Bleeding in early pregnancy

Abortion Definition Incidence Etiology Termination of pregnancy <20w or <500grams BW. Spontaneous abortion : 10-15% of clinical pregnancies ; st 80% of them occur in 1 trimester. A. Maternal factors : Systemic Local 1. Infections 1. Uterine defects: 2. Chronic ds - congenital : septate , 3. Endocrinal ds bicornuate 4. Drug & sub abuse - acquired : 5. Environment Submucous fibroid, toxins & radiation Ashermans synd 6. Immunologic 2. Cx incompetence factors - incarcerated RVF uterus APL synd Inherited thrombophilia 7. Trauma B. 1. 2. C. D. Fetal factors : Abnormal development zygote Chromosomal abnormalities ( commonest) Paternal factors : Chromosomal abnormalities in sperms Idiopathic Ectopic Implantation of fertilized ovum outside the normal uterine cavity. 2% of all pregnancies ( due to increased in PID & STD) Risk factors : 1) Pelvic inflammatory disease By Chlamydia trachomatis (50%) & Neisseria gonorrhoeae. 2) Hx of prior ectopic pregnancy 3) Hx of tubal surgery & conception after tubal ligation 4) Use of fertility drugs or ART 5) IUD : ~ 3-4% 6) Increasing maternal age : age 35-44 years 7) Smoking 8) Salpingitis isthmica nodosum : microscopic presence of tubal epiT in the myosalpinx or beneath the tubal serosa. 9) Others Sites : a) b) Tubal : ampullary (80%), isthmic (12%), fimbrae (5%), cornual & interstitial (2%) Non tubal : abdominal (1.4%), ovarian & cx ( 0.2 % each) Molar Abnormal pregnancy characterized by proliferative abnormalities of the trophoblast of the placenta. 1:1500

Diagnosis

Clinical triad : 1. Pain 2. Bleeding 3. Amenorrhea High suspicion for ectopic pregnancy :

I. Clinical features: Complete Partial Abnormal uterine Symp like st bleeding ( 1 hyperemesis, PET, trimester)-prune hyperthyroidism or

Bleeding in early pregnancy

o In any women who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass or tenderness. juice appearance. Late symp: - heavy bleeding -uterine size is larger than period of amenorrhea. -hyperemesis gravidarum (high hCG) II. US Complete Picture of snow storm with no fetal parts Partial Picture of missed abortion bilateral ovarian cysts are rare.

Lab investigations 1. Urine pregnancy test : +ve test with lower abdominal pain, tenderness & vx bleeding 2. Serum BhCG: Increase <66% 3. Progesterone </= 5ng/ml

Imaging US : TVS- empty uterus with +ve test for hCG ( ~1500-1800 mIU/ml) is diagnostic. Diagnostic procedure : 1. D&C - absence of villi 2. Laparoscopy - patients in pain &/ haemodynamically unstable Medical therapy: Methotrexate : -indications for medical ttt: Hemodynamically stable Size of ectopic gestational sac <4cm at its greatest dimension on US Pregnancy is not viable No contraindication to the use of MTX Abdominal pregnancy Cx pregnancy -contraindications : o BhCG >15,000 mIU/ml o Fetal cardiac xtvt o Free fluid in the cul de sac on US Single dose injection : MTX 50mg/m IM in a single injection Surgical therapy 1. Salpingectomy Resection of the tube ( or part ) that contains the ectopic pregnancy 2. Linear salpingostomy & milking the pregnancy out of the distal ampulla.
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III. Serum b-hCG levels: Complete Partial b-hCG level exceeds Not significantly 100,000 mIU/ml elevated. It consists of 2 phases : 1. Immediate evacuation of molar tissue 2. Subsequent follow up for detection of persistent trophoblastic proliferation or malignant transformation. Termination of pregnancy a) Vacuum aspiration : Methods of choice Large moles: a wide calibre IV line IV oxytocin : enhance uterine involution & minimize blood loss Biopsy from uterine contents & curettage is sent for histopatho. b) Hysterectomy Severe bleeding with closed cx Unavailable suction apparatus

Treatment

Follow up procedures: -early detection of malignant transformation. 1. Contraception for at least 1 year by COC 2. Serum BhCG measurement : 48h after evacuation Weekly until results ve for 3

Bleeding in early pregnancy

Laparoscopy : recommended approach Laparotomy : Ectopic w hemoperitoneum Extopic gestational sac >4cm in D Obesity Extensive pelvic adhesion (previous surgery or endometriosis) 1. tubal / uterine rupture, depend on location may lead to massive hemorrhage, shock, DIC st 2. it is leading cause of maternal death in 1 trimester 3. related to surgery ; bleeding, infection, damage to surrounding organs 4. complications secondary to anesthesia consecutive weeks Every month for 6 m Then, yearly A rise or persistent plateau hCG : malignancy ( initiation of chemo)

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Complications

1. 2. 3. 4. 5. 6.

Maternal mortality : In first 8 weeks : 0.7 per 100,000 procedures Doubles for each 2w after 8 weeks gestation. Severe hemorrhage & hemorrhagic shock Sepsis : septicaemia & septicemic shock in septic abortion Trauma (injury) : during attempts of surgical evacuation by inexperienced Rh isoimmunisation Late : Secondary infertility Low BW in subsequent pregnancies Ectopic PP Cx incompetence Placental abruption

Post evacuation complications : resp distress, resulting from : fluid overload trophoblast emboli thyrotoxic crisis ( thyroid storm) persistent trophoblastic disease or GTT occurs in 20% after complete mole & 4% after partial mole. DIC

Clinical types of abortion Threatened S&s of Present pregnancy Bleeding Begins b4 pain Pain Cx Suprapubic, colic -abdominal cramps, suprapubic discomfort Closed

Inevitable Present Severe (clots) Severe , suprapubic colic (myometrial pain) radiating to lower back. Internal os open Rupture of membranes & passage of AF Products of comception are separated from uterine wall but still inside uterine cavity.

Incomplete Start to dissapear Severe Severe, suprapubic colic (myometrial pain) Open & products of conception can be felt protrusing from external os Detects missed parts of conception products inside uterine cavity or cx

Complete Disappear Starts to stop Starts to stop Closed

Missed Gradually disappear Occurs in choriodecidual space around gestational sac.

Septic S&s of infections

Tender uterus Uterus become smaller than period of amenorrhea. Absent embryonic pole ( an embryonic pregnancy till 8w gestation) >8w : absent cardiac pulsation Retained products of conception within uterus

US

Detects gestational sac, embryonic pole (6-7w gestation & cardiac pulsation

Empty

Bleeding in early pregnancy

ttt Rest : physical, mental (sedation), avoiding sex intercourse Natural progesterone - only given if progesterone defncy was proved. Observation Follow up : US 1.Vacuum aspiration st - used in 1 trimester (safer) 2. medical evacuation nd -IV infusion of PG drip in 2 trimester 1.medical evacuation -using misoprostol ( PG E1 analogue) 50ng/6-8hrs orally / vaginally till expulsion 2. vacuum aspiration st -1 trimester Control infection: -triple Ab (penicillin, gentamycin, metronidazole) - antipyretics - IV fluids Termination : -vacuum aspiration -cont Ab according to culture observations

Medical ttt of abortion : A. Early : <49 days gestation : Anti progesterone : mifeprostone PG : misopristol Methrotrexate B. o o Late : 2 trimester abortion : Oxytocin in high doses PGE2, PGE1
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