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Bleeding in early pregnancy
- 1. 7We Care BLEEDING IN EARLY PREGNANCY DRISYA.V.R. 2ndYear PG Nursing
- 2. 7We Care DEFINITION Any vaginalbleeding before 20 wks period of gestation is defined as early pregnancy bleeding
- 3. 7We Care Causes ofbleeding in early pregnancy Abortion Ectopic pregnancy Hydatidiform mole
- 4. 7We Care Related topregnant state • Abortion • Ectopic pregnancy • Molar pregnancy • Implantation bleeding
- 5. 7We Care Associated withthe pregnant state • Cervical lesions like • Ruptured varicose veins
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- 9. 7We Care Pathology • Haemorrhageinto the decidua basalis. • Necrotic changes in the tissue adjacent to the bleeding. • Detachment of the conceptus. • The above will stimulate uterine contractions resulting in expulsion.
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- 11. 7We Care ABORTION Termination ofpregnancy before the fetus is capable of extra-uterine survival i.e. 20 wks or 500gm birth wt
- 12. 7We Care Types ofabortion Spontaneous 1. Isolated • Threatened abortion. • Inevitable abortion • Complete abortion. • Incomplete abortion. • Missed abortion • Septic abortion 2. Recurrent
- 13. 7We Care Induced • Legalabortion • Illegal abortion
- 14. 7We Care ETIOLOGY • Geneticfactors • Endocrine and metabolic abnormalities • Infections
- 15. 7We Care • Anatomicabnormalities
- 16. 7We Care • Immunologicdisorders a. Autoimmune disorders b. Alloimmune disorders c. Antifetal antibodies d. Maternal medical illness • Blood group and incompatibility • PROM • Environmental factors • Unexplained
- 17. 7We Care MECHANISM OFMISCARRIAGE • Before 8 weeks- the ovum surrounded by the villi with the decidual coverings, is expelled out intact. Sometimes the external os fails to dilate so that the entire mass is accommodated in the dilated cervical canal and is called cervical miscarriage.
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- 19. 7We Care • 8-14weeks-expulsion of the fetus commonly occurs leaving behind the placenta and its membranes • Beyond 14th week - The process of expulsion is similar to that of a mini labour. The fetus is expelled first followed by the expulsion of the placenta after a varying interval.
- 20. 7We Care THREATENED MISCARRIAGE Itis a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible.
- 21. 7We Care • Clinicalfeatures - Short period of amenorrhea. - Corresponding to the duration. - Mild bleeding (spotting). - Mild pain. - PV : closed cervical os. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus. - Serum progesterone Management - Reassurance. - Rest. - Drug – Diazepam 5 mg BD - Repeated U/S
- 22. 7We Care INEVITABLE ABORTION Clinical features: - Short period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - P.V.: opened cervical os. - Pregnancy test (hCG): + ve. - US: non-viable fetus and blood inside the uterus. • Management: - fluids…..blood. - methergin 0.2mg - evacuation of the uterus (medical/surgical).
- 23. 7We CareCOMPLETE ABORTION -expulsion of all products of conception. - Cessation of bleeding and abdominal pain. - P.V.: closed cervix. - US: empty uterus. Management - U/S - Anti – D gamma globulin
- 24. 7We Care INCOMPLETE ABORTIONCOMPLETE ABORTION
- 25. 7We Care MISSED ABORTION Features: - gradual disappearance of pregnancy Symptoms Signs. - Brownish vaginal discharge. - Milk secretion. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - US: absent fetal heart pulsations. Complications - Infection (Septic abortion) - DIC • Treatment - Wait 4 weeks for spontaneous expulsion - evacuate if: Spontaneous expulsion does not occur after 4 weeks. Infection. DIC. - Manage according to size of uterus - Uterus < 12 weeks : dilatation and evacuation. - Uterus > 12 weeks : try Oxytocin or PGs.
- 26. 7We Care SEPTIC ABORTION Anabortion complicated by infection Symptoms – Abdominal pain – Fever – Vaginal discharge (foul smelling) Signs – Sick looking, febrile or jaundiced – Tender uterus – Offensive vaginal discharge or bleeding – Cervix is usually soft and may be dilated
- 27. 7We CareClinical grading Grade1-the infection is localized in the uterus Grade2- the infection spreads beyond the uterus to the parametrium Grade 3-generalized peritonitis or endotoxic shock or jaundice or acute renal failure
- 28. 7We Care Complications ofseptic abortions Immediate • Haemorrhage • Peritonitis • Pelvic abscess, endometritis, • Septicemia, • Septic/haemorrhagic shock Late • PID • Pelvic adhesions • 2° Infertility
- 29. 7We Care Management 1. Resuscitation –IV fluids: RL, NS 2. Insert urethral catheter – Monitor Input/output 3. Blood grouping & Cross matching 4. Antibiotics: • Preferably cephalosporins, if not available ampicilin and metronidazole 5. Prophylactic antigasgangrene serum of 8000 units and 3000 units of antitetanus serum 6. Evacuation 7. Haematenics
- 30. 7We Care RECURRENT MISCARRIAGE •Defined as 3 or more consecutive pregnancy losses Other names: • habitual abortions • habitual miscarriage • recurrent abortions • recurrent miscarriages.
- 31. 7We Care Aetiology: Canbe established in only 30% • Genetic Factors • Endocrine Factors • Anatomic Causes – Congenital anomalies, in competencies, • Infectious causes • Immunologic problems
- 32. 7We Care ECTOPIC PREGNANCY Isone in which the fertilized ovum is implanted and develops outside the normal endometrial cavity.
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- 36. 7We Care • TubalFactors (salpingitis, previous tubal surgery) • Zygote Abnormalities (chromosomal abnormalities) • Ovarian Factors (ovum into contralateral tube) • Exogenous Hormone (oral contraceptives) • Other Factors (endometriosis, IUD) ETIOLOGY
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- 39. 7We Care CLINICAL FEATURES (1)Acute ectopic (2) Unruptured (3) Subacute (chronic or old)
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- 42. 7We Care Signs • Thepatient looks quiet and conscious, perspires and looks blanched • Pallor • Features of shock • Abdomen feels tense, tumid, and tender. No mass is usually felt, shifting dullness present • Pelvic examination reveals blanched white vaginal mucosa, uterus seen normal in size or slightly bulky • Extreme tenderness on fornix palpation or on movement of the cervix • No mass is usually felt through the fornix • The uterus floats as if in water
- 43. 7We Care Unruptured tubalectopic pregnancy symptoms • presence of delayed period or spotting with features suggestive of pregnancy • uneasiness on one side of the flank which is continuous or at times colicky in nature
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- 45. 7We Care Signs • uterusis usually soft • a pulsatile small ,well circumscribed tender mass may be felt through one fornix separated from the uterus
- 46. 7We Care Chronic orold ectopic Symptoms • Amenorrhea • lower abdominal pain • vaginal bleeding Signs • the patient looks ill • Pallor • pulse persistently high even during rest • features of shock • temperature may be slightly elevated
- 47. 7We CareOn abdominalexamination • tenderness and muscle guard on the lower abdomen specially on the affected side is striking feature • mass in the lower abdomen may be felt which is irregular and tender • Cullen’s sign- dark bluish discolouration , if found suggests intraperitoneal hemorrhage.
- 48. 7We Care Diagnosis ofectopic pregnancy • Pregnancy tests (postive-82.5%) • Hematocrit • White blood cell count • A negative test does not rule out an ectopic gestation
- 49. 7We CareSubacute (chronic)ectopic • Blood examination • Culdocentesis • Estimation of Beta HCG • Sonography • Colour Doppler Sonography • Combination of quantitative beta HCG values and Sonography Laparoscopy • Dilation and curettage • Serum progesterone • Laparotomy
- 50. 7We CareMANAGEMENT • EmergencyTreatment Immediate surgery, anti-shock(warm, oxygen) • Surgical treatment laparoscopic techniques • Medical treatment • Supportive treatment antibiotic, iron therapy, a high-protein diet
- 51. 7We Care UNRUPTURED TUBALPREGNANCY Expectant management Only observation is done hoping spontaneous resolution. Indications are: • initial serum HCG level less than 1000IU/L and the subsequent levels are falling • Gestational sac size <4 cm • No fetal heart beat on TVS • No evidence bleeding or rupture
- 52. 7We Care Conservative management eithermedical or surgical Medical management The drugs commonly used for salphingocentesis are methotrexate, potassium chloride, prostaglandin (PGF2α) or Actinomycin. Conservative surgery • Linear salphingostomy • Linear salphingotomy • Segmental resection • Fimbrial expression • salphingectomy
- 53. 7We Care CERVICAL PREGNANCY Clinicaldiagnostic criteria (Rubin – 1983) for cervical pregnancy are : • Soft enlarged cervix equal to or larger than the fundus • Uterine bleeding following amenorrhoea, without cramping pain • Products of conception entirely confined within and firmly attached to endocervix • A closed internal cervical os and a partially opened external os • Sonography • Confirmation is done by histological evidence of the presence of villi inside the cervical stroma.
- 54. 7We Care Gestational TrophoblasticDisease GTD Definition It is a term commonly applied to a spectrum of inter-related diseases originating from the placental trophoblast
- 55. 7We CareClassification The conventionalhistological classification includes: 1. Hydatidiform mole (complete or partial) 2. Invasive mole 3. Choriocarcinoma 4. Placental site trophoblastic tumour
- 56. 7We Care Modified WHOclassification on GTD is Hydatidiform mole;- complete, partial Invasive mole Placental site trophoblastic tumour Choriocarcinoma - nonmetastatic disease - metastatic disease
- 57. 7We Care 1. Lowrisk (good prognosis) • Disease is present <4 months duration • Initial serum hCG level <40,000 mIU/ml • Metastasis limited to lung and vagina • No prior chemotherapy • No preceding term delivery 2. High risk (poor prognosis) • Long duration of disease >4 months • Initial serum hCG >40,000 mIU/ml • Brain or liver metastasis • Failure of prior chemotherapy • Following term pregnancy
- 58. 7We Care Complications Death • AboutI in 1000 ectopic pregnancies result in maternal death • Untreated or mistreated ruptured ectopic tubal pregnancy 8-12% of all materal deaths • The majority of these deaths are preventable
- 59. 7We Care Tubal damage •Chronicsalpingitis •Infertility or sterility •Intestinal obstruction may develop after hemoperitoneum and peritonitis
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- 62. 7We Care • Itis an abnormal condition of the placenta where there are partly degenerative and partly proliferative changes in the young chorionic villi.
- 63. 7We Care Types • Complete •Incomplete
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- 68. 7We Care Clinical features •Vaginal bleeding • Varying degrees of lower abdominal pain • Constitutional symptoms • Expulsion of grape like vesicles per vaginum is diagnostic of vesicular mole • History of quickening is absent.
- 69. 7We Care Signs • Featuressuggestive of early months of pregnancy are evident • The patient looks ill • Pallor is present • Features of pre-eclampsia - hypertension, oedema, or proteinuria • Per abdomen-The size of the uterus is more than the expected period of amenorrhoea. The feel of the uterus is firm elastic, Fetal parts are not felt, Absence of fetal heart sound • Vaginal examination-Internal ballottement cannot be elicited. Unilateral or bilateral enlargement (theca lutein cyst) of the ovary. Findings of the vesicle in the vaginal discharge.
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- 72. 7We Care HYDATIFORM MOLE (Snowstorm appearance)
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