Bleeding

in early pregnancy
(Miscarriage)
Causes of bleeding in early
pregnancy
•Miscarriage
• Ectopic pregnancy
• Gestational trophoblastic disease
• Cervical lesions (erosion and/or
polyp)
Miscarriage
Definition
Causes
Clinical presentation & investigation
Types
Management options
 Miscarriage
Spontaneous loss of pregnancy
before viability(at or before24
weeks of gestation or<500gm
birth wt)
The incidence in a clinical
recognized pregnancy is 10-20%
decreasing to 3%if a viable fetus
has been recognized on ULS.
 Causes:
Fetal
Chromosomal & congenital
abnormalities:
More than 80 percent of
miscarriage occur in the
first 12 weeks of
pregnancy at least half
result from chromosomal
anomalies
 Matrenal
1-Advanced
maternal age :
due to decreased number
of good quality oocytes.
2-Medical diseases
of the mother
-SLE
-antiphospholipid
syndrome
-inherited thrombophilia
3-Endocrine
abnormalities

-PCOs
-Hypothyroidism
-Uncontrolled D.M
-CL insufficiency
 4-Uterine defects

-Uterine leiomyomas
-Congenital
abnormalities (septate
ut)
-Asherman’s syndrome
-Cervical incompetence
 5-Infections

-Listeria monocytogenes
-Mycoplasma hominis
-Ureaplasma urealyticum
-TORCHS
 6-Others
-Toxic chemicals ,
drugs, radiation
-Immunological
rejection of the
fetus
History
Typical symptoms of miscarriage include:

-Vaginal bleeding
-Cramping abdominal pain
-Passage of fetal tissue or clots

Other important areas to cover in the history

include:
- LMP
- Cause if present
 Examination
-BP ,Pulse rate ,Temperature
-Abdominal palpation
-Speculum examination
-Vaginal examination
Investigations
Urine:
- MSU/PT in urine
Blood:
-FBC
- PT & Quantitative βHCG
-Blood group and cross match (if patient is severely
compromised)

USS (transvaginal or abdominal)

Types of Ultrasound findings Clinical presentation
miscarriage

Threatened Viable intrauterine Mild vaginal bleeding &

miscarriage pregnancy pain absent or mild
Ex. cervical os close

Inevitable Intrauterine pregnancy Sever vaginal bleeding &

miscarriage pain
Ex. cervial os open

Incomplete Retained products of vaginal bleeding & pain

miscarriage conception
Complete No retained products of
miscarriage conception (empty uterus)
Missed miscarriage Fetal pole present, but no
fetal heart beat identified
or Gestational sac present
but no fetal pole identified
Ex. cervical os open,
products of conception
located in cervical os
Expulsion of conceptus
Pain & bleeding resolved
Ex. cervical os closed
With or without pain &
bleeding, uterus smaller
than expected ,mammary
changes regress ,DIC
Incomplete Abortion: Diagnosis
 Other categories of miscarriage and
abortion
Recurrent miscarriage is 3 or more consecutive,
spontaneous pregnancy losses, before viability in the same
pattern.

Septic abortion Most often associated with criminal induced

abortion. Metritis is usual outcome, but parametritis,
peritonitis, endocarditis, and septicemia may all occur

Therapeutic abortion Done if continuation of pregnancy

may threaten the life of women or seriously impair her health
e.g heart disease , advanced hypertensive vascular disease ,
invasive carcinoma of the cervix, or in case of severe
congenital abnormality of fetus which is incompatible with life.
 Management options
Expectant management
Medical evacuation
Surgical evacuation
Expectant Management
-Watch and wait
-Serial scans and HCG
Outcome:
-Bleeding may stop and pregnancy continue (if viable)
-Completely abort and bleeding stops
-May have prolonged bleeding which can need to convert
at any time to medical/surgical especially if bleeding is
heavy
Medical induction
of abortion :

Prostaglandins:
are cheap and effective in oral
& vaginal forms are used in
single or divided doses in both
1st and 2nd trimester.
Orally:
Misoprostol
Vaginally:
Gemeprost
Antiprogesterone :
RU 486 ( Mifepristone )

Oral agent used alone or in

combination with oral
Prostaglandins to induce
abortions in early gestation.
Oxytocin:

Successful induction of 2nd

trimester abortion is possible with
high doses of oxytocin
administered in small volumes of IV
fluids.

Women under going medical

management of miscarriage
may need surgical treatment if
medical treatment fails.
Surgical techniques for
abortion
Dilatation and Curettage :
Before 14 week
Performed first by dilating the cervix
then evacuating the product of
conception either by
-Mechanically scraping out of the
contents (sharp curettage)
-Vacuum aspiration (suction curettage)
Complications
-Uterine perforation
-Cervical incompetence
-Intrauterine synechiae
-Subfertility
Abdominal
Hysterotomy :

Failure or contraindication
for medical induction during
the late 2nd trimester
Medical abortion
Avoids invasive procedure
& anesthesia
Requires two or more visits
in hospital/clinic or in home
Days to weeks to complete
Available in early & late pregnancy
High success rate (95%)
Requires follow up to ensure
completion of abortion
Requires patient participation
throughout multi step process
Contraindicated in asthma & cardiac
disease
Complication: hemorrhage, Infection
, failure to remove pregnancy
Surgical abortion
Invasive procedure & usually
requires anesthesia
Usually requires one visit only
done in hospital/clinic
Completes in predictable short time
Available in early pregnancy
Higher success rate (99%)
Does not require follow up in all
cases
Requires patient participation in a
single step process
Not
Hemorrhage, infection, uterine
perforation, cervical damage
 Further management
-Psychological support ,information
-Contraception
-Future pregnancies advices
-Recurrent miscarriage should be investigated
-Folic acid
-Anti D
 Incompetent cervix
Painless dilatation of cervix in the
2ndor early in the 3rd trimester
Diagnosis :
Hysterography or Acceptance without
resistance at the internal os of
specifically sized cervical dilators
In pregnant women the use of TV ULS
for Cervix showing progressive
shortening & dilatation(Funneling)
Treatment:
surgically reinforcement of weak cervix
by some type of purse string suture
( Cerclage )performed between 12 &
14week
Types of operations commonly
used:
McDonald (trans vaginal)
Shirodkar (Trans abdominal
cerclage)))