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FIRST TRIMESTER FIRST TRIMESTER BLEEDING BLEEDING ESSAM JACOB, MD ESSAM JACOB, MD PGY3 PGY3

FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

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Page 1: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

FIRST TRIMESTER FIRST TRIMESTER BLEEDINGBLEEDING

ESSAM JACOB, MD ESSAM JACOB, MD PGY3 PGY3

Page 2: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

INTRODUCTIONINTRODUCTION

• First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients who are known to be pregnant.

Page 3: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

OBJECTIVESOBJECTIVES

• Every clinician who takes care of pregnant women needs to have a firm understanding of this event for earlier diagnosis and appropriate intervention.

• To understand possible causes and pathogenesis of early trimester bleeding

• Various diagnostic techniques useful for early diagnosis

• Management

Page 4: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

ETIOLOGYETIOLOGY

PREGNANCY RELATED CAUSES:

• Spontaneous abortion or miscarriage,50%

• Ectopic pregnancy

• Physiologic bleeding

• Gestational trophoblastic disease

Page 5: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

NONPREGNANCY-RELATED CAUSES:

• Trauma • Cervical cancer complicating pregnancy• Vaginal lesions• Infections• Increased friability of the cervix• Other causes

Page 6: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

PHYSIOLOGIC BLEEDING OF PHYSIOLOGIC BLEEDING OF EARLY PREGNANCYEARLY PREGNANCY

CAUSES:

• A common belief is that bleeding may occur at the time of expected menses, but sufficient explanations are lacking.

• Physiologic bleeding may accompany implantation of the conceptus into the decidualized endometrium

• Relative hormonal deficiency

Page 7: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Management and prognosisManagement and prognosis

• In many patients the bleeding is self-limited• The prognosis for pregnancies with physiologic

bleeding is somewhat less optimistic than for pregnancies without bleeding. Low birth weight, shortened gestation, and neonatal death are all more common in patients who bled.

• However, most pregnancies in which some spotting occurs in the first trimester continue on to a normal outcome. So, the clinician should be cautiously optimistic but vigilant for the complications

Page 8: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

ECTOPIC PREGNANCYECTOPIC PREGNANCY

DEFINITION:

• Ectopic pregnancy is any pregnancy in which the fertilized ovum implants in any tissue other than the endometrial lining of the uterus

Page 9: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Where do the majority of ectopic Where do the majority of ectopic pregnancies occur?pregnancies occur?

• 97.7% ------- in the fallopian tube (tubal pregnancy)

• 1.4% --------- abdominal

• < 1% --------- ovarian or cervical

Page 10: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

EPIDEMIOLOGYEPIDEMIOLOGY

• The incidence of ectopic pregnancy ranges from 1 of 64 to 1 of 241 pregnancies, with an average of approximately 20 per 1000 pregnancies.

• The incidence of ectopic pregnancies has increased dramatically in the past 20 years partly due to increase in certain risk factors but mostly due to improved diagnostics. Also the increase is due to a combination of increasing salpingitis and better antibiotics, which allow tubal patency following infection. The resultant tube is patent, but has luminal damage

Page 11: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• Ruptured ectopic pregnancy continues to be the most common cause of maternal death in the first half of pregnancy.

• Although the overall survival has increased, the risk of death associated with ectopic pregnancy remains higher among black and other non-white minority women.

Page 12: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES AND RISK FACTORS CAUSES AND RISK FACTORS FOR ECTOPIC PREGNANCYFOR ECTOPIC PREGNANCY

• The major cause of ectopic pregnancy is SALPINGITIS. Any mechanism that causes abnormal tubal motility, so that the blastocyst remains in the tube at the time of implantation, will cause an ectopic gestation.

Page 13: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Strong evidence for association as risk factor

• Pelvic inflammatory disease• Previous ectopic pregnancy• Endometriosis• Previous tubal surgery• Prior infertility and infertility treatments• Uterotubal anomalies• History of in utero exposure to diethylstilbestrol• Cigarette smoking

Page 14: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Weaker evidence for association

• Multiple sexual partners

• Early age at first intercourse

• Vaginal douching

Page 15: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Organisms that preferentially attack the fallopian tubes include

• Neisseria gonorrhea

• Chlamydia trachomatis

• Mixed aerobes and anaerobes

Page 16: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• What is the incidence of an intrauterine pregnancy with an ectopic pregnancy (hetero-topic pregnancy)?

• Newer ovulation induction methods and in vitro techniques have increased the risk to as high as 3%. These are difficult to diagnose, and 50% are identified after rupture

Page 17: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• What is the likelihood that a woman with ectopic pregnancy will have a subsequent ectopic pregnancy?

• Recurrence risk varies from 7% to 15%.

Page 18: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CLINICAL FINDINGS/APPROACHCLINICAL FINDINGS/APPROACH

• The approach to ectopic pregnancy begins with developing a clinical suspicion for the entity.

• Recent technology has made it possible to diagnose ectopic pregnancy earlier.

• The classic triad for the patient who presents with ectopic pregnancy is amenorrhea, abdominal pain, and vaginal bleeding (usually spotting which occurs 6-8 weeks after the last normal menstrual period). Unfortunately, these findings are nonspecific and actually occur more commonly in the patient who has a threatened miscarriage than ectopic pregnancy.

Page 19: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CLINICAL FINDINGS/APPROACHCLINICAL FINDINGS/APPROACH CONT’DCONT’D

• Less commonly ectopic pregnancy presents with pain radiating to the shoulder, profuse vaginal bleeding, syncope and/or hypovolemic shock.

• Absence of risk factors is not reassuring because at least 40% to 50% of patients with proven ectopic pregnancies have no known risk factors.

Page 20: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Physical Findings include• Normal or slightly enlarged uterus, pelvic pain

with movement of the cervix. A palpable pelvic mass is present in only 50% of patients.

• Abdominal tenderness(seen in over 90% of patients) with guarding and rebound suggest a leaking or ruptured ectopic pregnancy.

• One must remember that the pelvic examination is completely normal in approximately 10% of patients with ectopic pregnancy.

• Orthostasis is not commonly seen.

Page 21: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Why do some patients have shoulder pain?

Shoulder pain is referred from diaphragmatic irritation due to hemoperitonium and occurs in about in up to 25% of patients.

Page 22: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Threatened or incomplete abortion

• Gestational trophoblastic disease• Dysfunctional uterine bleeding• Ruptured corpus luteal cyst• Adnexal torsion• Salpingitis• Appendicitis• Endometriosis

Page 23: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

LABORATORY FINDINGS AND LABORATORY FINDINGS AND DIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION

• Proper history and physical examination is the foundation for initiating an appropriate work-up that will result in accurate and timely diagnosis

Page 24: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Standard urine pregnancy test• 99% sensitive and 99% specific for

pregnancy • It is a qualitative test rather than a

quantitative measure that identifies the presence of hCG in concentrations as low as 25 ml IU/ ml

• False negative results can occur especially if the urine is not very concentrated.

Page 25: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Serum B-HCG • HCG is a glycoprotein produced by

trophoblastic tissue, can be measured in the serum within 8-12 days after fertilization

• The normal dynamics for serum B-hCG are that during the first 6-7 weeks it doubles every 48 hours in 90% of intrauterine pregnancies, until it peaks

Page 26: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Serum B-HCGSerum B-HCG CON’TDCON’TD

• above 100,000 m IU/ml. This doubling rate slows somewhat after reaching 10,000 m IU/ml, however, at that time ultrasonography should be diagnostic

• 17% of ectopic pregnancies meet criteria for normal doubling times.

• Doubling times are not valid after 7 weeks of gestation

Page 27: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• The discriminatory zone: is the level of serum beta-subunit human chorionic gonadotropin above which a gestational sac can be consistently visualized.

• With transabdominal sonography, this value is ----- 6,500 m IU/ml

• With transvaginal sonography, this value is --------- > 1,500 m IU/ml

• Following titers in the stable patient is helpful in early gestations to r/o ectopic pregnancies.

Page 28: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Serum progesterone• It is another hormonal marker that has

been used in an attempt to determine whether the patient has a viable IUP

• In contrast with B- hCG, serum progesterone is not gestational age-specific and remains relatively constant during the first trimester whether the pregnancy is normal or abnormal.

Page 29: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Serum progesteroneSerum progesterone Cont’dCont’d

• Although a serum progesterone level of less than 11 ng/ml is indicative of an abnormal pregnancy, the measure does not distinguish between a normal ectopic pregnancy and a failing intrauterine pregnancy. Therefore, serum B-hCG levels are more often used especially in conjunction with ultrasonography.

• A progesterone level may be helpful if it is either very low or very high. A progesterone level above 25 ng/ml is associated with a viable IUP, but a level less than 5 ng/ml is highly suggestive of nonviable pregnancy

Page 30: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

ULTRASONOGRAPHYULTRASONOGRAPHY • Compared with abdominal ultrasonography,

transvaginal ultrasonography diagnose IUP an average of one week earlier because it is more sensitive and has a lower discriminatory zone.

• Abdominal ultrasound should consistently detect the gestational sac when the B-hCG is greater than 6,500 mIU/ml. Therefore, absence of an intrauterine gestational sac on abdominal ultrasound in conjunction with a B-hCG level of greater than 6,500 mIU/ml suggests ectopic pregnancy.

Page 31: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• Culdocentesis • Used primarily when ultrasonography is not

readily available. It is performed only rarely , because ultrasonography can reveal any free fluid

• A culdocentesis that is positive for nonclotting bloody fluid strongly suggests the presence of a bleeding ectopic pregnancy

• A culdocentesis that is positive for yellow or straw-colored fluid is more consistent with ruptured ovarian cyst than an ectopic pregnancy.

Page 32: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

Why is the blood obtained by culdocentesis nonclotting?

The nonclotting blood results from lysis of blood that has been clotted previously.

Page 33: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

LAPAROSCOPYLAPAROSCOPY

• If the patient has a subnormal rise in HCG titers or an abnormal ultrasound ------- frozen section D&C may be performed ------------ if the result is negative, the laparoscope will allow visualization of the tube. However, false-negative rates approach 4% and may be higher if surgery is performed early in the pregnancy.

Page 34: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

MANAGEMENTMANAGEMENT

• Once the diagnosis of ectopic pregnancy has been definitively established, the next decision is between surgical and expectant/medical management

Page 35: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

EXPECTANT OR MEDICAL EXPECTANT OR MEDICAL MANAGEMENTMANAGEMENT

• Attempted if the patient remains stable and is reliable.

• Expectant management is an option for the patient with a small ectopic pregnancy (less than 3.5 cm in greatest dimension) and low declining B-hCG who is willing and able to adhere with follow up.

Page 36: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

• Advantages are avoidance of surgery and its hazards. Preservation of tubal patency and function and lower coast.

• Chemical agents that has been investigated include: hyperosmolar glucose, urea, cytotoxic agents (methotrexate [Rheumatrex] and actinomycin-D), prostglandins and mifeproston (RU486

Page 37: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

How does MTX work?

• It acts as a folic acid antagonist and interferes with DNA synthesis and cellular multiplication. It has been used in treating gestational trophoblastic disease for years with excellent results

Page 38: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

What risks are associated with MTX treatment?

• Stomatitis, dermatitis, pleuritis and altered LFTs. Also, 60% of patients experience increased pelvic pain during the first few days after treatment

Page 39: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

What is the role of mifeprostone (RU486)?

• It is an antiprogestin used for pregnancy termination. Therapy has not been successful in treating ectopic pregnancy as a single agent. However, the combination of MTX and 600mg. of mifeprostone increased the success rate to 97%.

Page 40: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

SURGERYSURGERY • Previously, salpingectomy by laparotomy was

the gold standard for the treatment of ectopic pregnancy. Currently, the preferred technique is linear salpingostomy through laparoscopic surgery.

• Salpingectomy is preferred only in patients with uncontrolled bleeding , extensive tubal damage or recurrent ectopic pregnancy in the same tube. It is also used when the patient wants a sterilization procedure to be performed

• Regardless the treatment approach (expectant, medical or surgical), the B-HCG level should be followed until it becomes undetectable or decreases to < 5 mIU/ml.

Page 41: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

What about subsequent fertility after ectopic pregnancy?

• IUP rate is about 80%

• If the patient is nulliparous, the rate is 40%

• Patients with ruptured ectopic pregnancies has less rate compared with unruptured ectopic pregnancies

(65% vs. 82% respectively)

Page 42: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

WHAT IS ABORTION?WHAT IS ABORTION?

• A termination of pregnancy before 20 weeks as calculated from the date of onset of last menses, or

• Delivery of fetus weighing < 500gms.

• Abortion maybe spontaneous or induced.

Page 43: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

TYPES OF ABORTION:TYPES OF ABORTION:

• Threatened Ab = bloody discharge from the uterus without cervical dilatation, it may subside and pregnancy may continue to term.

• Inevitable Ab = uterine bleeding with effaced or dilated cervix, abortion usually proceeds.

• Missed Ab = fetal death before 20 weeks of gestation without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter, cervix is usually closed.

Page 44: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CONT’D.CONT’D.

• Septic Ab = incomplete Ab + infection, it can lead to sepsis.

• Induced Ab = as the word implies.• Blighted ovum = Identifiable sac +

placental tissue but no embryo.• Complete Ab = spontaneous expulsion

of all fetal and placental tissues from the uterus prior to 20 weeks’ gestation. Cervix is closed.

Page 45: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES:CAUSES:

1. Genetic:• Trisomy and translocations, both, …account

for 50%-70% of spontaneous abortions.

• Chromosomally abnormal abortus markedly increases after maternal age of 35 years

Page 46: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES CONT’D.CAUSES CONT’D.

2. Environmental:

. Uterine: Congenital uterine anomalies

Leiomyomas

Intrauterine adhesions or

synechiae

. Cervical:

Incompetent cervix

Page 47: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES CONT’D.CAUSES CONT’D.

. Endocrine: Progesterone deficiency (inadequate luteal phase) Uncontrolled thyroid disease Uncontrolled diabetes mellitus

. Immunologic: Antiphospholipid syndrome Systemic Lupus ErythematosIs (SLE)

Page 48: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES CONT’D.CAUSES CONT’D.

• Infections: Toxoplasma gondii

Listeria monocytogenes

Chlamydia trachomatis

Neisseria gonorrhoea

Trponema pallidum

Herpes simplex

Page 49: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES CONT’D.CAUSES CONT’D.

• Toxins: Alcohol

Caffeine

Smoking

Medications (methotrexate,

misoprostol, tretinoin)

Page 50: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

HABITUAL ABORTION = HABITUAL ABORTION = RECURRENT PREGNANCY RECURRENT PREGNANCY

LOSS:LOSS:

Three or more

consecutive spontaneous

abortions

Page 51: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CAUSES:CAUSES:

• Anatomic abnormalities of the uterus

• Endocrine disorders, e.g. uncontrolled DM,

thyroid dysfunction.

• Autoimmune disorders, e.g.antiphospholipid

syndrome, SLE • Alcohol, tobacco

Page 52: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

MANAGEMENT:MANAGEMENT:

1. Follow serial HCGs to determine fetal viability (should double Q2-3days. in weeks 4-8)

2. Ultrasonography

Page 53: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

MANAGEMENT CONT’D.:MANAGEMENT CONT’D.:

4. According to type: .Complete Ab: No further intervention necessary Ultrasonography to confirm an empty uterus.Incomplete Ab: IV hydration, type and screen/cross Suction and curettage

Page 54: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

MANAGEMENT CONT’D.:MANAGEMENT CONT’D.:

.Threatened Ab: Ultrasound to document

fetal viability

Modified activity and pelvic

rest

.Inevitable Ab: Expectant management or

evacuation of pregnancy by

surgical or medical

termination

Page 55: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

MANAGEMENT CONT’D.:MANAGEMENT CONT’D.:

.Missed Ab: Suction curettage or medical

termination

.Septic Ab: IV antibiotics followed by

suction curettage

Page 56: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

APPROACH TO A PATIENT APPROACH TO A PATIENT WITH FIRST TRIMESTER WITH FIRST TRIMESTER

BLEEDINGBLEEDING . History: LMP? How much bleeding and for

how long? Cramping? Passage of fetal tissue? Fever, chills, abdominal tenderness

. Exam: .Vitals (include orthostatics and Signs of shock) . Speculum exam: tissue at the os?/ Purulent discharge . Bimanual exam : cervical dilatation.

Page 57: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CONT’D.CONT’D..If patient in shock ( BP <90/60, P > 110)

A. Start IVF

B. Send blood for type & cross-match

2Units, CBC, PT/PTT, fibrinogen, quantitative HCG

C. Do U/S: if IUP and + FHR; then <1% chance of miscarriage

D. Do culdocentesis --- if blood is present,

probable ruptured ectopic

Page 58: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CONT’D.CONT’D.

1.Take immediately to the O.R. for

laparotomy

2. Transfuse with PRBC’s as rapidly

as possible

Page 59: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CONT’D.CONT’D.

. If not in shock: A. On P.E.: 1.CMT suggests various diagnoses 2.May see local source for bleeding 3.Uterine/adnexal tenderness suggests infection

Page 60: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

CONT’D.CONT’D.

B. Do vaginal u/s. Look for gestational sac (visible in IUP @ 6 weeks), fetal heart (after 6 weeks), adnexal masses, fluid in cul-de-sac C. Laparoscopy sometimes indicated. If stable and IUP, manage as spontaneous abortion/threatened abortion

Page 61: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

WHEN TO GIVE RhoGAM?WHEN TO GIVE RhoGAM?

• Patients who are Rh negative with miscarriage or ectopic pregnancy must be given RhoGAM within 72 hours.

• What about spotting in IUP that continues?

Page 62: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

PSYCHOLOGICAL ASPECTS OF PSYCHOLOGICAL ASPECTS OF PREGNANCY LOSSPREGNANCY LOSS

• Grief reaction

• Patient’s belief system

• Comfort, sympathy, support

• Reassure future reproductive options

Page 63: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

RESOURCESRESOURCES

• UpToDate clinical reference library.

• ICSI-Institute for Clinical Systems Improvement www.icsi.org

• Clinical evidence website www.clinicalevidence.com

Page 64: FIRST TRIMESTER BLEEDING ESSAM JACOB, MD PGY3. INTRODUCTION First trimester vaginal bleeding is a common event, occurring in approximately 25% of patients

RESOURCESRESOURCES

• UpToDate clinical reference library

• Clinical evidence website www.clinicalevidence.com

• ICSI-Institute for ClinicalSystems Improvement www.icsi.org

• AAFP

• NEJM