Bledding in pregnancy

Causes of early bleeding in pregnancy

• Abortion
• Ectopic pregnancy
• Hidatidiform mole
 Abortion/Miscarriage

• Definition: any fetal loss from conception until the time

of fetal viability at 24 weeks gestation. OR: Expulsion of
a fetus or an embryo weighing 500 gm or less
• Incidence: 15 - 20% of pregnancies total reproductive
losses are much higher if one considers losses that
occur prior to clinical recognition.
• Classification:
1. spontaneous: occurs without medical or mechanical
means.
2. induced abortion
 Pathology
• Haemorrhage into the decidua basalis.
• Necrotic changes in the tissue adjacent to the
bleeding.
• Detachment of the conceptus.
• The above will stimulate uterine contractions
resulting in expulsion.
 Causes of miscarriage
Fetal causes:
• 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 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 miscarriage
Maternal causes:
1. Immunological
2. uterine abnormality
3. Endocrine
 Types of abortion
• Threatened abortion.
• Inevitable abortion.
• Incomplete abortion.
• Complete abortion.
• Missed abortion
• Septic abortion: Any type of abortion, which is
complicated by infection
• Recurrent abortion: 3 or more successive
spontaneous abortions
 ECTOPIC PREGNANCY
• Pain, bleeding, fainting
• Examination – abdominal, vaginal
• Tenderness, cervical excitation tenderness
• Ultrasound – TVS
IU sac seen with Bhcg
>1500IU
• Serial Bhcg – doubling up in normal pregnancy
• Laparoscopy
 MANAGEMENT OF ECTOPIC PREGNANCY
• Haemo-dynamically unstable: surgery
• Surgical : Laparoscopic salpingotomy
Laparoscopic salpingectomy
Open Laparotomy
• Medical : Asymptomatic, small ectopic, low
Bhcg levels
Methotrxate
Need observation
• Conservative - only if haemodynamicaly stable,
asymptomatic, suggestive of tubal miscarriage
 Molar pregnancy
• Bleeding, passage of vesicles
• Large for gestational age
• High Bhcg
• Hyperthyroidism
• Ultrasound – snow storm appearance
• Suction Evacuation, rarely hysterectomy
• Persistence, chorio-carcinoma (1%)
• Methotrxate
Vaginal Bleeding in Late Pregnancy
• Placenta Previa
• Abruption
• Ruptured vasa previa
• Uterine scar disruption
• Cervical polyp
• Bloody show
• Cervicitis or cervical ectropion
• Vaginal trauma
• Cervical cancer
 Placenta Previa
Prevalence of Placenta Previa
• Occurs in 1/200 pregnancies that reach 3rd
trimester
• Low-lying placenta seen in 50% of ultrasound
scans at 16-20 weeks
- 90% will have normal implantation when
scan repeated at >30 weeks
- No proven benefit to routine screening
ultrasound for this diagnosis
 Risk Factors for Placenta Previa
• Previous cesarean delivery
• Previous uterine instrumentation
• High parity
• Advanced maternal age
• Smoking
• Multiple gestation
 Physical Exam – Placenta Previa
• Vital signs
• Assess fundal height
• Fetal lie
• Estimated fetal weight (Leopold)
• Presence of fetal heart tones
• Gentle speculum exam
• NO digital vaginal exam unless placental
location known
 Placental Abruption
• Premature separation of placenta from
uterine wall
• Partial or complete
• “Marginal sinus separation” or “marginal sinus
rupture”
• Bleeding, but abnormal implantation or
abruption never established
• Epidemiology of Abruption
Occurs in 1-2% of pregnancies
• Risk factors
Hypertensive diseases of pregnancy
Smoking or substance abuse (e.g. cocaine)
Trauma
Overdistention of the uterus
History of previous abruption
Unexplained elevation of MSAFP
Placental insufficiency
Maternal thrombophilia/metabolic abnormalities
Sher’s Classification - Abruption
• Grade I - mild, often retroplacental clot
identified at delivery
• Grade II - tense, tender abdomen and live
fetus
• Grade III with fetal demise
III A - without coagulopathy (2/3)
III B - with coagulopathy (1/3)