!) , manual removal of POCs,
ruptureing the bulging membranes
– If in shock resuscitate with i.v.fluids till haemodynamically
stable
 Incomplete abortion
• Hx of having passed out something(POCs)
• Heavy per vaginal bleeding with clots
• Cramp-like uterine contractions
• Open cervix
• Some POCs in vaginal canal
• Uterus feels bulky/full
• Management:
– reassess the pt:
• vital signs,
• pallor,
• level of consciousness to r/o shock
– Aim at arresting bleeding:
– Manual removal of POCs
– Uterotonic agentsMisoprostol(Cytotec) 600mcg
rectally/400 mcg PO or Oxytocin 10mg im/iv push
• Management cont…
– If signs of shock give i.v fluidsRL, Saline
0.9%, haemacele
– Arrange for MVA or sharp curettage to
remove POCs and control bleeding
– Pain relief
– Psychological support
– Counsel and provide FP method
• Drugs:
– Haematinicsfefol
– Antibiotics if sepsis
• Follow-up:
– If persistent bleeding >10/7, think of:
• Inadequately evacuated uterus
• Choriocarcinoma
 Missed abortion
• Embryonic death in the first half of pregnancy
• Intra-uterine death(IUFD) thereafter
• Presentation:
– History:
• Threatened abortion that settled down
• Ceasation of uterine growth
• Muddy, brownish and malodorous p.v
discharge that persists
• Examination:
– Closed cervix
– Muddy, brownish and malodorous p.v
discharge
– Smaller for dates fundus
• Investigations
– Previously positive pregnancy test reverts to
negativity
– Ultrasoundno foetal heart
• Management:
– Await spontaneous expulsion of conceptus for
at least 4 weeks
– Weekly platelet count for fear of
afibrinogenaemia and
thrombocytopaeniaDIC
– Psychosocial support
– D&C , MVA with Cytotec priming of the cervix
– POCs sent for histology
 Recurrent/habitual abortions
• Definition:
– Three or more successive abortions
• Causes:
– Uterine malformations
– Cervical incompetence
– Chromosomal abnormality
– Endometrial infection
– Endocrine dysfunction
– Systemic disease
– Sperm/immune factors
 Recurrent/habitual abortions cont…
• Investigations &management
• Submucus myomas
– Confirm by U/S
– SurgeryTAH, myomectomy
• Cervical incompetence
– Shirodker/McDonald’s suture @ level of internal
cervical os. Use Mersilk 4 (non absorbable)
• Endometrial infectionsculture &sensitivity of
endometrial tissues
 Recurrent/habitual abortions cont…
• Cervical incompetence diagnosis based on:
• Hx of recurrent abortions>12/40 starting with
painless leaking of amniotic fluid
• Easy passage of size 9 cervical (hegar’s) dilator
through the internal cx os of a non preg woman
and the absence of a snap on its withdrawal
• Gradual dilatation of the internal cx os to more
than 3cm during preg thru U/S
• Endocrine dysfunctionsU/S
• Uterine malformationsU/S; some may be
surgically repaired
• Chromosomal, immunological &autoimmune
disordersrefer
 Septic abortion
• May occur with any abortion
• Mostly in backyard- induced abortions &incomplete
abortions
• Organisms involved: anaerobic strep, staph or E. coli
• Infection involves the myometrium and spreads to
oviducts, pelvic cellular tissues/peritoneum
• Generalised peritonitis and circulatory collapse out
of endotoxins released by E. coli or Clostridium
welchii
Clinical presentation
• Pyrexia
• Tachycardia
• Offensive vaginal discharge
• Poorly contracted tender uterus
• Diagnostic triad:
– Temperature >37.8°c
– Foul smelling pink discharge
– Leucocytosis in excess of 15000
• Invx
• Blood culture & sensitivity
• High vaginal swab (HVS)
• Treatment
– Stabilise pt
• IV RL/NS
• Parenteral antibiotics(ceftriaxone, metro, ampicillin,
genta depends on organism sensitivity
• monitoring of vital signs
– Evacuation of POC
 Complications of abortions
• Haemorrhage: α gestattion
• Shock: due to haemorrhage and at times infection
• Infertility due to:
– Pituitary atrophy
– Pelvic infections
– Trauma to reproductive organs
• Sepsis
• Perforation of intra-abdominal organs
Ectopic gestation/pregnancy
 Definition

A fertilized ovum implants in an area other than

the endometrial lining of the uterus.
Derived from Greek ektopos= out
of place
 History of ectopic gestastion
• First described in the 11th century
• Was usually fatal until the middle of 18th
century
• First successful surgical operation by john
Bard 1759 new york
• Poor survival rate post-op in the 19th century
• Currently good prognosis(improvement in
anaesthesia, antibiotics and blood transfusion)
Animation of intrauterine implantation
Animation of ectopic implantation
 Sites of ectopic pregnancy
>95% ectopic
pregs in fallopian
tubes
70% ampulla
12% isthmic
11.1% fimbrial
3.2% ovarian
2.4% interstitial
1.3% abdominal
 Etiology
• Anything hampering migration of embryo to the endometrial
cavity
– Adhesions from previous infections/tubal surgery
– Congenital tubal abnormalities
– Extra-tubal tumours
• Zygote Abnormalities (chromosomal abnormalities)
• Ovarian Factors (zygote into contralateral tube)
• Use of fertility drugs or assisted reproductive
technologyclomiphene citrate or injectable gonadotrphin
therapy
• Other Factors (endometriosis, IUD)
 Sequel of the pregnancy

Abortion
Rupture
 Sequel of the pregnancy
• Tubal abortion through the osteum
– Secondary abdominal pregnancy
– Mummification of the foetus (lithopaedion)
– Spontaneous regression
• Tubal/cervical/ovarian rupture
– (Interstitial, Angular, Cornual): into the uterine cavity, the
broad ligament or the peritoneal cavity.
– Cervical rupture into the cervical canal
– Abdominal: rupture into the peritoneal cavity, into the
retroperitoneal space
– Ovarian rupture into the peritoneal cavity
 Clinical Findings
• Classical triad of: amenorrhea, vaginal bleeding &
lower abdominal pain
• Symptoms of early pregnancy
• Pelvic tenderness, enlarges uterus, adnexal mass
or tenderness
• Compromise of haemodynamics suggests rupture
• Diffuse lower abdominal pain
***Over 15% of ectopic pregnancy as surgical
emergencies.
 Behaviour of uterine mucosa in ectopic
pregnancy
• Uterine mucosa responds by a decidual
reactionuterine enlargement
• Upon embryonic death the decidua is cast
offbleeding
 Laboratory Findings
• Pregnancy tests (positive-82.5%); A negative
test does not rule out an ectopic gestation
• Hematocrit
• White blood cell count
 Special Examinations
• Ultrasonic scanning
• Culdocentesis
• Quadrant tap
• Laparoscopy
• Exploratory laparotomy
 Differential Diagnosis
• Appendicitis
• Salpingitis
• Ruptured corpus luteum cyst
• Uterine abortion
• Twisted ovarian cyst
• Urinary tract disease
• Degenerating leiomyomas
 Essentials of Diagnosis
• Amenorrhea followed by irregular vaginal
bleeding
• Adnexal tenderness or mass
• Ultrasonographic evidence of adnexal mass
and no intrauterine gestation
• Positive ß-hCG
 Complications
• About I in 1000 ectopic
pregnancies result in
maternal death
• Untreated or mistreated
Death ruptured ectopic tubal
pregnancy 8-12% of all
materal deaths
• The majority of these
deaths are preventable
 Complications

•Chronic salpingitis
•Infertility or sterility
Tubal damage •Intestinal obstruction
may develop after
hemoperitoneum and
peritonitis
 Treatment
• Emergency Treatment
– Resuscitation
– Blood samples
– Prophylactic antibiotics
– Counseling& consent for surgery
– Immediate surgery
• Medical treatmemt-MTX (metho
traxate)
• Supportive post-op care:
– antibiotic,Iron therapy, HPD
Salpingectomy
Indications for Conservative Drug Therapy

• No signs of active intra-abdominal bleeding

• Diameter of mass ＜ 3cm
• Serum ß-hCG ＜ 2000U/L
• No embryonic blood vessle pounding
• No contraindication for MTX application
• Normal liver and kidney function
• Normal RBC count
 Prognosis
• Another tubal pregnancy will occur in 10-20%
of patients treated
• Infertility develops in approximately 50% of
patients