Vaginal bleeding in early pregnancy
Dr.Shelan O.Jaafar
Hawler Medical University
College of Medicine
Department of Obstet. &
Gynaecol.
Contents
Objectives
Key concepts
Case scenario
Likely differential diagnosis
How you approach a patient with ealy pregnancy
bleeding.
History ,examination and investigations.
Conclusions and Questions.
Objectives:
1.Know the typical characterstics of different
types of miscarriages(spontaneous abortion).
2. Understand the clinical presentations of and
the treatments for the different types of
miscarriages.
3. Understand the role of the hCG level and the
threshold for transvaginal sonogram.
Key concepts
Misscarriage: pregnancy loss from time of conception
untill 24 weeks of gestation
Ectopic pregnancy: Implantation of the fertilized ovum
outside the normal endometrial impalntation site
Molar pregnancy:Abnormal proliferation of gestational
trophoblastic tissues.
Local gynaecological lesions e.g. cervical ectopy, polyp,
dysplasia, carcinoma and rupture of varicose vein.
Key concepts
Definition of miscarriage :The spontaneous loss of
pregnancy before the fetus reaches viability all
pregnacy losses from the time of conception until
24weeks of gestation.
WHO definition :Expulsion of a fetus or an embryo
weighing 500gm or less.
Incidence:15-20%of pregnancies.
Key concepts
Risk factors:
Chromosomal abnomalities.
Congenitel abnormality of uterus.
Medical ,Endocrine disorders.
Infections/Torch.
Drugs/chemicals.
Autoimmune disease
Risk factors
-Advanced maternal age.
-Smoking
-Prior miscarriage
-Cocaine use
-Fever
Miscarriage (types)
- Inevitable
- Threatened
- Missed
- Induced Abortion
- Recurrent
- Septic
- Complete
- Incomplete
Classification of miscarriage
Terminoil history Passage of Cervical Viability of treatment
ogy tissue os pregnancy
Threatened Vaginal NO closed Uncertain,u TVU and
bleeding p to 50%will hCG levels
miscarry
Inevitable Cramping NO Open Abortion is Currtage vs
,bleeding inevitable expectant
Incomplete Cramping, Some but not Open Nonviable Currtage
Bleeding(conti all tissues
nuing) passed
Complete Cramping All tissues Closed Non viable Follow hCG
bleeding passed levels to
previously but negative
now subsided
Missed No symptoms No Closed Nonviable D&C vs
(Diagnosed expectant
on US
Case Scenario
Bahar is 27years old ,her first pregnany with 9
weeks peroid in a previous regular cycle
presenting with bright red intermittent spotting
she has no abdominal pain home prgnancy
test is positive?
Likely differential diagnosis:
Miscarriage
Threatened
Complete
Incomplete
Inevitable
Missed
• Ectopic
• Molar pregnacy
What issues in history support the diagnosis?
9 weeks peroid and a positive pregnancy test after
regular cycle indicate an early pregnancy .
The possibilty of ectopic pregnancy must be
considered in any case with vaginal spotting and or
lower abdominal pain.
Degree of bleeding associated pain and passage of
products of conception would indicate the type of
miscarriage.
What additional features in the history would you
seek to support a particular diagnosis?
whether slight amount or large containing
clot ,pieces or not which occur in incomplete or
complete if containing vesicle is more in molar
pregnancy.
Also bright blood more in threatened abortion
while dark color blood in missed.
What clinical examination would you perform?
Temperature (high temperature indicate septic miscarriage).
Blood pressure and pulse rate,hemodynamically unstable
patient either in sever bleedings as in incomplete miscarriage or
ectopic pregnancy.
Abdominal examination :
Rebound tenderness and acute abdomen in ectopic
Soft non tender abdomen with no palpable mass in miscarriage.
What clinical examination would you perform?
Speculum examination should be performed to
visualize the cervical os and determine whether fetal
tissue is present in the os or the vagina.
Cervical os (open/closed) on digital examination will
help to distinguish between the different types of
miscarriage.
Clinical examintion (cont.)
Exclude local causes for vaginal bleeding by speculum
exmination either:
cervicitis
ectropian(associated with post coital bleeding
cervical polyp
cervical mass (Carcinoma)although rare but should
not be missed.
Clinical examination (cont.)
Uterine size should be assessed during bimanual
examination.
Uterine tenderness is unlikely unless there is septic
abortion.
Vaginal examination may elicit cervical excitation and
adnexal tenderness in ectopic pregnancy.
What investigations would be most helpful and why?
Urine BhCG more reliable than home prgnancy test.
FBC
BG and Rh ,cross match in case of shock.
Serum BhCG,if below threshold level for sonographic
visualization then should be repeated after 48 hrs it
should be doubled if decreasing in titre either missed or
complete .
What investigations would be most helpful and why?
Ultrasound :
The fetus intra or extra uterine
Viable or not(missed or threatened).
Retained products of conception(incomplete)
If pregnancy test positive and empty cavity
then possible diagnosis of ectopic pregnancy
or complete miscarriage.
What investigations would be most helpful and why?
Any tissue expelled from the uterus should be
sent for histology to exclude molar pregnancy.
Sometimes the tissue is an endometrial cast
without any trophoblast, indicating an ectopic
pregnancy.
What treatment options are appropriate?
According to the condition ,most probable diagnosis is
Threatened abortion treatment is:
Reassurance
No need for admission,if bleeding cease no need for
progestrone,bed rest or avoidance of sexual intercoarse
Follow up
What treatment options are appropriate?
In missed:
• Expectant (wait and see)
• Medical:include
Prostaglandins orally(misoprotol) or
vaginally(gameprost)synthetic PGE1
Mifepristone(progestrone antagonist)
• Surgical(evacuation of retained products of conception)
Surgical(evacuation of retained products of
conception)
Conclusions
Vaginal bleeding in preganacy is associated with
miscarrige in up to 50% of cases but the risk is lower if
the bleeding is light.
After a fetal heart beat has been visualized the chance
of miscarrige is 5%.
Early in the course of a normal intrauterine pregnancy
the BhCG should rise by at least 66%over 48hours.
Questions
A 22-year-old woman, para 0, was admitted with vaginal
bleeding after 8 weeks of amenorrhoea. She had a
positive home pregnancy test, and described passing
some tissue per vaginum. Ultrasound scan showed an
empty uterus, although urinary B-hCG was still positive?
19 years old woman presents at 13 wks gestation with
vaginal bleeding and a smelly watery discharge ,feels
generaly unwell and has had fevers for the
last48hrs,reduced appetite,abdominal pain,vomiting and
loose stool.
