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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 discharge occur 2 days PH 3-7/28~30. she has occurred morning sickness for 7 days, pregnancy test (+),yesterday she found the brown discharge . No pain. She is very nervous and had a bad sleep.

case 2
female, 29, LMP July 11,2009 CC: Amenorrhoea for 7 weeks, vaginal bleeding accompany 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 dilated and something stayed in cervical canal. But didnt find any tissue expelled out.

case 3
female, 19, LMP august 12,2009 CC: Amenorrhoea for 9 weeks, vaginal bleeding accompany with cramping pain PH: 3-5/28~30 , the blood was as a heavy red loss with clots,and with conceptional products. Examinition: pale , cold and sweating. a low blood pressure , thin thread pulse. Vaginal examnition: some products were expelled and some material obstruct the endocervical canal. Advice: admit to hospital, transfusion and antishock, curettage and remove 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 isnt viable 2) gestational week is less than 28 weeks 3) the fetal weight is less than 500g

classification

abortion
spontaneous
isolated recurrent induced

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 the products of conception are retained within the uterus, and either become surrounded 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 abnormality of the embryo or chorion. About 70% of these abortions are associated with chromosomal abnormality. The incidence of chromosomal abnormality increases with maternal 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 infections: 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 termination. During pregnancy, unsupported membranes bulge through the dilated os, rupture and miscarriage generally follows.

Etiology (3)
B. Congenital malformation of the uterus in the form of bicornuate 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 (ashermans syndrome) has been linked to spontaneous abortion, caused by an inadequate amount of endometrium to support implantation. It may be a consequence of overzealous curettage or endometritis, may cause early fetal losses.

Etiology (4)
3) endocrine factors
An increased association of abortion is found in conditions of hypothyroidism, hyperthyroidism and diabetes mellitus. Inadequate corprs luteal state is considered to be related with unsatisfactory ovular growth and development and hence its expulsion.

4) Environmental factors
it is related to environmental toxins, radiation,and immunologic factors.Both smoking and alcohol consumption have been 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 containing foreign antigens which derive from the paternal genome. The exact mechanism by which the conceptus is protected from rejection by the host mother is not understood. At present the cause of abortion may be aberrations of the normal immunological mechanism. Women with autoimmune disease have a markedly increased incidence of abortion. systemic lupus erythematosus.

Mechanism of abortion (1)


In spontaneous early abortion, hemorrhage into the decidua basali offen occurs. Necrosis and inflammation appear in the region of implantation. The pregnancy becomes partially or entirely detached and is, in effect, a foreign body in the uterus. Uterine contractions and dilatation of the cervix result in expulsion of most or all of the products of conception. In the early weeks, death of the ovum occurs first, followed by its expulsion.

Mechanism of abortion (2)


In late abortions (missed abortion), several outcomes are possible. The retained fetus may undergo maceration, in which the skull bones collapse, the abdomen distends with blood-stained fluid, and the internal organs degenerate. The skin softens and peels off in utero or at the slightest touch. In the later weeks, maternal environmental factors (rupture, trauma) are involved leading to expulsion of the fetus which 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 with the decidual coverings, is expelled out intact. 8-13weeks: expulsion of the fetus commonly occurs leaving 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 abdominal pain after amenorrhea Early weeks ----Bleeding precedes abdominal pain.The
attachment of the chorion to the decidua is so delicate that separation may follow uterine contractions. The resulting hemorrhage into the choriodecidual space leads to further separation. So bleeding is before low abdomen pain.

8W complete abortion 8~12W incomplete abortion

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 bleeding. 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 prognosis in threatened abortion. the mainstay of scientific management is to confirm the diagnosis by identifying the presence of fetal cardiovascular pulsation on ultrasound scan as soon as possible. Fetal cardiovascular pulsation should be detectable by 7 weeks and an empty gestation sac after 8 weeks is a reliable sign of a non-continuing pregnancy. Ultrasonography is especially useful to determine if an early pregnancy is intact. Ultrasonography, in conjunction with quantitative 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 through the open os. Before the 10th week it is quite common for the entire contents of the uterus to be extruded, and for the abortion to become complete. After the 10th week the membranes often rupture and the fetus 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 unaided but some of the products of conception may be retained requiring surgical evacuation. If the abortion is not quickly completed, or if hamorrhage becomes severe, the contents of the uterus are removed manually or with a blunt suction curette. Conservative management of these patients significantly increases the risk of infection.

Inevitable abortion

Complete abortion
Complete abortion refers to a documented pregnancy that spontaneously aborts all of the products of conception. Early in pregnancy, the fetus and placenta are generally expelled in toto. On examination, pain is absent and bleeding is slight, the cervix has closed again. ultrasound Management Once the pain has ceased and the bleeding is minimal, no further treatment is generally needed, but an ultrasound scan can be requested to confirm that the cavity is empty.

Incomplete abortion
In this case some tissue is retained, bleeding and pain result. The uterus may be smaller than expected for the period of amenorrhea and the cervix is open. The amount of bleeding varies, but it can be severe enough to provoke hypovolamic shock.

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 gestation sac is retained in the uterus for several weeks or even months. These patients present with an absence of uterine growth and may have lost some of the early symptoms of pregnancy. Pelvic examination reveals a firm uterus which is smaller than 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 hypofibrinogenaemia, 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. There is no satisfactory explanation for many of these cases. Those before about the 12th week have been attributed to progesterone deficiency, but repeated midtrimester abortion may result from incompetence of the internal os of the cervix. Progesterone, cerclage

Recurrent abortion

Septic abortion
it is associated with infection of the genital organs. The uterine cavity may become infected before an abortion begins 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 temperature and increased pulse rate. There may be little vaginal bleeding and few uterine contractions; the cervical canal may remain closed. The lower abdomen is tender, with guarding, 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 organisms. Cephalosporin and metronidazole would be suitable.

Septic abortion
It is wose to continue antibiotic treatment for at least 5days after the temperature has returned to normal. Evacuation of the uterus will be required but should usually be deferred for about 24 hours to allow the benefit of the antibiotic therapy. However, in many cases the amount of bleeding is such that evacuation cannot be deferred, and the uterus should be emptied under anaesthesia with a suction curette or sponge forceps taking special care not to perforate the uterus as it is more friable in the presence of infection.

spontaneous abortion
threatened abortion
Bleeding Enlarged uterus Os closed, FH present

missed abortion
Bleeding ,undersi zed uterus, os closed , FH absent

inevitable abortion continuing pregnancy


Bleeding and pain. Undersized uterus 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 pregancy. Negative pregnancy test or quantitative hcg that is not properly increasing Adverse ultrasonic findings(eg.empty gestational sac, fetal disorganization, lack of fetal growth)