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