Lesson 2 • Cervix may bleed more easily during pregnancy-more

HIGH RISK PREGNANCY: THE PREGNANT WOMAN WHO DEVELOPS blood vessels are developing in this area.
COMPLICATIONS
• Spotting or light bleeding after sexual intercourse or after
BLEEDING DURING PREGNANCY a Pap test or pelvic exam.

• Any degree of vaginal bleeding is potentially serious. INCIDENCE

• amount visualized may be a fraction of actual • When bleeding occurs in 1 st trimester 30% of pregnancies
loss will miscarry.

• undilated cervix and intact membranescan
contain uterine bleeding
• Evaluate mother for possible significant blood
loss or shock
• 10 % to 15% will be an ectopic pregnancy, 0.2% will be
hydatidiform mole and 5% will have termination of
pregnancy.
• The remaining 50% will continue beyond the 20weeks.

CAUSES

• Related to the pregnant state:

• Abortion 95%

• Ectopic pregnancy

• Hydatidiform mole

• Associated with pregnant state: Lesions are unrelated to

pregnancy – either pre-existing or aggravated during
pregnancy.

• Cervical lesions

• Vascular erosion
• Hypovolemic shock
• Polyps
• 10% of blood loss
• Ruptured varicose veins
• Fetal distress
• Malignancy
• 25% of blood loss
ABORTION
• Goal of management
• aboriri—to miscarry
• RESTORE circulating blood volume
• spontaneous or induced termination of pregnancy before
• STOP source of hemorrhage fetal viability: 20wks, 500g birthweight

• Bleeding in early pregnancy • “early pregnancy loss, wastage, or failure”.

• before 20 weeks AOG • 10-20% of all clinical pregnancies end in miscarriage

• Bleeding in late pregnancy • 10% induced illegally

• genital tract during 3rd trimester. • 75% end before 16th week and 75% of these occur before
8th week of pregnancy
• after gestational age of viability
PATHOLOGY
Bleeding in early pregnancy
• Haemorrhage into the decidua basalis.
• Common
• Necrotic changes in the tissue adjacent to the bleeding.
• In many cases does not signal a major problem
• Detachment of the conceptus.
• 15–25% of pregnant women
• The above will stimulate uterine contractions resulting in
• Light bleeding or spotting can occur 1–2 weeks: expulsion.
IMPLANTATION
CLASSIFICATION
 • Before 8 weeks

• ovum surrounded by the villi with the decidual

coverings, is expelled out intact

• Sometimes the external os fails to dilate

• Entire mass is accommodated in the dilated

cervical canal- CERVICAL MISCARRIAGE

• 8-14weeks- expulsion of the fetus commonly occurs

leaving behind the placenta and its membranes
ETIOLOGY
• Beyond 14th week - The process of expulsion is similar to
• Genetic factors: 50% of early miscarriages. mini labour

• Endocrine and metabolic factors • Fetus is expelled first followed by placenta

• 10-15% LPD, deficient progesterone, thyroid TYPES OF ABORTION

abnormalities, DM.
THREATENED MISCARRIAGE
• Infections
• It is a clinical entity where the process of miscarriage has
• 5% viral , bacterial, parasitic. started but has not progressed to a state from which
recovery is impossible.
• Anatomic abnormalities
Clinical features
• 10-15% mostly related to 2nd trimester, cervical
• Short period of amenorrhea.
• uterine (congenital malformation or fibroid).
• Corresponding to the duration.
Uterine Abnormalities
• Mild bleeding (spotting).

• Mild pain.

• Closed cervical os.

• Pregnancy test (hCG): + ve.

• US: viable intra uterine fetus

• Serum progesterone

Fate

• Bleeding stops:
ETIOLOGY
• The embryo or fetus is still alive and pregnancy continues
• Immunologic disorders (50%).

• 5-10% Autoimmune disorders • The embryo or fetus dies but is retained in the uterus
leading to missed abortion.
• Alloimmune disorders
• Bleeding continuous:
• Antifetal antibodies
• Uterine contractions occur, and cervix dilates leading to
• Maternal medical illness: heart disease, inevitable abortion.
hemoglobinopathies
Management
• Blood group incompatibility
• Rest (physical, mental and sexual).
• PROM
• Treatment of the cause : If obvious.
• Environmental factors
• Natural Progesterone (vaginal suppository or
• Unexplained intramuscular)
MECHANISM • Diazepam 5 mg BD
 • Repeated U/S
INEVITABLE ABORTION
• changes have progressed to a state from where
continuation of pregnancy is impossible.
Clinical picture :
• Bleeding, usually severe.
• Pain : It is colicky intermittent felt in the supra pubic
region (uterine contractions) and may be accompanied
with low backache (cervical dilatation).
• Uterus is enlarged and the internal os of the cervix is
dilated. The products of conception may be felt through
the dilated cervix.
Management
• fluids…..blood.
• methergin 0.2mg
• evacuation of the uterus (medical/surgical).
COMPLETE ABORTION
• All the products of conception are expelled from uterus.
• Bleeding is slight and gradually diminishes
• Pain is absent
• Uterus is smaller than the period of amenorrhea
• Cervix is closed or closing.
• Uterus is empty, nothing is done.
• If remnants are seen evacuation is carried out
INCOMPLETE ABORTION
• Part of the products of conception is expelled from the
uterus and part is retained
• In clinical picture and treatment same as inevitable
abortion.
• second trimester abortion due to drop in
secretion of estrogen which normally blocks the
action of prolactin on the breast
• A dark brown vaginal discharge may occur
Clinical Picture
• Uterus is smaller and fails to enlarge; firm
• Cervix is closed
• No FHS
• USG shows no fetal heart activity; collapsed sac
• HCG is negative within 2wks after death
Complications
• Intrauterine infection
• DIC in neglected cases
Treatment
• If not expelled spontaneously, evacuation is done
• Uterus < 12 weeks : dilatation and evacuation.
• Uterus > 12 weeks : Oxytocin or PGs
SEPTIC ABORTION
• An abortion complicated by infection
Symptoms
• Abdominal pain; rigidity
• Fever
• Vaginal discharge (foul smelling)
Signs
• Sick looking, febrile or jaundiced
• Tender uterus
• Offensive vaginal discharge or bleeding

MISSED ABORTION • Cervix is usually soft and may be dilated

• The embryo or fetus are dead and retained inside the Causative agents
uterus.
• Most common: anaerobic streptococci
• Symptoms of threatened abortion may or may not occur.
Clinical grading
• Pregnancy symptoms gradually disappear as nausea,
vomiting and breast symptoms. • Grade1- the infection is localized in the uterus

• Failure of the abdomen to increase in size. • Grade2- the infection spreads beyond the uterus to the
parametrium
• Failure to feel fetal movements or cessation of fetal
movements if previously present. • Grade 3- generalized peritonitis or endotoxic shock or
jaundice or acute renal failure
• Milk secretion
Immediate Complications
• may start spontaneously
• Haemorrhage
 • Peritonitis • may lead to abortion or preterm labor

• Pelvic abscess, CAUSES

• endometritis, • Congenital

• Septicemia, • Acquired

• Septic/haemorrhagic • Gynecological causes: rapird excess dilatation;

cervical operation
• shock
• Obsetric causes: unrepaired cervix tear due to
Late Complications forceps application, breech exctraction before
• PID full dilatation

• Pelvic adhesions • Charasteristics of abortion

• 2° Infertility • Mid-trimester

MANAGEMENT • Gestational age decrease with time

• Resuscitation • Painless

• IV fluids: RL, NS • ROM, followed by delivery of fetus then placenta

• Insert urethral catheter • Examination

• Monitor Input/output • Speculum examination reveal cervical tears

• Blood grouping & Cross matching • USG reveals decrease cervical length, funneling
of canal and herniation of sac
• Antibiotics:

• Preferably cephalosporins, if not available

• ampicilin and metronidazole

• Prophylactic antigasgangrene serum of 8000 units and

3000 units of antitetanus serum

• Evacuation/ hysterectomy

RECURRENT ABORTION

• 3 or more consecutive pregnancy losses

• habitual abortions
Management:
• habitual miscarriage
• In between pregnancies: repair of tear
• recurrent abortions
• During pregnancy: cerclage may be abdominal or vaginal
• recurrent miscarriages.
INDUCTION OF ABORTION
Etiology
• It is the medical or surgical termination of pregnancy
• Genetic Factors chromosomal.3-5 % before the time of fetal viability.
• Endocrine Factors • Types:
• Anatomic Causes • Therapeutic Abortion.
• Congenital anomalies, in competencies, • Elective (Voluntary) Abortion.
• Infectious causes • Methods:
• Immunologic problems • 4-7 weeks : Medical using mifepristone and
prostaglandins.
Cervical Insufficiency

• Inability of the cervix to maintain pregnancy till term

 • 7-12 weeks : Suction termination under general • ACQUIRED
anaesthesia
• PID (6-10 times)
• >12 weeks : Medical using mifepristone and
multiple doses of PGs • Chlamydia trachomatis is most common

• Hysterotomy. In some cases. • Contraceptive Faliure

ECTOPIC PREGNANCY • Tubal sterilization faliure -40%

• Any pregnancy where the fertilised ovum gets implanted & • Reversal of sterilisation
develops in a site other than normal uterine cavity. • Tubal reconstructive surgery (4-5 times)

• Previous Ectopic Pregnancy 7-15% chances of repeat

ectopic pregnancy

OTHER RISK FACTORS

• Age 35-45 yrs

• Previous induced abortion

• Previous pelvic surgeries

• Cigarette smoking

• Infertility

• Salpingitis Isthmica Nodosa

INCIDENCE
• Genital Tuberculosis
• Increased due to PID, use of IUCD, Tubal surgeries, and
Assisted reproductive techniques (ART). • Fundal Fibroid & Adenomyosis of tube
• Ranges from 1:25 to 1:250 • Transperitoneal migration of ovum
• Average range is 1 in 100 normal pregnancies.

• Late marriages and late child bearing -> 2% • Recurrence

rate - 15% after 1st, 25% after 2 ectopics

ETIOLOGY

• Any factor that causes delayed transport of the fertilised

ovum through the tube.

• Fallopian tube favours implantation in the tubal mucosa

itself thus giving rise to a tubal ectopic pregnancy.

• These factors may be Congenital or Acquired.

ETIOLOGY

• CONGENITAL

• Tubal Hypoplasia

• Tortuosity

• Congenital diverticuli

• Accessory ostia

• Partial stenosis

• Elongation
ACUTE ECTOPIC PREGNANCY
• Intamural polyp
• Classical triad is present in 50% of pt with rupture ectopic.
• Entrap the ovum on its way.
 • PAIN: most constant feature in 95% pt; variable in severity • Can be done only when patient is
and nature haemodynamically stable.

• AMENORRHOEA:- 60-80% of pt • It confirms the diagnosis and removal of ectopic

mass can be done at the same time
• there may be delayed period or slight

• spotting at the time of expected menses.

• VAGINAL BLEEDING: scanty dark brown

• Feeling of nausea,vomiting,fainting attack, syncope

attack(10%) due to reflex vasomotor disturbance.

• The patient looks quiet and conscious, perspires and looks

blanched

• Pallor

• Features of shock

• Abdomen feels tense, tumid, and tender. No mass is

usually felt, shifting dullness present
MANAGEMENT OF RUPTURED
• Pelvic examination reveals blanched white vaginal mucosa,
uterus seen normal in size or slightly bulky • Resuscitation and Laparotomy

• Extreme tenderness on fornix palpation or on movement • ANTI SHOCK TREATEMENT

of the cervix
• IV line made patent, crystalloid is started
• No mass is usually felt through the fornix
• Blood sample for Hb, blood grouping & cross
• The uterus floats as if in water matching, BT, CT

UNRUPTURED TUBAL PREGNANCY • Folley’s catheterization done

• presence of delayed period or spotting with features
suggestive of pregnancy
• uneasiness on one side of the flank which is continuous or
at times colicky in nature
• Diagnosed accidentally in Laparoscopy or Laparotomy
CHRONIC ECTOPIC PREGNANCY
• It can be diagnosed by high clinical suspicion.
• Patient had previous attack of acute pain from which she
has recovered.
• She may have amenorrhoea, vaginal bleeding with dull
pain in abdomen,and with bladder and bowel complaints
like dysuria,frequency or retention of urine, rectal
tenesmus.
ECTOPIC PREGNANCY
• DIAGNOSIS
• Urine pregnancy test:- positive in 95% cases.
• Culdocentesis:- (70-90%)
• Positive tap is 0.5ml of non clotting blood.
• Transvaginal Sonography (TVS)
• Diagnostic Laparoscopy (Gold standard)
• Colloids for volume replacement
• LAPAROTOMY:
• Principle is ‘Quick in and Quick out’
• Rapid exploration of abdominal cavity is done
• Salpingectomy is the definitive surgery (sent for
HP study)
• Blood transfusion to be given
• Autotransfusion only when donated blood not
available.
• Only observation is done hoping spontaneous resolution.
• Indications are:
• initial serum HCG level less than 1000IU/L and
the subsequent levels are falling
• Gestational sac size <4 cm
• No fetal heart beat
• No evidence bleeding or rupture
MANAGEMENT OF UNRUPTURED
• Conservative management: either medical or surgical
• Medical management
 • The drugs commonly used for salphingocentesis
• are methotrexate, potassium chloride,
pic
• prostaglandin (PGF2α) or Actinomycin.
• Conservative surgery
• Linear salphingostomy
• Linear salphingotomy
• Segmental resection
• Fimbrial expression
• Salphingectomy
GESTATIONAL TROPHOBLASTIC DISEASE
• GTD is a clinical spectrum that includes all neoplasms that
derive from abnormal placental (trophoblastic)
proliferation :
• Hydatidiform (vesicular) mole, also known as molar
pregnancy :
• Complete mole.
• Partial mole.
• Gestational trophoblastic neoplasia :
• Invasive mole (chorioadenoma destruens).
• Choriocarcinoma.
• Placental site trophoblastic tumor.
Hydatidiform Mole
• It is a benign tumor of chorionic villi and characterized by :
• Marked proliferation of the trophoblast.
• Edema or hydropic degeneration of the villi
which leads to their distension and the
formation of vesicles.
• Avascularity of the villi : The blood vessels
disappear from the villi, which explain the early
death of the embryo.
• Incedince: Asian live in Asia 1:200 while in US 1:1500 with
recurrence 1-2%.
• Risk factors
• Race : more in Asian women.
• Maternal age :Less than 20 ys. OR - More than 40 ys.
• Increased paternal age.
• History of molar pregnancy.
• Smoking.
• Protein or vit. A deficiency.
• Irregular cycles
• Uterus : It is usually larger than the period of amenorrhea
in complete type.
• Vesicles :
• A large number of vesicles which are closely
packed together.
• They vary in size from 2 mm – 2 cm in diameter.
• Each vesicle has a fine pedicle.
• The fluid content is clear and watery.
• Fetus :
• Absent in complete type.; Present in partial type
(usually malformed).
• Ovaries :
• large size (10 cm or more).
• They are due to stimulation of the ovaries by the
excessive human Chorionic Gonadotrophin (hCG)
produced by the proliferated trophoblast.
• Cysts disappear within few months (2-3), after
evacuation of the mole.
• Symptoms :
• Symptoms of early pregnancy.
• Symptoms of pre-eclampsia: headache, and edema.
• Abnormal abdominal enlargement in some cases due to
distension of the uterus with vesicles.
• Vaginal bleeding : (main complaint).
• It is due to separation of vesicles from the
uterine wall.
• There may be a blood stained watery discharge,
the watery part is from ruptured of vesicles.
 • Prune juice discharge may occur, the blood is CLASSIFICATION
brown because it has been retained for some
time in the uterine cavity. Placental site bleeding: (62%)

• The passage of vesicles is diagnostic. • Placenta praevia (22%): separation of a placenta

wholly or partially implanted in the lower terine
• Pain segment.

• Dull aching abdominal pain due to rapid • Abruptio placentae (30%): Premature separation
distension of the uterus. of a normally implanted placenta.

• Localized sharp pain and tenderness on the • Marginal separation(10%)ý: Bleeding from the
uterus due to perforating mole. edge of a normally implanted placenta

• Ovarian pain due to stretching of the ovarian • Non-placental site bleeding: (28%)
capsule or complication in the ovarian cyst as
torsion. • Vasa praevia: Bleeding from ruptured foetal
vessels.
• Diagnostics :
• Rupture uterus.
• USG :snowstorm appearance and no fetus is seen
• Bloody show.
• Partial mole: abnormally formed fetus.
• Cervical ectopy, polyp or cancer.
• Very high serum level of HCG (more than 100,000 mlU/ml).
• Vaginal varicosity.
• The result is compared with the level for normal pregnancy
at the same age. PLACENTA PREVIA

• X-ray of the chest should be performed in every case of • The placenta is partially or totally attached to the lower
trophoblastic tumor. uterine segment.

• Complications: Incidence

• Hemorrhage. • 0.5% of pregnancies

• Perforation of the uterus. • More common in multiparas and in twin pregnancy due to
the large size of the placenta.
• Uterine infection.
Etiology
• Development of choriocarcinoma.
• Low implantation of the blastocyst.
• Hyperthyroidism .
• Development of the chorionic villi in the decidua capsularis
• Disseminated intravascular coagulation (DIC). leading to attachment to the lower uterine segment.

• Trophoblastic embolization. • Large placenta as in twin pregnancy

• Recurrent mole. Types:

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA • 1st degree: P.P. lateralis = low-lying placenta

• Post molar syndrome or persistent GTN : • The lower edge within 5 cm from internal os.

• After molar evacuation, there are : • 2nd degree: P.P. marginalis

• Persistent bleeding. • The lower edge of the placenta is just reaching

the internal os but not covering it.
• Subinvolution of the uterus.
• 3rd degree: P.P. incomplete centralis
• +ve pregnancy test.
• The placenta cover the closed internal os.
• No malignant changes in endometrial biopsy.
• 4th degree: P.P. complete centralis
• Ultrasound with Doppler examination and MRI is
necessary. • The placenta completely cover the internal os
even when dilated.
• Treatment: chemotherapy.
Mechanism
BLEEDING IN LATE PREGNANCY
 • Progressive stretching of the lower uterine segment • Resuscitation:
normally occurs during the 3rd trimester and labour
• I.V. line & fluid, cross matched blood.
• Inelastic placenta cannot stretch with it
• Indication of termination:
• Inevitable separation of a part of the placenta with
unavoidable bleeding. • Mature fetus (after 37 w).

• The closer to term, the greater is the amount of bleeding. • Dead fetus or congenital malformation
incompatible with extrauterine life.
Symptoms:
• Active labour pain.
• Causeless, painless and recurrent bright-red vaginal
bleeding; • Attack of severe bleeding.

• causeless, but may follow sexual intercourse or • Conservative management

vaginal examination. • In mild attack or the attack has stopped and Gestational
• painless, but may be associated with labour age less than 37w with living fetus.
pains . • Hospitalization.
• recurrent, but may occur once in slight placenta • Cross matched blood.
praevia lateralis
• Antenatal corticosteriod.
Diagnostic Evaluation:
• Tocolytics.
• U/S: Trans-abdominal versus Transvaginal
• Anti D for Rh -ve mother.
• Confirm diagnosis & degree of P.P.
ABRUPTIO PLACENTA
• Viability,
• Premature separation of normally implanted placenta.
• HB level & HCT value
• Occurs in 1% of pregnancy
• MRI: When placenta accreta is suspected.
ETIOLOGY

• Idiopathic.

• Pre-eclampsia.

• Trauma.

• Sudden drop of intrauterine pressure due to PROM.

• Smoking.

• Myoma in placental bed.

TYPES

• Revealed

• Marginal (peripheral) detachment of placenta.

• EFFECTS ON PREGNANCY
• External hemorrhage.
• Increase incidence of:
• Concealed
• Malpresentation.
• Central separation with adherence of edge.
• Preterm labour.
• Retroplacental hematoma provoke more
• CS. separation.

• Placenta accreta. • Blood may dissect through the myometrium

between muscle fibers to reach peritoneal cavity
• Postpartum hemorrhage. (couvelaire’s uterus)

TREATMENT • Mixed
 MANAGEMENT: Revealed Type

• Severe hge:

• Correction of shock followed by CS.

• Mild Hge.

• Hospitalization.

Concealed accidental Hge. • Careful monitoring of maternal & fetal condition.

• Severe abdominal pain. • Anti D for Rh -ve mother.

• Shock ( hemorrhage & pain). • Tocolytics contraindicated.

• Abdominal examination. VASA PREVIA

• Tender & rigid abdomen. • Very rare.

• Fundal level higher than period of amenorrhea • Fetal blood vessels cross or run near the internal opening
of the uterus
Revealed accidental Hge.
• Occur due to velamentous insertion of the cord & some
• Vaginal bleeding. fetal vessels pass near the internal os.

• Mild abdominal pain. • It leads to early fetal distress.

• Signs hypovolemic shock. • May cause bleeding of fetal origin.

DIAGNOSTIC EVALUATION • Treatment by immediate CS.

• U/S: HYPEREMESIS GRAVIDARUM

• Exclude placenta previa. • HYPER : EXCESSIVE

• Viability of fetus. • EMESIS : VOMIT

• Retroplacental hematoma. • GRAVIDARUM : PREGNANCY

• Urine analysis: • Nausea/vomit of moderate intensity are especially

common until about 16 week.
• Proteinurea.
• HEG occurs when vomiting becomes intractable in early
COMPLICATIONS: Concealed Type
pregnancy & cause fluid & electrolyte imbalances &
• Fetal death. nutritional deficiency.

• Acute tubular necrosis & acute renal failure. • Women usually needs to be hospitalized.

• DIC & consumptive coagulopathy. • Severe vomiting particularly during early pregnancy

• Escape of thromboplastin-like substances into the • Vomiting sufficiently sever to produce weight loss, DHN,
maternal circulation. acidosis from starvation, alkalosis from loss of HCl and
Hypokalemia
• Postpartum He
• ETIOLOGY
MANAGEMENT: Concealed Type
• Unknown
• Correction of shock.
• More common in
• Termination usually by amniotomy & inductionof labour.
• Trophoblastic disease
• CS indicated only in:
• Multiple pregnancy
• Living fetus.
• Nulliparity
• Deterioration of maternal condition in spite of
resuscitative measures. • Female fetus

• Other obstetrics indication. • Age > 30year

 • Maternal obesity • Anorexia

• Smoking • Dehydration

• Those who had HEG in previous pregnancy • Muscle wasting

• Has got familial history • Ketosis

• HORMONAL THEORY : • Weight loss > 5% of pregnancy weight

• excess of HCG & estrogen trigger vomiting centre • Tachycardia

• progesterone excess causes relaxation of cardiac • Postural hypotension

sphincter which causes retension of gastric fluid.
• Dry coated tongue
• PSYCHOGENIC THEORY:
• Sunken eyes
• trigerred by nausea
• Acetone smell in breath
• neurogenic trigger
Principles of management
• DIETARY DEFICIENCY:
• To control vomiting.
• Due to low CHO reserve deficiency of vitamin B1,
B6 & protein may be the effect rather than • To correct fluid & electrolyte imbalance.
cause. • To correct metabolic disturbance.
• ALLERGIC OR IMMUNOLOGICAL BASIS • To prevent serious complications of severe
• DECREASE GASTRIC MOTILITY vomiting.

• ANY PATHOLOGY OF : MEDICAL MANAGEMENT

• LIVER • Antiemetic

• KIDNEY • Promethazin 25mg IM bd or tds

• HEART • Trifluopromazine 10mg IM

• BRAIN • Metachlopromide 10mg IM

• Hydrocortisone:- 100mg IV in drip

• Prednisolone orally

• Nutritional support: Vitamin B1, vitamin B6, vitamin B12 &

vitamin C

• Fluid therapy

NURSING MANAGEMENT

• Initiate measures to alleviate nausea including medication

therapy. If unsuccessfully on weight loss & electrolyte
• Excess vomiting & retching day & night. imbalances occur, IV administration of fluid & electrolyte
replacement or total parenteral nutrition may be
• Vomiting initially watery & bilious.(Weight loss seen) necessary.
• Oliguria • Monitor lab data & for sign of dehydration & electrolyte
imbalances
• Seldom mental symptoms
• Initiate measures to alleviate nausea including medication
• EPIGASTRIC pain
therapy. If unsuccessfully on weight loss & electrolyte
• Constipation imbalances occur, IV administration of fluid & electrolyte
replacement or total parenteral nutrition may be
• Ptyalism necessary.
• Spitting • Monitor lab data & for sign of dehydration & electrolyte
imbalances
• Fatigue