Bleeding in early Bleeding in early pregnancypregnancy

Dr.Sushma Sharma Dr.Sushma Sharma

Causes of early bleeding in Causes of early bleeding in pregnancypregnancy

AbortionAbortionEctopic pregnancyEctopic pregnancy

Hydatidiform moleHydatidiform mole

Abortion/MiscarriageAbortion/Miscarriage

DefinitionDefinition: : any fetal loss from conception until the time of any fetal loss from conception until the time of fetal viability at 24 weeks gestation.fetal viability at 24 weeks gestation.

OR:OR:

Expulsion of a fetus or an embryo weighing 500 gm or less Expulsion of a fetus or an embryo weighing 500 gm or less IncidenceIncidence: 15 - 20% of pregnancies total reproductive losses : 15 - 20% of pregnancies total reproductive losses

are much higher if one considers losses that occur prior to are much higher if one considers losses that occur prior to clinical recognition.clinical recognition.

ClassificationClassification::

1. spontaneous:1. spontaneous:

occurs without medical or mechanical means.occurs without medical or mechanical means.

2. induced abortion2. induced abortion

Pathology Pathology

Haemorrhage into the decidua basalis.Haemorrhage into the decidua basalis. Necrotic changes in the tissue adjacent to Necrotic changes in the tissue adjacent to

the bleeding.the bleeding. Detachment of the conceptus.Detachment of the conceptus. The above will stimulate uterine The above will stimulate uterine

contractions resulting in expulsion.contractions resulting in expulsion.

Causes of miscarriageCauses of miscarriage

Fetal causes:: Chromosome Abnormality: Chromosome Abnormality:

- - 50% of spontaneous losses are associated with fetal chromosome abnormalities.

- autosomal trisomy (nondisjunction/balanced translocation): is the single largest category of abnormality and → recurrence.

- monosomy (45, X; turner): occurs in occurs in 7% of spontaneous abortions

and it is caused by loss of the paternal sex chromosome. -- triploids: found in 8 to 9% of spontaneous abortions. it is the

consequence of either dispermy or failure of extrusion of the

second polar body,,

Causes of miscarriageCauses of miscarriage

Maternal causesMaternal causes::

1. 1. Immunological:

- alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of a normal pregnancy.

- autoimmune disease: antiphospholipid antibodies especially lupus anticoagulant (LA) and the anticardiolipin antibodies (ACL)

2. uterine abnormality:

- congenital: septate uterus → recurrent abortion.

- fibroids (submucus): → (1) disruption of implantation and development of the fetal blood supply, (2) rapid growth and degeneration with release of cytokines, and (3) occupation of space for the fetus to grow. Also polyp > 2 cm diameter.

- cervical incompetence: → second trimester abortions.

Causes of miscarriageCauses of miscarriage

Maternal causes:Maternal causes:3. Endocrine :

- poorly controlled diabetes (type 1/type 2).

- hypothyroidism and hyperthyroidism.

- Luteal Phase Defect (LPD): a situation in which the endometrium is poorly or improperly hormonally prepared for implantation and is

therefore inhospitable for implantation. . (questionable).(questionable).

4. Infections (maternal/fetalInfections (maternal/fetal): as TORCH infections, Ureaplasma ): as TORCH infections, Ureaplasma urealyticum, listeriaurealyticum, listeria

EnvironmentalEnvironmental toxins: alcohol, smoking, drug abuse, ionizing toxins: alcohol, smoking, drug abuse, ionizing radiation……radiation……

Types of abortionTypes of abortion

Threatened abortion.Threatened abortion. Inevitable abortion.Inevitable abortion. Incomplete abortion. Incomplete abortion.

Complete abortion.Complete abortion. Missed abortionMissed abortion Septic abortion:Septic abortion: Any type of Any type of

abortion, which is abortion, which is complicated by infectioncomplicated by infection

Recurrent abortion: Recurrent abortion: 3 or more 3 or more successive spontaneous abortionssuccessive spontaneous abortions

Clinical features/managementClinical features/management

Threatened abortion:Threatened abortion: - Short period of amenorrhea. - Short period of amenorrhea. - Corresponding to the duration.- Corresponding to the duration. - Mild bleeding (spotting).- Mild bleeding (spotting). - Mild pain.- Mild pain. - P.V.: closed cervical os.- P.V.: closed cervical os. - Pregnancy test (hCG): + ve.- Pregnancy test (hCG): + ve. - US: viable intra uterine fetus.- US: viable intra uterine fetus. ManagementManagement- reassurance.reassurance.- Rest.Rest.- Repeated U/SRepeated U/S

Inevitable abortionInevitable abortion

Clinical featureClinical feature: :

- - Short period of amenorrhea.Short period of amenorrhea.

- heavy bleeding accompanied - heavy bleeding accompanied with clots (may lead to shock).with clots (may lead to shock).

- Severe lower abdominal pain.- Severe lower abdominal pain.

- P.V.: opened cervical os. - P.V.: opened cervical os.

- Pregnancy test (hCG): + ve.- Pregnancy test (hCG): + ve.

- US: non-viable fetus and blood - US: non-viable fetus and blood inside the uterus.inside the uterus.

Management:Management:

- fluids…..blood.- fluids…..blood.

- ergometrinn & sentocinon.- ergometrinn & sentocinon.

- evacuation of the uterus - evacuation of the uterus (medical/surgical).(medical/surgical).

Incomplete abortionIncomplete abortion

Clinical featureClinical feature:: - Partial expulsion of - Partial expulsion of

productsproducts

- Bleeding and colicky pain - Bleeding and colicky pain continue.continue.

- P.V.: opened cervix… - P.V.: opened cervix… retained products may be retained products may be felt through it.felt through it.

- US: retained products of - US: retained products of

conceptionconception..

TreatmentTreatment

as inevitable abortionas inevitable abortion

Complete abortionComplete abortion

- expulsion of all products of conception.- expulsion of all products of conception.

- Cessation of bleeding and abdominal pain.- Cessation of bleeding and abdominal pain.

- P.V.: closed cervix.- P.V.: closed cervix.

- US: empty uterus.- US: empty uterus.

Missed abortionMissed abortion

Feature:Feature: - gradual disappearance of - gradual disappearance of

pregnancy Symptoms Signs.pregnancy Symptoms Signs. - Brownish vaginal discharge.- Brownish vaginal discharge. - Milk secretion.- Milk secretion. - Pregnancy test: negative but - Pregnancy test: negative but

it may be + ve for 3-4 weeks it may be + ve for 3-4 weeks after the death of the fetus.after the death of the fetus.

- US: absent fetal heart - US: absent fetal heart pulsations.pulsations.

ComplicationsComplications - Infection (Septic abortion)- Infection (Septic abortion) - DIC- DIC

TreatmentTreatment- - Wait 4 weeks for spontaneous Wait 4 weeks for spontaneous

expulsionexpulsion - evacuate if: - evacuate if: Spontaneous expulsion does not Spontaneous expulsion does not

occur after 4 weeks. occur after 4 weeks. Infection. Infection. DIC. DIC. - Manage according to size of - Manage according to size of

uterus uterus - Uterus < 12 weeks : dilatation - Uterus < 12 weeks : dilatation and evacuation.and evacuation.- Uterus > 12 weeks : try - Uterus > 12 weeks : try Oxytocin or PGs. Oxytocin or PGs.