Bleeding in Early

Pregnancy
Objectives: at the end of this lecture the student
will be able to:
• Type causes of bleeding in early pregnancy.
• Define abortion.
• List different types of abortion.
• Mention clinical picture, prognosis and management of each type.
• Differentiate between all types.
• Define ectopic pregnancy.
• List possible sites for ectopy.
• Mention fate of ectopic pregnancy.
• Define Hydatidiform mole of pregnancy.
• Mention possible causes and prognosis the mole preg.
Causes:
• Abortion.
• Ectopic pregnancy.
• Vesicular mole.
• Local gynaecological lesions e.g. cervical ectopy, polyp, dysplasia,
carcinoma and rupture of varicose vein.
I - ABORTION
 Definition
Termination of pregnancy before viability of the foetus i.e. before 28 weeks
(in Britain) and before 20 weeks or if the foetal weight is less than 500 gm
(in USA and Australia).

When the abortion occurs spontaneously, the term " miscarriage" is often
used.
Aetiology

• Chromosomal abnormalities: cause at least 50% of early abortions e.g.

trisomy.
• Blighted ovum (anembryonic gestational sac).
• Maternal infections: Acute fever for whatever the cause can induce
abortion.
• Trauma: external to the abdomen or during abdominal or pelvic
operations.
• Endocrine causes: Progesterone deficiency ,Diabetes mellitus,
Hyperthyroidism.
• Drugs and environmental causes:
• Maternal anoxia and malnutrition.
• Over distension of the uterus: e.g. acute hydramnios.
Continued,

• Immunological causes:
• Systemic lupus erythematosus.
• Antiphospholipid antibodies that are directed against platelets
and vascular endothelium leading to thrombosis, placental
destruction and abortion.
• Ageing sperm or ovum.
• Uterine defects Septum, Asherman's syndrome
(intrauterine adhesions).
• Nervous, psychological conditions and over fatigue.
• Idiopathic.
Threatened Abortion

Clinical picture:
• Symptoms and signs of pregnancy coincide with its
duration.
• Vaginal bleeding slight or mild, bright red in colour.
• Pain is absent or slight.
• Cervix is closed.
• Pregnancy test is positive.
• Ultra-sonography shows a living foetus.
Prognosis:

• If the blood loss is less than a normal menstrual flow and is not
accompanied by pain of uterine contraction there is a reasonable
chance for continuing pregnancy. This occurs in 50% of cases while
other half will proceed to inevitable or missed abortion.
Treatment:

• Rest in bed until one week after stoppage of bleeding.

• No intercourse as it may disturb pregnancy by the
mechanical effect and the effect of semen
prostaglandins on the uterus.
• Sedatives: if the patient is anxious.
• Treatment of controversy:
• Progestogens.
• Gonadotrophins may be of benefit in cases of luteal phase
deficiency and those get pregnant with ovulatory drugs.
Inevitable Abortion

Clinical picture:
• Symptoms and signs of pregnancy coincide (match) with
its duration.
• Vaginal bleeding is excessive and may accompanied
with clots.
• Pain is colicky felt in the suprapubic region radiating to
the back.
• The internal os of the cervix is dilated and products of
conception may be felt through it.
• Rupture of membranes between 12-28 weeks is a sign
of the inevitability of abortion.
Treatment

• Any attempt to maintain pregnancy is useless.

Incomplete Abortion

• Retention of a part of the products of conception inside the uterus. It

may be the whole or part of the placenta which is retained.
Clinical picture

• The patient usually noticed the passage of a part of the conception

products.
• Bleeding is continuous.
• The uterus is less than the period of amenorrhoea but still large in
size. The cervix is opened and retained contents may be felt through
it.
• Ultrasonography: shows the retained contents.
Complete Abortion

• All products of conception have been expelled from the

uterus.
Clinical picture:
• The bleeding is slight and gradually diminishes.
• The pain ceases.
• The cervix is closed.
• The uterus is slightly larger than normal.
• Ultrasound: shows empty cavity.
Missed Abortion

• Retention of dead products of conception for 4 weeks or more.

Symptoms:
• Symptoms of threatened abortion may or may not be developed.
• Regression of pregnancy symptoms as nausea, vomiting and breast
symptoms.
• The abdomen does not increase and may even decrease in size.
• The foetal movements are not felt or ceases if previously present.
• A dark brown vaginal discharge may occur (prune juice discharge).
Signs:
• The uterus fails to grow and becomes firmer and The
cervix is closed.
• The foetal heart sounds cannot be heard.
Investigations:
• Pregnancy test becomes negative within two weeks from
the ovum death.
• Ultrasound shows either a collapsed gestational sac,
absent foetal heart movement or foetal movement.
Complications:

• Disseminated intravascular coagulation (DIC) may occur if the dead

conceptus is retained for more than 4 weeks.
• Superadded infection.
Treatment:

• The dead conceptus is expelled spontaneously in the

majority of cases.
Evacuation of the uterus is indicated in the following
conditions:
• spontaneous expulsion does not occur within four
weeks,
• there is bleeding,
• infection or DIC developed or,
• patient is anxious. Although some gynaecologists advise
evacuation of the uterus once sure diagnosis of missed
abortion is made.
Evacuation is carried out as following:

• If the uterine size is less than 12 weeks’ gestation:

vaginal or suction evacuation is done
• If the uterine size is more than 12 weeks' gestation:
evacuation can be done by
• Prostaglandins: given intravaginally (PGE2), intravenously, intra-
or extra- amniotic (PGF2α).
• Oxytocin infusion.
• Combination.
• Hysterotomy: is rarely indicated in 2nd trimester missed
abortion if the medical induction fails initially and after
repetition few days later.
Septic Abortion

• It is any type of abortion, usually criminal abortion, complicated by

infection.

• Microbiology:
• E.Coli, bacteroids, anaerobic streptococci, clostridia, streptococci and
staphylococci are among the most causative organisms.
Clinical picture:

• General examination:
• Pyrexia and tachycardia.
• Rigors suggest bacteraemia.
• A subnormal temperature with tachycardia is ominous and
mostly seen with gas forming organisms.
• Malaise, sweating, headache, and joint pain.
• Jaundice and /or haematuria is an ominous sign, indicating
haemolysis due to chemicals used in criminal abortion or
haemolytic infection as clostridium welchii.
• Abdominal examination:
• Suprapubic pain and tenderness.
• Abdominal rigidity and distension indicates peritonitis.
• Local examination:
• Offensive vaginal discharge. Minimal inoffensive vaginal discharge is
often associated with severe cases.
• Uterus is tender.
• Products of conception may be felt.
• Local trauma may be detected.
• Fullness and tenderness of Douglas pouch indicates pelvic abscess
which will be associated with diarrhoea.
Treatment

• Isolate the patient . Bed rest in semi-sitting

position??????????????????.
• An intravenous line is established for therapy.
• Observation for vital signs:
• A cervico-vaginal swab is taken for culture and
sensitivity,
• Antibiotic therapy:.
• Fluid therapy:
• Blood transfusion: is given if CVP is low (normal: 8-
12 cm water).
 Continued,

• Oxytocin infusion: to control bleeding and enhances expulsion of the

retained products.
• Surgical evacuation of the uterus can be done after 6 hours of
commencing IV therapy but may be earlier in case of severe bleeding or
deteriorating condition in spite of the previous therapy.
• Hysterectomy may be the last choice to safe life
Other types of abortion

Therapeutic Abortion
• Abortion induced for a medical indication.
Criminal Abortion
• Illegal abortion induced for a non-medical indication.
Recurrent (Habitual) Abortion
• Three (two by some authors) or more consecutive abortions.
Ectopic pregnancy
Definition

• Ectopic means "out of place." In an ectopic pregnancy, a fertilized egg

has implanted outside the uterus. The egg settles in the fallopian
tubes in more than 95% of ectopic pregnancies. This is why ectopic
pregnancies are commonly called "tubal pregnancies.
Signs and Symptoms

• Ectopic pregnancy can be difficult to diagnose because symptoms

often mirror those of a normal early pregnancy. These can include
missed periods, breast tenderness, nausea, vomiting, or frequent
urination.
• The first warning signs of an ectopic pregnancy are often pain or
vaginal bleeding.
Most common site
Other sites
Fate of ectopic pregnancy

• Tubal abortion

• Tubal rupture
Morbidity and Mortality Rates

• Abdominal pain occurs in 97% of women with an

ectopic pregnancy,
• Vaginal bleeding in 79%,
• abdominal tenderness in 91%, and infertility in 15%.
• Persistent ectopic pregnancy after surgical treatment
occurs in 5–10% of cases.
• Ectopic pregnancy accounts for 10–15% of all maternal
death; the mortality rate for ectopic pregnancy is
approximately one in 2,500 cases.
Hydatidiform pregnancy
Hydatidiform Mole

• A hydatidiform mole is a relatively rare condition in

which tissue around a fertilized egg that normally would
have developed into the placenta instead develops as
an abnormal cluster of cells. (This is also called a molar
pregnancy.) This grapelike mass forms inside of the
uterus after fertilization instead of a normal embryo.
 Causes

• The cause of hydatidiform mole is unclear;

• some experts believe it is caused by problems with the chromosomes
• A mole sometimes can develop from placental tissue that is left behind
in the uterus after a miscarriage or childbirth.
Symptoms

• Women with a hydatidiform mole will have a positive pregnancy test

and often believe they have a normal pregnancy for the first three or
four months.
• However, in these cases the uterus will grow abnormally fast.
• By the end of the third month, if not earlier, the woman will
experience vaginal bleeding ranging from scant spotting to excessive
bleeding.
• Sometimes, the grapelike cluster of cells itself will be shed with the
blood during this time.
• Other symptoms may include severe nausea and vomiting and high
blood pressure. As the pregnancy progresses, the fetus will not move
and there will be no fetal heartbeat.
Prognosis

• A woman with a molar pregnancy often goes through

the same emotions and sense of loss.
• In addition, there is the added worry that the tissue left
behind could become cancerous.
• In the unlikely case that the mole is cancerous the cure
rate is almost 100%. As long as the uterus was not
removed, it would still be possible to have a child at a
later time.
Summary