Haemorrhage

in early pregnancy

 Those related to the pregnant state

 Abortion
 Ectopic pregnancy
 Hydatidiform mole
 Those associated with the pregnant state
 Cervical lesions
 malignanc
 case 1

 Outpatient clinic----Aug.19, 2009

female, 23, LMP July 7,2009
CC: Amenorrhoea for 6 weeks, and a brown dischar
ge occur 2 days
PH 3-7/28~30.
she has occurred morning sickness for 7 days, pr
egnancy test (+),yesterday she found the brown di
scharge . No pain. She is very nervous and had a b
ad sleep.
case 2

female, 29, LMP July 11,2009

CC: Amenorrhoea for 7 weeks, vaginal bleeding a
ccompany with superapubic pain
PH: 3-7/28~30. a brown discharge 3d, and bright
bleeding for a day,
examination: vital signs normal. the cervical os dil
ated and something stayed in cervical canal. But
didn’t find any tissue expelled out.
case 3
female, 19, LMP august 12,2009
CC: Amenorrhoea for 9 weeks, vaginal bleeding accompany with cra
mping pain

PH: 3-5/28~30 , the blood was as a heavy red loss with clots,and w
ith conceptional products.
Examinition: pale , cold and sweating. a low blood pressure , thin th
read pulse.
Vaginal examnition: some products were expelled and some material
obstruct the endocervical canal.

Advice: admit to hospital, transfusion and antishock, curettage and r

emove the rest of the products from the endocervical canal
case 4
 female,31y, G6P0
 Chief Complaint(CC): 13+3weeks pregnant.,
 History of Present Illness(HPI): her menses is regular,her last
menstrual period (LMP)was Mar.25th, 2009,and her expected date
of confinement (EDC)is Jan.4th, 2010.45 days ago .
 Former pregnancy and generation condition:
 1999y. 40days’ gestation ,induced abortion ;
 2000y. 5months’ gestation spontaneous abortion ;
 2001y. 4months’ gestation spontaneous abortion ;
 2002y. 4months’ gestation spontaneous abortion ;
 2003y. more than 3months’ gestation missed abortion .
 PE: T 36.5℃, P 82 /min., Bp 120/80 mmHg ,
 Fetal heart rate: 140 bpm
 ABORTION
 Definition
Abortion is the termination of a pregnancy before the
period of viability which is considered to occur at 28th
week.
 International acceptance, the limit of viability is brought
down to either 20th week or fetus weighing 500g.
1) the fetus isn’t viable
2) gestational week is less than 28 weeks
3)   the fetal weight is less than 500g
 classification
abortion

spontaneous induced

isolated recurrent legal illegal

threatened inevitable complete incomplete missed septic

ABORTION----TYPE
 A threatened abortion is said to occur when a
pregnant patient bleeds or threatens to lose the
products of conception. About 80% of women
who threaten to abort carry on to a normal
delivery.
 An inevitable abortion occurs when a pregnant
patient not only bleeds but has uterine
contractions sufficiently strong and painful
enough to dilate the cervix, so that the products
of conception will eventually be passed through
the cervix.
ABORTION----TYPE
 An incomplete abortion occur when a
portion of the products of conception has
been expelled through the dilated cervix
but some products still remain in the
uterus.
 A complete abortion occurs when the
products of conception have been
completely expelled from the uterus.
ABORTION--special TYPE
 A missed abortion occurs when the fetus
dies following a threatened abortion but t
he products of conception are retained wit
hin the uterus, and either become surroun
ded with layers of inspissated blood or are
gradually absorbed.
ABORTION--special TYPE
 Recurrent abortion: refers to three or
more consecutive spontaneous abortions.

 A septic abortion occurs when organisms

invade the site of the implanted
pregnancy. It commonly follows
interference to the pregnancy.
Etiology(1)—Fetal factors, maternal factors, immunologic factors

1) Fetal factors ： chromosomal abnormalities

The commonest identifiable cause of early abortion is an abnor
mality of the embryo or chorion. About 70% of these abortions are
associated with chromosomal abnormality.
The incidence of chromosomal abnormality increases with mate
rnal age, approximately 50-60% of chromosomal abnormalites are
associated with a chromosomal defect of the conceptus.
Etiology (2)
2) maternal factors (infection, anatomic defects, endocrine
factors, Environmental factors)
 General disease of the mother : acute fevers, maternal infectio
ns: rubella,genital herpes,syphilis,toxoplasmosis, diabetes,
hypertension, renal disease, malnutrition
 anatomic defects
these are related mostly to the second trimester abortion.
A. cervical incompetence,it is usually the result of obstetric damage or
of excessive injudicious surgical dilation of the cervix for therapeutic ter
mination. During pregnancy, unsupported membranes bulge through th
e dilated os, rupture and miscarriage generally follows.
Etiology (3)
B. Congenital malformation of the uterus in the form of bico
rnuate or septate uterus may be responsible for midtrimester or
recurrent abortion.
C.uterine leiomyomata specially of the submucous variety
might be responsible not only for infertility but also for abortion
due to distortion of the cavity and increased uterine irritability
D.intrauterine synechiae (asherman’s syndrome) has been l
inked to spontaneous abortion, caused by an inadequate amount
of endometrium to support implantation. It may be a consequen
ce of overzealous curettage or endometritis, may cause early feta
l losses.
Etiology (4)

3) endocrine factors
An increased association of abortion is found in conditions
of hypothyroidism, hyperthyroidism and diabetes mellitus. Ina
dequate corprs luteal state is considered to be related with uns
atisfactory ovular growth and development and hence its expu
lsion.
4) Environmental factors
it is related to environmental toxins, radiation,and immun
ologic factors.Both smoking and alcohol consumption have bee
n linked to miscarriages.
Etiology (5)

5)trauma
Direct trauma on the abdominal wall by blow or fall or
operative trauma either vaginal or abdominal may be
related to abortion.
6)Psychic: emotional upset or change in environment
may lead to abortion by affecting the uterine activity.
Etiology (6)

7)Immune factors
the implanting embryo should be regarded as an allograft c
ontaining foreign antigens which derive from the paternal gen
ome. The exact mechanism by which the conceptus is protecte
d from rejection by the host mother is not understood.

At present the cause of abortion may be aberrations of the n

ormal immunological mechanism. Women with autoimmune
disease have a markedly increased incidence of abortion. syste
mic lupus erythematosus.
Mechanism of abortion (1)
In spontaneous early abortion, hemorrhage into the d
ecidua basali offen occurs. Necrosis and inflammatio
n appear in the region of implantation. The pregnanc
y becomes partially or entirely detached and is, in eff
ect, a foreign body in the uterus. Uterine contractions
and dilatation of the cervix result in expulsion of mos
t or all of the products of conception.
In the early weeks, death of the ovum occurs first, fol
lowed by its expulsion.
Mechanism of abortion (2)
In late abortions (missed abortion), several outcomes are p
ossible. The retained fetus may undergo maceration, in wh
ich the skull bones collapse, the abdomen distends with blo
od-stained fluid, and the internal organs degenerate. The s
kin softens and peels off in utero or at the slightest touch.

In the later weeks, maternal environmental factors (ruptu

re, trauma) are involved leading to expulsion of the fetus w
hich may have signs of life but is too small to survive. Pain
precede bleeding
Mechanism of abortion(3)
 Before 8 weeks: the ovum, surrounded by the villi wit
h the decidual coverings, is expelled out intact.
 8-13weeks: expulsion of the fetus commonly occurs l
eaving behind the placenta and the membranes. A part
of it may be partially separated with brisk hemorrhage
or remains totally attached to the uterine wall.
 Beyond 13th week: the process of expulsion is similar to that of
a “mini labor”. The fetus is expelled first followed by expulsion
of the placenta after a varying interval.
 Clinical features and pathologic change

The major symptom ： vaginal bleeding and abdomina

l pain after amenorrhea
Early weeks ： ----Bleeding precedes abdominal pain.The attach
ment of the chorion to the decidua is so delicate that separation may follo
w uterine contractions.
The resulting hemorrhage into the choriodecidual space leads to further
separation. So bleeding is before low abdomen pain.
 8W 以内， complete abortion 。
8~12W ，绒毛发育良好，不易完全剥离，表现为 incompl
ete abortion ，出血量较大。
Late ： Abdominal pain precedes bleeding
Clinical type :
Different steps of process of abortion

continue pregnancy
Threatened abortion complete
inevitable
incomplete
Clinical type
 Threatened abortion(symptoms)

 There is bleeding into the choriodecidual space. The

presentation is with unexpected and usually painless ble
eding.
Slight, dark, brown, no pain or dull pain
Pain appears usually following hemarrhage.
When abdominal cramps supervene the process may
move in the direction of inevitability, in particular if the
cervix opens.
.
Threatened abortion(signs)

On examination the cervix is closed and the uterus

is appropriately sized for gestation.
Abortion does not always follow, even after
repeated attacks of bleeding , some women with a
viable pregnancy will continue to term uneventfully.
Threatened abortion (Management)
No treatment has been demonstrated to alter the prognosi
s in threatened abortion. the mainstay of scientific manageme
nt is to confirm the diagnosis by identifying the presence of fet
al cardiovascular pulsation on ultrasound scan as soon as poss
ible. Fetal cardiovascular pulsation should be detectable by 7
weeks and an empty gestation sac after 8 weeks is a reliable si
gn of a non-continuing pregnancy.
Ultrasonography is especially useful to determine if an ear
ly pregnancy is intact. Ultrasonography, in conjunction with q
uantitative hCG, has been used to identify viable pregnancies
at various stages of gestation.
Inevitable abortion

 A threatened abortion becomes inevitable when

the membrane rupture/or cervix dilates. Bleeding
may increase while rhythmic and strong uterine
contractions may follow. Blood loss, low abdomen
pain
 An inevitable abortion can be complete or
incomplete depending on whether or not all fetal
and placental tissues have been expelled from the
uterus.
 The typical features of incomplete abortion are
heavy, sometimes intermittent, bleeding with
passage of clots and tissue, together with lower
abdominal cramps.
Inevitable abortion

The products of conception often can be felt thro

ugh the open os. Before the 10th week it is quite com
mon for the entire contents of the uterus to be extru
ded, and for the abortion to become complete. After
the 10th week the membranes often rupture and the f
etus is passed, leaving the placenta behind , and then
all the complications of an incomplete abortion may
arise.
Inevitable abortion

 Management of inevitable abortion

The uterus usually expels its contents unaide
d but some of the products of conception may be r
etained requiring surgical evacuation. If the abort
ion is not quickly completed, or if hamorrhage bec
omes severe, the contents of the uterus are remove
d manually or with a blunt suction curette. Conse
rvative management of these patients significantly
increases the risk of infection.
Inevitable abortion
Complete abortion

 Complete abortion refers to a documented pregnancy that sponta

neously aborts all of the products of conception. Early in pregnan
cy, the fetus and placenta are generally expelled in toto. On exami
nation, pain is absent and bleeding is slight, the cervix has closed a
gain. ultrasound

 Management
 Once the pain has ceased and the bleeding is minimal, no furthe
r treatment is generally needed, but an ultrasound scan can be req
uested to confirm that the cavity is empty.
Incomplete abortion

In this case some tissue is retaine

d, bleeding and pain result. The ut
erus may be smaller than expected
for the period of amenorrhea and t
he cervix is open. The amount of bl
eeding varies, but it can be severe
enough to provoke hypovolamic sh
ock.
Incomplete abortion

Management
The chief risks associated with retained products are
hemorrhage and sepsis.
Suction curettage of the uterus is usually necessary to
remove the remaining products of conception and prevent
further bleeding and infection. If the bleeding is severe there
may be shock, an intravenous line should be established and
blood given. And then perform evacuation.
Missed abortion

Missed abortion occurs when the embryo dies but the gestati
on sac is retained in the uterus for several weeks or even month
s. These patients present with an absence of uterine growth an
d may have lost some of the early symptoms of pregnancy.
Pelvic examination reveals a firm uterus which is smaller tha
n would be expected from the duration of amenorrhea and the
cervix is closed. Gestational test is negative.
Ultrosound scan
A rare complication is defective blood coagulation due to hyp
ofibrinogenaemia, because thromboplastins from the chorionic
tissue enter the maternal circulation.
Missed abortion

Management
All missed abortions are
eventually expelled
spontaneously , but
sometimes not for many
weeks. Once the diagnosis
has been made the uterus
should be emptied by suction
curettage.
Recurrent abortion

It is a term used when a patient has had more than two

consecutive or a total of three spontaneous abortions. The
re is no satisfactory explanation for many of these cases.
Those before about the 12th week have been attributed
to progesterone deficiency, but repeated midtrimester abo
rtion may result from incompetence of the internal os of th
e cervix.
Progesterone, cerclage
Recurrent abortion
Septic abortion ：

it is associated with infection of the genital organs. The u

terine cavity may become infected before an abortion begin
s as the result of a criminal attempt to procure abortion by
passing an unsterile instrument through the cervical canal.
The patient is ill with suprapubic pain, a raised temper
ature and increased pulse rate. There may be little vaginal
bleeding and few uterine contractions; the cervical canal m
ay remain closed. The lower abdomen is tender, with guard
ing, and the uterus is very tender on bimanual examination
.
Septic abortion ：

Management
All cases should be admitted to hospital. The
patient should be treated with a broad spectrum
antibiotic which includes cover for anaerobic org
anisms. Cephalosporin and metronidazole would
be suitable.
Septic abortion

It is wose to continue antibiotic treatment for at least 5

days after the temperature has returned to normal. Evacu
ation of the uterus will be required but should usually be d
eferred for about 24 hours to allow the benefit of the antibi
otic therapy. However, in many cases the amount of bleedi
ng is such that evacuation cannot be deferred, and the uter
us should be emptied under anaesthesia with a suction cur
ette or sponge forceps taking special care not to perforate t
he uterus as it is more friable in the presence of infection.
 spontaneous abortion
threatened abortion missed abortion
Bleeding Bleeding ,undersi
Enlarged uterus zed uterus,
Os closed, FH present os closed , FH
absent

inevitable abortion

continuing Bleeding and pain.

Undersized uterus
pregnancy Os open
Fh sometimes

incomplete abortion
Bleeding
Undersized uterus,
os open
Retained products
complete abortion
Minimal bleeding,
Normal sized uterus
Os closed,
cavity empty

classification of abortion
Essentials of diagnosis of
abortion
 Suprapubic pain and uterine cramping
 Vaginal bleeding
 Cervical dilatation
 Extrusion of products of conception
 Disappearance of symptoms and signs of pregan
cy.
 Negative pregnancy test or quantitative hcg that
is not properly increasing
 Adverse ultrasonic findings(eg.empty gestational
sac, fetal disorganization, lack of fetal growth)