First Trimester Bleeding
A Case Series
Case 1● 27 yr old G5A4 at 6w 5d POG
● Post IUI pregnancy
● c/o spotting P/V for 1 day
● No c/o pain abdomen
● O/E – Afebrile, PR 84/min, BP 130/80 mm Hg, No pallor
● P/A – soft, non-tender, no organomegaly
● P/S/V – Altered blood at os +, uterus 6-8 wk size, mild Rt fornyceal tenderness
● TVS – SLIUF, FCA+, Rt cornual pregnancy
● CORNUAL (INTERSTITIAL) PREGNANCY
● Medical management with Inj Methotrexate, both locally (intra sac instillation) and systemic
Case 2
● 30 yr old G2A1 at 7w 5d POG, Post IVF-ET pregnancy
● c/o pain abdomen, bleeding P/V since 3 hrs
● P/A – soft, non-tender, uterus not palpable
● P/S/V – altered blood at os +, uterus 8w size, No adnexal mass, no fornyceal tenderness
● TVS – SLIUF, FCA+, CRL 7w4d, 2.1 x 1.6 cm clot present anterior to internal os ?subchorionic haemorrhage
● THREATENED ABORTION
● Admitted and managed with rest, progesterone support. Discharged after 1 week, with resolution in size of clot
Case 3
● 24 yr old G2P1L1 at 8 wk POG
● c/o worsening nausea/vomiting since 2 weeks
● Bleeding P/V, irregularly since last 7 days
● P/A – uterus just palpable, non tender
● P/S/V – altered blood at os, uterus 12wk size, no adnexal mass, no fornyceal tenderness
● TVS – Heterogenous intrauterine mass with multiple follicles seen in “snow storm” appearance
● HYDATIDIFORM MOLE
● Admitted, D&E done. Discharged subsequently and on regular follow up with β-HCG monitoring and advise on contraception
EARLY PREGNANCY BLEEDING
Introduction● Pregnancy complications
– More during first trimester (upto 12 weeks gestation)– 20-40% of women
● Most commonly– Bleeding per vaginum– Pain abdomen
● Accurate diagnosis is needed– Reassurance to patient if pregnancy is well– Appropriate intervention if not– Worse prognosis if heavy bleeding or extends into second
trimester
Differential Diagnosis● Pregnancy related
– Implantation Bleeding– Abortion– Ectopic Pregnancy– Hydatidiform mole– Single fetal demise
● Gynae conditions asso with pregnancy
– Ruptured corpus luteum– Ovarian cyst accident– Torsion or degeneration of
pedunculated fibroid
● Non-gynaecological
– Appendicitis– Renal Colic– Cholecystitis
● Gynaecologic conditions
– Pelvic Inflammatory Disease
– DUB– Endometriosis
Evaluation
● History– Last menstrual periods, regularity of cycles– Amount and character of bleeding (fresh, altered)– Severity of early pregnancy symptoms, esp
nausea/vomiting– Character and severity of pain– Past history (ectopic, abortion, GTD, medical disorders,
risk factors)
Evaluation
● Physical Examination– Vitals– Abdominal exam (distention, guarding, rebound
tenderness)– Speculum exam
● Local causes – warts, vaginitis, cervicitis, ectropion, cervical polyps
● Character of blood – fresh, altered, clots● Open cervical os – tissue available for examination
– Bimanual exam:● Uterine enlargement, cervical/adnexal tenderness, adnexal
masses
Evaluation
● Ultrasound– Forms the cornerstone of evaluation
● Transvaginal preferred over transabdominal
– Gives immediate information regarding● Location of pregnancy● Fetal viability and dating● Rare findings (GTD, single fetal demise)
– Correlation of USG findings with β-HCG values
● Gestational Sac– Anechoic area within the uterus surrounded by two
echogenic rings● Decidua vera (outer ring)● Decidua capsularis (inner ring)
– Known as double decidual sac sign– Sac alone is not a definitive diagnosis of intrauterine
pregnancy– Corresponding β HCG values >1500 IU (Threshold
value)
Pseudosac vs Gestational Sac
● Yolk sac– Earliest definitive sign of pregnancy– Seen on TVS at
● 4-5 wks POG● Β-HCG >2000● Thin echogenic ring within the gestational sac
– Readily seen when Gest sac >10 mm
Yolk Sac
● Embryo (Fetal Pole)– Thickened area adjacent to yolk sac– Seen on TVS when ~2 mm size – CRL (Crown Rump Length) measured at this stage
accurately determines gestational age– Should be seen when Gest Sac >18mm size
● Fetal Cardiac Activity (FCA)– Earliest seen on TVS at 6 wks or fetal pole >5mm– Important prognostic indicator– Rate of spontaneous abortion reduces to 2-4% once
FCA visualised
Embryonic Fetal Demise
● Gest Sac > 10mm without yolk sac● Gest Sac > 18 mm without fetal pole
● Embryo without cardiac activity – Beyond 7 wks GA– Fetal pole >5mm
Evaluation
● Laboratory:– β-HCG concentration complement information available
from TVS– Absolute values of help only in confirmation of
pregnancy● Value > 1500 and if no intra-uterine gest sac seen, highly
suggestive of ectopic pregnancy● Exercise caution if IVF pregnancy – heterotropic pregnancy
– Serial titres of clinical significance● Rise of minimum 66% in 48 hrs suggestive of a viable
pregnancy
Implantation Bleeding
● Disruption of lacunar spaces in syncytiotrophoblast due to incresed blood flow– Extravasation of blood into endometrial cavity
● Occurs 8-10 days post-fertilization● Corresponds to date of expected menses● Diagnosis of exclusion● Physiological bleeding
Abortion
● Derived from Latin aboriri – to miscarry● Literally means – premature birth before a live birth
is possible (Oxford Dictionary)● WHO defines – pregnancy termination prior to 20
weeks or fetus born with weight less than 500 gms● Bleeding
– in 1/5th of pregnancies before 20 weeks– 50% end in spontaneous abortions
● Pregnancy Loss Iceberg
Causes● Major genetic abnormality
● Internal environment
– Uterine: anomalies, leiomyomata, incompetent cervix
– Luteal phase defect
– Immunologic factors
– Endocrine abmormalities: Hypothyroidism, Diabetes ● External environment
– Substance abuse (tobacco, alcohol, cocaine, caffeine)
– Radiation
– Infection
– Occupational chemical exposure● Advanced maternal age
Types
● Missed abortion
– In utero demise of the fetus before 20 wks with retention of pregnancy for prolonged period of time
– Managed:● Surgically – D&E● Medical – Misoprostol● Expectant
● Threatened abortion
– Closed uneffaced cervix, uterine size appropriate for gestation
– FCA + if gestation sufficiently advanced
– Management● Expectant, Progesterone support
Types
● Inevitable abortion– External os closed, cervical canan ballooned– Increased bleeding with cramps, passage of clots– Management
● Surgical● Medical● Expectant
Types
● Complete/Incomplete abortion– Complete:
● small contracted uterus, cervix closed, scant bleeding/pain● No intervention required, observation
– Incomplete:● Some products retained in utero● Uterus smaller than gestation, not well contracted● Cervix open, POC present at os● Variable bleeding/cramps● Management:
– Surgical– Medical
Types of abortion
Missed Abortion/Blighted Ovum
Complete abortion
Types
● Septic Abortion– Fallout of illegal abortions: relook at MTP Act?– Rare with spontaneous abortions– Signs/Symptoms:
● Fever with chills/rigors, tachycardia● Pain abdomen, bleeding P/V, foul-smelling discharge● Cervix dilated, uterus boggy and tender
– Management:● Stabilize pt, obtain blood and endometrial cultures● Broad spectrum antibiotics● D&E
Prognostic Factors
● Abnormal Yolk sac (Irregular, large for gestation)● Fetal bradycardia (HR <85 bpm at 6-8 wk have 0%
chance of survival)● Small Sac (<5 mm)● Subchorionic hematoma (if > 25% of gestational
sac volume, abortion rates double)
Psychological Aspects of Abortions
Long walks, Papaya & Missed Sleep
● Universal seeking of explanation● Self blame● Belief/concern that doctors can do something to
prevent miscarriage
● Dispel guilt● Comfort, support from physician and family● Counsel, reassure about future● Include partner in psychological care● Assess level of grief and adjust counselling
accordingly– Half of pregnancies are unintended!!
Ectopic Pregnancy
● Pregnancy outside the endometrial cavity– Most common in the fallopian tube
● 15% of first trimester bleeding● Occurs in 1:100 pregnancies● Leading cause of maternal mortality in first trimester● Early diagnosis is critical!!!● Classic triad of symptoms:
– Amenorrhoea, bleeding P/V, pain abdomen
Risk Factors
● Previous ectopic pregnancy● Prior tubal surgery● Pelvic inflammatory disease● Progestin-only contraceptives● IUCD● Iatrogenic – ART procedures● No Risk Factor!!!!
Initial Evaluation
● Pregnancy test on all women in reproductive age group with irregular bleeding
● Ectopic suggestive when:– Complex adnexal mass on USG with UPT + and empty
uterine cavity– Fluid filled adnexal mass surrounded by echogenic ring– Free fluid in POD
Diagnosis of Ectopic
● Laparoscopy – Gold Standard● Ultrasound (Transvaginal)
– No intra-uterine sac and β-HCG >1800 is highly suggestive
– Gestational sac/embryo outside uterus confirms ectopic– Pitfalls: pseudogestational sac, ruptured corpus luteum
● Failure of β-HCG to double in 48-72 hrs
β-HCG
● Rises in a curvilinear fashion, peaking at 10 weeks, then plateaus
● Mean doubling time: 1.4 – 2.1 days
● Should rise by atleast 66% within 48 hrs
● Ectopic pregnancy – only 21% follow this rule
Hemoperitoneum from Ectopic
● Always assess RUQ view in suspected ectopic
Right Tubal Ectopic
Right Interstitial Ectopic
Ovarian Ectopic
Abdominal Pregnancy
Abdominal Pregnancy
Ruptured Ectopic
Heterotropic Pregnancy
● Presence of both Intra-uterine as well as ectopic pregnancy
● Rare– 1:8000 in spontaneous pregnancy– 1:100 in IVF pregnancies
Heterotropic Pregnancy
Management
● Expectant
● Surgical– Laparoscopic– Laparotomy
● Medical (Methotrexate)
Gestational Trophoblastic Disease
● Disorders arising from the trophoblastic cells of the placenta:– Hydatidiform Mole (most common)
● Complete● Partial
– Invasive Mole– Choriocarcinoma– Placental site trophoblastic tumours
Epidemiology
● Incidence 1:1000● Risk factors:
– Extremes of age (> 40 yrs, < 20 yrs)– Previous GTD– Smoking– Blood type A, B or AB– H/o infertility– Use of OCPs
Clinical Manifestation
● Bleeding P/V● Pelvic pressure/pain● Hyperemesis gravidarum● Passage of hydropic vesicles P/V● Anaemia● Hyperthyroidism● Enlarged uterus● Theca lutein cysts● Pre-eclampsia prior to 20 wks
Complete Mole
● No fetus present● Results from aberrant fertilisation followed by
trophoblastic proliferation● 46XX (both X paternal)● Uterine height more than period of gestation● Excessively elevated β-HCG (>100,000)● USG shows central heterogenous mass with
swelling of hydropic chorionic villi – snow storm appearance
Complete mole
Snow Storm Appearance
Incomplete/Partial Mole
● Associated with fetus and amniotic fluid● Polyploidy, usually triploidy● Less associated with signs/symptoms of excessive
β-HCG● USG shows possible fetus, often growth restricted,
reduced amniotic fluid, swiss cheese pattern of chorionic villi
Incomplete Mole
Management
● Prompt evacuation of the uterus (D&E)● Serial β-HCG monitoring● Contraception for 1 year● Recurrence:
– 20% with complete mole– May invade myometrium or become metastatic– Treated with methotrexate
● Most can conceive, carry normal pregnancy
Conclusion
● First trimester bleeding is common– Correct clinical approach
● Ectopic pregnancy has a high mortality rate, keep high degree of suspicion
● Ultrasound (TVS) and β-HCG important pillars of diagnosis
● Abortions – significant physical and psychological morbidity
Thank You