Early pregnancy

bleeding
1. Abortion
2. Ectopic pregnancy
3. GTD

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ABORTION

Gynacology,early pregnancy bleeding 2

 Session objectives
• Define abortion

• Describe the magnitude abortion

• Classify abortion based on different criteria

• Manage abortion based on their clinical
condition its relate complications
• List the component post abortion care
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 Introduction

Abortion is one of the leading cause of

maternal mortality it accounts
13% world wide
4% in Africa
32%in Ethiopia (facility based)
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 Introduction…………….

Globally every minute of every day:-

 380 women become pregnant

 190 women face unplanned or unwanted pregnancy

 110 women experience a pregnancy related complication

 40 women have an unsafe abortion

 1 woman dies from a pregnancy-related complication

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Gynacology,early pregnancy bleeding 6
 Causes of Maternal Death*

Others Haemorrhage
15% 10%
Sepsis
12%

Hypertention
Abortion 9%
32%
Obstructed
labor
22%

*Facility based
, Ethiopia
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 Definition
Abortion is expulsion of the products of
conception prior to viability of the fetus
(before 28 weeks of gestation) or less than

1000gm weight/
WHO gest. age<20 weeks or weight less
than 500 gm.
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 Classification of abortion
Based on:
 Etiologic
1. Spontaneous abortion a loss of a fetus due to natural
causes, before fetal development has reached 28 weeks
2. Induced abortion is the medical or surgical termination
of pregnancy before the time of fetal viability. it can be
legal or illegal, therapeutic (safe) or un safe( septic ).

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 Etiology

o chromosome problems(common 50%)

o Endocrine disorder like Luteal Phase defects

o Advanced age

o Drug and any poisons

o Exposure to environmental toxins

o Hormone problems

o Infection like TORCH

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 Etiology………….
o Multiple pregnancies
o Physical problems with the mother's
reproductive organs
o Problem with the body's immune response
o systemic diseases in the mother e.g. diabetes
o Smoking and alcohol
o Trauma Gynacology,early pregnancy bleeding 11
 Classification……………..
Based on gestational age
i. Early-less than 12 weeks
ii. Late-greater than 12 weeks

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 Classification………
Based on clinical feature
1.Threatened abortion
slight intermittent bleeding with or without cramping
The cervix remains closed and no cervical effacement
At least 20–30% of pregnant women have some first-trimester
bleeding.
In most cases, this is thought to represent an implantation bleed.
More than 50-80% go to term
RX-Bed rest and pelvic rest
-Avoid coitus, douching and strenuous exercise

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Gynacology,early pregnancy bleeding 14
 2.Inevitable abortion

The cervix has dilated, but the products

of conception have not been expelled
Abdominal or back pain and mild to
severe vaginal bleeding
cervical effacement, cervical dilatation,
and/or rupture of the membranes is noted.
It is Irreversible

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 Treatment

Depends on the gestational age:

1. GA less than 12weeks-insert misoprostol
and revise with MVA
2.GA greater than 12 weeks-D@C

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 3.Incomplete abortion

Some, but not all, of the products of conception have been

passed; retained products may be part of the fetus, placenta,
or membranes

In gestations of less than 10 weeks' duration, the fetus and

placenta are usually passed together. After 10 weeks, they
may be passed separately, with a portion of the products
retained in the uterine cavity.
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Sign and symptoms
o Cramps are usually present

o Profuse persistent bleeding

o HX of passing concepts tissue

o Some times visible or palpable concepts tissue through the
opening cervix
Complications
o Anemia, hemorrhage and infection
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18
 Treatment
 Evacuation based on gestational age

 Uterotonic agents

 Blood and fluid replacement

 Antibiotic

 The prognosis for the mother is excellent

if the retained tissue is promptly and
completely evacuated.
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 4.Complete abortion

All products of conception have been passed without

need for surgical or medical intervention.
 Slight bleeding may continue for a short time
 pain usually ceases after pregnancy has traversed the
cervix

Rx-observed for further bleeding.

-The products of conception should be examined.

-prognosis for theGynacology,early

mother pregnancyis excellent
bleeding 20
 5.Missed abortion

Def. a pregnancy in which there is a fetal demise (usually for a

number of weeks) but no uterine activity to expel the products of
conception.
Clinical features
 Regress sx/s of pregnancy , Uterine size decreased, cervix
closed, Brownish vaginal discharge

Complications

Infection, DIC, AF embolism

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 Treatment
Expectant management

-3-4 weeks follow up

-Clotting profile

Active management

>14weeks

- insert Prostaglandin or balloon catheter to dilate

Cervix and put on pittocin drip

<14 weeks :-MVA

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 6. Habitual abortion (recurrence )

Three or more consecutive spontaneous termination of pregnancy .

Causes:-

Cervical incompetence

Uterine malformation

Myoma

Infection –TORCH ,brucella

chromosomal , chronic malnutrition

Aloimminaization

Rx-treat causes ,cerclage (2nd trimester (14-18 wks)

-myomectomy

-Treat infection

-Anti-D Gynacology,early pregnancy bleeding 23

 7. Septic abortion
Abortion complicate by infection of the uterus

and sometimes surrounding structures .

C/F of septic abortion

Fever

Shivering ,restlessness

Abdominal pain and rebound tenderness

Vaginal discharge which is offensive

Low BP, tachypnea, tachycardia

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 Management of septic abortion
Lab.investgation- CBC,Hgb,blood group, RH ,cross
match ,BF,culture (blood ,pus and urine )

Give Antibiotics
Monitor –V/S,HCT

Blood transfusion (if needed)

TAT, anti D
Hysterectomy –in gangrenous ux ,sever
bleeding and uncontrolled.
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 Differential diagnosis

Idiopathic bleeding in a viable pregnancy

Ectopic pregnancy

Molar pregnancy

Infection of the vagina or cervix

Cervical abnormalities

Malignancy, polyps, trauma

Vaginal trauma Gynacology,early pregnancy bleeding 26
 Diagnosis

1.History
2.P/E
3.Laboratory
-HCG levels
-Progesterone levels

4.Ultrasound
- Status of the pregnancy
- Intrauterine? Ectopic?
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 Abortion ?or not?
Progesterone HCG Ultrasound Abortion?

Increases
>25 ng per mL Normal No
(48 hours)

Plateau or Nonviable
<5 ng per mL Yes
decrease pregnancy
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 Laboratory investigations

Blood type and RH factor

Complete blood count

HCG to confirm pregnancy

WBC and differential to rule out
infection Gynacology,early pregnancy bleeding 29
 Induced abortion

Induced abortion is the medical or surgical

termination of pregnancy before the time of fetal
viability. it can be legal or illegal, therapeutic
(safe) or un safe( septic )

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 Safe abortion

“ any procedure for terminating an unwanted

pregnancy (carried out) either by persons who
has the necessary skills or in an environment
fulfills minimal medical standards, or both . . .”
It can be terminated medically or

surgically!!!
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1.First trimester termination of pregnancy

Methods:

A. Medical
B. Surgical
*The choice is up to the mother

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 Medication abortion

 Safe and effective before 9 weeks from the

LNMP
 Highly successful when used with in 7 week

 Use mefiprosone (progesterone blocker) and

misoprostol (Prostaglandin analogue)-PGE1

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 Mifepristone
 1st developed and approved for clinical use in
1988 in France (RU-486)
 Blocks progesterone activity in the uterus,
leading to detachment of the pregnancy
 Causes the cervix to soften and uterus to
contract

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 Misoprostol

 Prostaglandin analogue that stimulates uterine

contractions
 Inexpensive, stable at room temperature, and
readily available in the market
 Easily absorbed orally or vaginally

 Commonly used for treatment of gastric ulcers

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 Effectiveness

 Combination of 2 drugs more effective than

either used alone
 92-98% effective in pregnancies 9 weeks
LMP

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 Contraindications
 Ectopic pregnancy (confirmed or suspected), or undiagnosed adnexal

mass

 Allergy to mifepristone, misoprostol or other prostaglandin

 Current use of long-term systemic corticosteroid

 Chronic adrenal failure

 Hemorrhagic disorder

 Current anticoagulant therapy

 Inherited porphyria

 IUD in place (remove before givingpregnancy

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bleeding 37
 Protocol for Misoprostol Administration
 Day 1 is defined as the day mifepristone is taken. Administer 200 mg
mifepristone orall
Vaginal use:

56 days/8 weeks On Day 2, 3 or 4, insert four 200mcg tablets

(800mcg total) of misoprostol

56–63 days/ 8–9 weeks On Day 2 or 3, insert four 200mcg tablets

(800mcg total) of misoprostol

Oral use:

49 days/7 weeks On Day 2 or 3, insert four 200mcg tablets

(800mcg total) of misoprostol

49–63 days/ 7–9 weeks Not recommended due to lower efficacy—use

vaginal misoprostol.

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Instructions for Vaginal Insertion

 Empty the bladder

 Wash hands

 Insert all misoprostol tablets, one after the

other
 Push tablets far up into the vagina
 No problem if tablets don’t fully dissolve
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 Misoprostol Alone

 Effectiveness: 85-90% ≤ 63 days/9 weeks

LMP
 Current recommended regimen:
-800 mcg misoprostol vaginally, taken two times
24 hrs apart = 1600 mcg total

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Abortion Complications

 Few serious complications

 Occasionally:
– continuing pregnancy
– hemorrhage
– infection

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Abortion Complications
 Severe or persistent hemorrhage life threatening.

 Sepsis develops most frequently after self-induced abortion.

 Intra abdominal injury

- Perforation of the uterine wall

- injury to the bowel and bladder
 Other complications of abortion
-Anemia
- Renal failure
-Infertility

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 Post abortion care
PAC is an approach for:-
 Reducing morbidity and mortality
from complications of unsafe and
spontaneous abortion, and
 improving women’s sexual and
reproductive health and lives.
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Essential Elements of Post abortion Care

1. Treatment
• Treat incomplete and un safe abortion and
potentially life threatening complications.

2. Contraceptive and family planning services

• Help women prevent unwanted pregnancy or
practice birth spacing.
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 cont..

3. Reproductive and other health services

• Preferably provide on - site, or via referrals to
other accessible facilities in provides’ networks.

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 Cont..

4. Community and service provider partnerships

• Prevent unwanted pregnancies and unsafe abortion.

• Mobilize resources to help women receive

appropriate and timely care for complications from
abortion.

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 Cont..

5. Counseling
• Identify and respond to women's emotional and
physical healthy needs and other concerns

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THANK YOU!

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