Bleeding in Early Pregnancy
Bleeding in Early Pregnancy
Bleeding in Early Pregnancy
OUTLINE OF PRESENTATION
DEFINITION
AETIOLOGY
PATHOPHYSIOLOGY
CLASSIFICATIONS
INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS
TREATMENT
DEFINITION
Genetic factors,
Environmental factors,
Anatomic causes,
Infectious causes,
Immunologic problems.
AETIOLOGY-1
20-25% of fertilized ovum end up in miscarriage
Maternal Causes
Congenital anomalies
Infections- malarial parasites, gonorrhoea, syphilis
causes acute fever- interferes with placental
oxygenation
Chronic medical conditions- renal disease,
hypertension
Drugs- large doses of drugs are poisonous, avoid
working in industries- toxic substances
AETIOLOGY-2
Fetal
Ovum abnormalities
Developmental abnormalities of zygote, embryo, fetus,
placenta
Sperm anomalies
Chromosomal anomalies- >30% of 2nd trimester
abortions
Combined
Stress and exhaustion affect functioning of the
hypothalamic region of the puituary gland- affects
uterine activity and causes abortion.
Haemorrhage into decidua basalis causes necrosis
CONT
Immunological factors- ABO incompatibility
Anatomical causes- congenital anomalies like a
retroverted uterus is not able to rise out the pelvis
may occasionally predispose to abortion. This
anomaly can be detected on abnominal ultrasound
scan. Early detection allows correction.
Developmental defects like bicornuate uterus and
myomas distort uterine cavity and inhibit uterine
enlargement may cause mid-trimester abortion.
CONT
Cervical incompetence- may be present due to
congenital weakness, trauma resulting from
previous dilatation and curettage.
Cervical cerclage /Shirodkar suture- a purse-string
suture of strong non- absorbable material is
inserted beneath the cervicovaginal mucosa to
encircle the cervix at the level of internal os and
then tied, and can be removed btn 38th-39th weeks
of gestation.
PATHOPHYSIOLOGY
Improper fertilization
Failure of development of the fertilized ovum
Failure of implantation
Detachment from endometrium
Hostile endometrium
Cervical incompetence
CLASSIFICATION/TYPES
According to Onset
Spontaneous
Induced
Medical
Criminal
According to Stage of abortion
Threatened abortion: bleeding without opening of the cervix
and/or evacuation of POC; it resolves by itself with no medical
treatment
Inevitable- bleeding with contractions and dilation of cervix and
POC are visible, pregnancy will not continue and will proceed to
incomplete or complete abortion
Incomplete-products of conception partially passed
Complete abortion: POC are completely expelled
Light bleeding*
Closed cervix
Uterus corresponds to date
Cramping Lower abdominal pain
Uterus softer than normal
• Heavy bleeding
• Dilated cervix
• Uterus corresponds to dates
• Cramping Lower abdominal
pain
• Tender uterus
• No expulsion of products of
conception
Heavy bleeding**
Dilated cervix
Uterus smaller than
dates Cramping
Lower abdominal
pain
Partial expulsion of
products of
conception
Light bleeding
Closed cervix
Uterus smaller than dates
Uterus softer than normal
Light cramping
Lower abdominal pain
History of expulsion of products
of conception
CLASSIFICATION
Missed- Dead fetus retained without expulsion
Blighted ovum->50% degenerated or absent embryo
According to complications
Septic –fever over 38 due to infection/parametritis-
septicemia
INDUCED ABORTION
Termination of pregnancy through a deliberate
intervention intended to end the pregnancy
Can be conducted in either a safe or an unsafe
medical setting according to legal and health
policy guidelines, or it may occur outside the
medical system.
DISTINCTION BETWEEN SAFE AND UNSAFE ABORTION
Safe abortion
is a procedure and technique performed by trained health-care
providers with proper equipment, correct technique, and
sanitary standards.
Unsafe abortion
a procedure performed either by persons lacking necessary
skills or in an environment lacking minimal medical standards
or both.
Sepsis conditions are a frequent complication of unsafe
abortion involving unsterilized instrumentation and procedure.
CLINICAL FEATURES
Major
PV Bleeding
Lower abdominal pain
Period of amennorhoea
Associated
Fever
Shock
Anaemia
DIFFERENTIAL DIAGNOSIS
Urinary Tract Infection
Ectopic Pregnancy
Specific
B-hcg
Ultrasound
TREATMENT
Supportive
Correct complications
Surgical
Evacuation
D&C
MVA
Septic Incomplete
Antibiotics
Fluid management
Evacuation
Incomplete Abortion
If bleeding is slight to moderate and pregnancy is less
than 16 weeks, use fingers or ring (or sponge) forceps to
remove products of conception protruding through the
cervix.
If bleeding is heavy and pregnancy is less than 16 weeks,
evacuate the uterus: MVA is the preferred method of
evacuation. Evacuation by sharp curettage should only
be done if MVA is not available.
If evacuation is not immediately possible, give
ergometrine 0.2 mg IM (repeated after 15 minutes if
necessary) or misoprostol 400 ug orally (repeated once
after 4 hours if necessary).
MANAGEMENT (CONT)
Incomplete Abortion
If pregnancy is greater than 16 weeks:
infuse oxytocin 40 units in 1 L IV fluids (normal saline
or Ringer’s lactate) at 40 drops per minute until
expulsion of POC occurs.
if necessary, give misoprostol 200 mcg vaginally every 4
hours until expulsion, but do not administer more than
800 mcg.
evacuate any remaining POC from the uterus.
ensure follow-up of the woman after the treatment.
MANAGEMENT(CONT)
Complete Abortion
Evacuation of the uterus is usually not necessary.