Bleeding in first half of Pregnancy

Pattarawin Arunratsamee, MD.

1/11/55
 First trimester bleeding

• Occurs in 20-40% women

• Prognosis:
– Worse prognosis with heavier bleeding or extending
into second trimester
– Vaginal bleeding in >1 trimester associated with 7 fold
increased in PPROM
 Evaluation
• History
– associated symptom
– Past history
• Previous ectopic
• Prior abortion
• Medical disorders
• Risk factors
 Physical examinatiion
– Vital signs
– Tissue if available
– Abdominal exam
– Speculum exam – look for lacerations, warts,
vaginitis, cervical polyps, fibroids, cervicitis,
neoplastic process
– Bimanual exam – assess adnexal/cervical
tenderness, adnexal masses, uterine enlargement
 Differential diagnosis
• Abortion (threatened, inevitable, complete,
incomplete, missed)
• Ectopic pregnancy
• Molar pregnancy
• Trauma, wounds, vaginitis, vaginal/cervical neoplasia,
warts, polyps, fibroids
• Physiologic/implantation (diagnosis of exclusion)
I - ABORTION
 Definition

Termination of pregnancy before viability of the

foetus i.e. before 28 weeks (in Britain) and
before 20 weeks or if the foetal weight is less
than 500 gm (in USA and Australia).

When the abortion occurs spontaneously, the term

" miscarriage" is often used.
 Aetiology

• Chromosomal abnormalities: cause at least 50% of early abortions

e.g. trisomy. (13,16,18,21,22)
• Blighted ovum (anembryonic gestational sac).
• Maternal infections: Acute fever ,TORCH
• Trauma: external to the abdomen or during abdominal or pelvic
operations.
• Endocrine causes: Progesterone deficiency ,Diabetes mellitus,
Hyperthyroidism.
• Drugs and environmental causes:
• Maternal anoxia and malnutrition.
• Over distension of the uterus: e.g. acute hydramnios.
 Continued,

• Immunological causes:
– Systemic lupus erythematosus.
– Antiphospholipid antibodies that are directed against platelets
and vascular endothelium leading to thrombosis, placental
destruction and abortion.
• Ageing sperm or ovum.
• Uterine defects Septum, Asherman's syndrome
(intrauterine adhesions).
• Nervous, psychological conditions and over fatigue.
• Idiopathic.
 Abortion
• Spontaneous
• Induced abortion
– Therapeutic

– Criminal
 Types of abortion
⦿ Threatened
⦿ Inevitable
⦿ Complete
⦿ Incomplete
⦿ Missed
 First-trimester Milestones
• 5 weeks: Gestational sac
(~5mm) seen with TVUS
• 6 wks: Embryo (1-2mm)
visible on TVUS
• Yolk sac: Seen with TVUS
when GS>10mm (>20 w/
TAUS)
– Cardiac activity: Seen with
TVUS when GS >18mm Normal gestational sac at arrow,
(>25mm on TAUS)Cardiac endometrial cavity at curved arrow
activity should always be
seen when embryo >5mm
“Double decidual sac” sign

GS=gestational sac, DP=decidua parietalis, * =

endometrial cavity, arrow=decidua capsularis
 Normal US Findings

Yolk sac (at arrow) within gestational sac Yolk sac (at curved arrow) with embryo
(between X’s)
 Normal US Findings

Embryo (black arrow); amnion (small arrow)

does not fuse with chorion (large arrow) until
12-16wks gestation.
 Abnormal US Findings
A B

c
 Threatened Abortion
Clinical picture:
• Symptoms and signs of pregnancy coincide with its
duration.
• Vaginal bleeding slight or mild, bright red in colour.
• Pain is absent or slight.
• Cervix is closed.
• Pregnancy test is positive.
• Ultra-sonography shows a living foetus.
 Prognosis:
• If blood loss < menstrual flow and no pain
: 50% continuing pregnancy.
• If fetal cardiac activity present : significant
lower risk
• Preterm labor, Low birth weight, perinatal
death
 Treatment:

• Rest in bed until one week after stoppage of

bleeding.
• No intercourse
• Sedatives: if the patient is anxious.
• Treatment of controversy:
– Progestogens.
– Gonadotrophins may be of benefit in cases of
luteal phase deficiency and those get pregnant
with ovulatory drugs.
 Inevitable Abortion
Clinical picture:
• Symptoms and signs of pregnancy coincide (match) with
its duration.
• Vaginal bleeding is excessive and may accompanied with
clots.
• Pain is colicky felt in the suprapubic region radiating to
the back.
• The internal os of the cervix is dilated and products of
conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign of
the inevitability of abortion.
 Treatment
• Any attempt to maintain pregnancy is useless.
 Incomplete Abortion

• Retention of a part of the products of

conception inside the uterus. It may be the
whole or part of the placenta which is
retained.
 Clinical picture
• The patient usually noticed the passage of a
part of the conception products.
• Bleeding is continuous.
• The uterus is less than the period of
amenorrhoea but still large in size. The cervix
is opened and retained contents may be felt
through it.
• Ultrasonography: shows the retained
contents.
 Complete Abortion
• All products of conception have been expelled from the
uterus.
Clinical picture:
• The bleeding is slight and gradually diminishes.
• The pain ceases.
• The cervix is closed.
• The uterus is slightly larger than normal.
• Ultrasound: shows empty cavity.
 Missed Abortion
• Retention of dead products of conception for 4
weeks or more.
Symptoms:
• Regression of pregnancy symptoms as nausea,
vomiting and breast symptoms.
• The abdomen does not increase and may even
decrease in size.
• The fetal movements are not felt or ceases if
previously present.
• A dark brown vaginal discharge
Signs:
• The uterus fails to grow and becomes firmer and The
cervix is closed.
• The fetal heart sounds cannot be heard.
Investigations:
• Pregnancy test becomes negative within two weeks from
the ovum death.
• Ultrasound shows either a collapsed gestational sac,
absent fetal heart movement or foetal movement.
 Complications:
• Disseminated
intravascular
coagulation (DIC) may
occur if retained for
more than 4 weeks.
• Superadded infection.
 Treatment:

• The dead conceptus is expelled spontaneously in the

majority of cases.
Evacuation of the uterus is indicated in the following
conditions:
• spontaneous expulsion does not occur within four weeks,
• there is bleeding,
• infection or DIC developed or,
• patient is anxious. Although some gynaecologists advise
evacuation of the uterus once sure diagnosis of missed
abortion is made.
 Evacuation is carried out as following:

• If the uterine size is less than 12 weeks’ gestation: vaginal

or suction evacuation is done
• If the uterine size is more than 12 weeks' gestation:
evacuation can be done by
– Prostaglandins: given intravaginally (PGE2), intravenously,
intra-or extra- amniotic (PGF2α).
– Oxytocin infusion.
– Combination.
– Hysterotomy: is rarely indicated in 2nd trimester missed
abortion if the medical induction fails initially and after
repetition few days later.
 Septic Abortion

• It is any type of abortion, usually criminal

abortion, complicated by infection.

• Microbiology:
• E.Coli, bacteroids, anaerobic streptococci,
clostridia, streptococci and staphylococci are
among the most causative organisms.
 Clinical picture:

• General examination:
– Pyrexia and tachycardia.
– Rigors suggest bacteraemia.
– A subnormal temperature with tachycardia is ominous and
mostly seen with gas forming organisms.
– Malaise, sweating, headache, and joint pain.
– Jaundice and /or haematuria is an ominous sign, indicating
haemolysis due to chemicals used in criminal abortion or
haemolytic infection as clostridium welchii.
 Clinical presentation
• Abdominal examination:
– Suprapubic pain and tenderness.
– Abdominal rigidity and distension indicates peritonitis.
• Local examination:
– vaginal discharge
– Uterus is tender.
– Products of conception may be felt.
– Local trauma may be detected.
 Treatment

• Admit. Bed rest in semi-sitting position, O2

• An intravenous line is established for therapy.
• Observation for vital signs:
• A cervico-vaginal swab is taken for culture and
sensitivity,
• Antibiotic therapy, TT, TAT
• Fluid therapy
• Blood transfusion: is given if CVP is low (normal:
8-12 cm water).
 Continued,
• Oxytocin infusion: to control bleeding and
enhances expulsion of the retained products.
• Surgical evacuation of the uterus can be done
after 4-6 hours of commencing IV therapy but
may be earlier in case of severe bleeding or
deteriorating condition in spite of the previous
therapy.
• Hysterectomy may be the last choice to safe
life
 Other types of abortion
Therapeutic Abortion
• Abortion induced for a medical indication.
Criminal Abortion
• Illegal abortion induced for a non-medical
indication.
Recurrent (Habitual) Abortion
• Three (two by some authors) or more
consecutive abortions.
 Summary
• Threatened: Vaginal bleeding without cervical
dilation
• Incomplete: Vaginal bleeding with partial expulsion
of products of conception (POC) + cervical dilation
• Missed: Embryonic demise prior to 20 wks without
expulsion of POC +/-vaginal bleeding
• Complete: Vaginal bleeding + expulsion of all POC
• Inevitable: Vaginal bleeding + cervical
dilation+/-ROM
• Septic: Any of the above + uterine infection
 Ectopic pregnancy
• Ectopic means "out of place." In an ectopic
pregnancy, a fertilized egg has implanted
outside the uterus. The egg settles in the
fallopian tubes in more than 95% of ectopic
pregnancies. This is why ectopic pregnancies
are commonly called "tubal pregnancies”.
Ectopic pregnancy
 Ectopic pregnancy

⦿ 3 classic symptoms:
⦿ Abdominal pain (99%)
⦿ Amenorrhea (74%)
⦿ Vaginal bleeding (56%)
⦿ Occur with both ruptured and unruptured
cases
⦿ Shoulder pain can also be seen
 Fate of ectopic pregnancy
• Tubal abortion

• Tubal rupture
 Morbidity and Mortality Rates

• Abdominal pain occurs in 97% of women with an ectopic

pregnancy,
• Vaginal bleeding in 79%,
• abdominal tenderness in 91%, and infertility in 15%.
• Persistent ectopic pregnancy after surgical treatment
occurs in 5–10% of cases.
• Ectopic pregnancy accounts for 10–15% of all maternal
death; the mortality rate for ectopic pregnancy is
approximately one in 2,500 cases.
 Management
• Indications for surgery:
– Ruptured
– Inability to comply with medical therapy or
contraindications
– Lack of access to medical facility in event of
rupture
– Failed medical therapy
 Management cont’d
• Consider medical therapy when:
– Unruptured
– Compliant patients
– hCG <5000
– Small tubal diameter
– Gest sac <3.5 cm
– No FCA
• Usually given as 1-2 injections of 50 mg/m2 IM
Molar pregnancy
 Causes

• The cause of hydratidiform mole is unclear;

• some experts believe it is caused by problems
with the chromosomes
• A mole sometimes can develop from placental
tissue that is left behind in the uterus after a
miscarriage or childbirth.
 Symptoms&sign
• Vaginal bleeding
• Hyperemesis gravidarum
• Large for date
• Preeclampsia
• Hyperthyroidism
• Theca lutein cyst
• Passage of molar vesicle
 Diagnosis
• ซักประวัติ
• ตรวจรางกาย
• ตรวจคนพิเศษเพิ่มเติม U/S : snow storm,
numerous cystic echo-densities
• Amniography: moth-eaten, honeycomb
• hCG level > 100,000 unit/L
 Complete mole
• พบไดบอย และพบวา มีโอกาสรอยละ 20 ที่จะ
เจริญไปเปน gestational trophoblastic
neoplasia
• เกิดจากการที่ sperm ผสมกับ empty egg หรือ
inactivated chromosome หลังจากนั้นจะมีการ
duplication ของ haploid chromosome เปน
46,xx
 Partial mole
• พบไดนอย และมีโอกาสที่จะกลายเปน
malignant disease ไดนอย (2%)
• เกิดจากการที่มี sperm 2 ตัวปฎิสนธิกับ egg 1
ฟองจึงทําใหได triploid karyotype
 Partial mole

• คลายกับกลุม complete
hydratidiform mole มักมาพบ
แพทย เมื่ออายุครรภมากมักไมพบ
ภาวะ large for date /ภาวะ
preeclampsia พบไดแตนอยกวา
และชากวา อาจไดรับ การวินิจฉัย
เบื้องตนวาเปน missed abortion or
 Treatment
• Evaluation
• Termination : suction curettage, TAH
• Follow up and contraception
 Follow up
• Beta HCG q 1 wk until normal x 2
• Then q 1 mo x6
• Then q 2 mo until 1 year
• PV q 2 mo
• Contraception: condom/OCP 1 yr
• Thank you!!