Bleeding in early pregnancy

Differential Diagnosis of First-Trimester

Vaginal Bleeding

Implantation bleeding
Spontaneous abortion
Molar pregnancy
Ectopic pregnancy
Vaginal trauma
Idiopathic bleeding in a viable pregnancy
Cervical abnormalities (e.g., excessive
friability, malignancy, polyps, trauma)
Infection of the vagina or cervix


Implantation bleeding

After ovulation the egg travels into the uterus and
burrows into the lining of the uterus. For some
women implantation will cause slight bleeding or
spotting. This is called implantation bleeding. This
is sometimes confused for an early period. small
amount of vaginal bleeding around 11 or 12 days after
conception (close to the time of missed period).

Contd
The bleeding may be caused by the fertilized
egg burrowing into the blood-rich lining of
uterus a process that starts just six days
after fertilization
The bleeding is very light (appearing as red
spotting or pink or reddish-brown staining)
and lasts only a day or two.
Definition of abortion
Any process by which a pregnancy
ends with the death and removal or
expulsion of the fetus, regardless of
whether it's spontaneous or
intentionally induced,before the period
of viability.
Spontaneous abortion is the natural or
spontaneous end of a pregnancy at a
stage where the embryo or the fetus is
incapable of surviving, generally
defined in humans at a gestation of
prior to 20 weeks. (28 weeks)

Contd.
Very early abortion- those which
occur before the sixth week LMP are
medically termed early pregnancy
loss or chemical pregnancy.(sub-
clinical abortion)
Abortions that occur after the sixth
week LMP are medically termed
clinical spontaneous abortion.

Causes/Aetiology

Abortion can occur for many reasons,
not all of which can be identified.
25% unknown.
First trimester
Most abortions (more than three-quarters)
occur during the first trimester.
Chromosomal abnormalities are found in more
than half of embryos miscarried in the first 13
weeks. Most chromosomal problems happen by
chance, have nothing to do with the parents,
and are unlikely to recur.
A pregnancy with a genetic problem has a 95%
chance of ending in abortion. Genetic problems
are more likely to occur with older parents; this
may account for the higher abortion rates
observed in older women.

Contd
Another cause of early abortion may be
progesterone deficiency. Women
diagnosed with low progesterone
levels in the second half of their
menstrual cycle (luteal phase) may be
prescribed progesterone supplements,
to be taken for the first trimester of



Second trimester

Up to 15% of pregnancy losses in the
second trimester may be due to uterine
malformation, (fibroids), or cervical
incompetence.These conditions may also
contribute to premature birth.
One study found that 19% of second
trimester losses were caused by problems
with the umbilical
cord(knots,twists,entanglement).
Problems with the placenta
(circumvallate,infection,tumor)may also
account for a significant number of later-
term abortion.

Risk Factors for Spontaneous Abortion

Advanced maternal age
*Anesthetic gas use (e.g., nitrous oxide)
Chronic maternal diseases: poorly controlled
diabetes, celiac disease, autoimmune diseases
(particularly antiphospholipid antibody
syndrome),severe anemia,HT,chr.nephritis

Contd
Conception within three to six months after
delivery
Maternal infections: bacterial vaginosis;
mycoplasmosis, herpes simplex virus,
toxoplasmosis, listeriosis, chlamydia, human
immunodeficiency virus, syphilis, parvovirus B19,
malaria, gonorrhea, rubella, cytomegalovirus
Medications: misoprostol (Cytotec), retinoids,
methotrexate, nonsteroidal anti-inflammatory
drugs

Contd
Multiple previous elective abortions
Previous spontaneous abortion
exposure to environmental toxins :
arsenic, lead, ethylene glycol, carbon
disulfide, polyurethane, heavy metals,
organic solvents
Uterine abnormalities: congenital
anomalies, adhesions, leiomyoma

General risk factors

Pregnancies involving more than one
fetus are at increased risk of abortion.
Uncontrolled diabetes greatly
increases the risk of abortion. Women
with controlled diabetes are not at
higher risk ofabortion. Because
diabetes may develop during
pregnancy (gestational diabetes), an
important part of prenatal care is to
monitor for signs of the disease.

Contd
Tobacco (cigarette) smokers have an
increased risk of abortion. An increase in
abortion is also associated with the father
being a cigarette smoker.
Contd
Severe cases of hypothyroidism increase the
risk of abortion. The effect of milder cases of
hypothyroidism on abortion rates has not been
established. Certain immune conditions such as
autoimmune diseases greatly increase the risk
of abortion.
Cocaine use increases abortion rates.
Physical trauma, obesity, high caffeine intake (>
300 mg/day), high levels of alcohol
consumption, high fever (37.8C (= 100F) or
higher) , use of an IUD during the time of
conception.

Prevalence

Determining the prevalence of abortion
is difficult. Prospective studies using
very sensitive early pregnancy tests
have found that 25% of pregnancies are
aborted by the sixth week LMP .
The risk of abortion decreases sharply
after the 8th week, i.e. when the fetal
stage begins. Clinical abortions(those
occurring after the sixth week LMP)
occur in 8% of pregnancies.

Contd
The prevalence of abortion increases
considerably with age of the parents.
In women, by the age of forty-five, 75% of
pregnancies may end in abortion.
Forms and types
Blighted ovum/anembryonic pregnancy.
Threatened abortion
Inevitable abortion
Incomplete abortion
Missed abortion
Complete abortion
Septic abortion.
Recurrent/habitual abortion
Induced abortion-safe/unsafe.

anembryonic pregnancy

An empty sac is a condition where the
gestational sac develops normally,
while the embryonal part of the
pregnancy is either absent or stops
growing very early. Other terms for
this condition are blighted ovum and
anembryonic pregnancy.
Treatment-same as missed abortion.

threatened abortion
Process of abortion has started but has
not progressed to a state from which
recovery is impossible.
The clinical presentation of a
threatened abortion describes any
bleeding seen during pregnancy prior
to viability, that has yet to be assessed
further.
Pain-usually painless,may be
backache/ dull lower abdominal pain.
Management of threatened abortion
At investigation it may be found that
the fetus remains viable and the
pregnancy continues without further
problems.
Bed rest improves the chances of the
pregnancy continuing when a small
subchorionic hematoma has been
found on ultrasound scans.
Sedation, laxatives,progesterones-
micronised progesterone 100-
400mg/day or 17 OH progesterone
caproate (proluton depot)-250-
500mg/alt day and folic acid 5mg.

Contd
Advice on discharge-limited activity,
abstinence.
Prognosis-2/3
rd
preg continuous >28
wk, rest terminates in inevitable/
missed abortion.
Increased chance of preterm labor,
placenta previa, dysmature baby and
fetal malformation.
inevitable abortion
Type of abortion where the changes have
progressed to a state from where continuation of
pregnancy is impossible.
Gestational sac with fetus having
become detached from the
implantation site, leading to
spontaneous abortion within the next
few hours.


USG-inevitable abortion
Sac situated low within the uterus.
Sac surrounded by perigestational
hemorrhage.
Dilated cervix.
Uterine contractions originating in the
uterine fundus may be observed
sonographically.


Clinical feature & management
CF- increased vag. Bleeding, painful ut
cont, o/e the cervix has dilated, but the
products of conception have not been
expelled. 2
nd
trimester ROM.This usually
will progress to a complete abortion.
General condition proportionate to
blood loss.
Tt-Admission, termination-D&E in 1
st

trimester, oxytocin drip in 2
nd

trimester.

Incomplete abortion
When some, but not all, of the products of
conception have been passed; retained products
may be part of the fetus, placenta, or membranes.
Commonest
CF-H/o expulsion of a fleshy mass followed by
pain &vaginal bleeding.
O/e-uterus smaller than period of amenorrhoea,
patulous cervical os & POC can be felt,bleeding.



Contd
The products left behind may lead to-profuse
bleeding and shock,sepsis, placental polyp,and
rarely choriocarcinoma.
Management- Resuscitation if shock.
1
st
trim- D& E

2
nd
trim-exploration digital/ instrumental removal
of POC & sent for HPE.

Missed abortion
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.
It is also referred to as delayed
abortion.
Clinical presentation
*questionable vaginal bleeding
uterus small for dates
cervix is closed
few obvious symptoms
Diagnosis:
pregnancy test is either positive or negative
fetal heart, movements and ultrasound evidence
of fetal life are all absent
Management:

assess clotting status

ERPC

Rhesus prophylaxis if appropriate

Bleeding into the chorio-decidual space
may result in the formation of an
organized, laminated mass called a
carneous mole.

carneous mole

The bleeding and clot from a missed
abortion can become organised and
laminated, forming a carneous mole.
Histologically, there is an ovum
surrounded by clotted blood with a
disordered capsule intervening.





termination
In cases of an empty sac, or missed abortion
there are three treatment options:
With no treatment (watchful waiting), most of
these cases (65-80%) will pass naturally within
two to six weeks.
Medical-oxytocin-10-20units in 500ml dextrose,
can increase max upto 100units.
Prostaglandins-PGF2a 250 microgm 3hrly, max
10.
PGE2-gel 5mg,repeat. Vag suppository20mg 3
hrly 4 doses.
PGE1-misoprostol-400 microgm 4 hrly,6-8
doses. About 95% of cases treated with
misoprostol will complete within a few days.

Contd
Surgical- S&E in 1
st
trimester.
* Surgical treatment (most commonly
vacuum aspiration, sometimes referred
to as a D&C or D&E) is the fastest way
to complete the abortion. It also
shortens the duration and heaviness of
bleeding, and is the best treatment for
physical pain associated with the
abortion.In cases of repeated abortion
or later-term pregnancy loss, D&C is
also the best way to obtain tissue
samples for pathology examination.

complete abortion
A complete abortion is when all
products of conception have been
expelled without the need for surgical or
medical intervention.

Clinical features
*H/o expulsion of a fleshy mass pv
followed by subsidence of abdominal
pain .
*vaginal bleeding trace/absent

uterus small for dates

cervix is closed

few obvious symptoms

ultrasound-empty uterus with

thickened endometrium
Management
No treatment is necessary for a
diagnosis of complete abortion (as
long as ectopic pregnancy is ruled out).
* Assess effect of blood loss-treat.
If doubt-Check curettage.
Rh ve women- Anti D 50 microgm in
1
st
trim abortion & 100 microgm in
2
nd
trim abortion.
Septic abortion
Definition-A spontaneous/induced abortion that is
complicated by intrauterine infection.
Pathophysiology: Infection usually begins as
endometritis and involves the endometrium and
any retained products of conception. If not
treated, the infection may spread further into the
myometrium and parametrium. Parametritis may
progress into peritonitis. The patient may
develop bacteremia and sepsis at any stage of
septic abortion. Pelvic inflammatory disease
(PID) is the most common complication of
septic abortion.

Mortality/Morbidity
Septic abortion was once the leading cause of
maternal death around the world. The condition
remains a primary cause of maternal mortality in
the developing world, mostly as a result of illegal
abortions.
In the US, mortality from septic abortion rapidly
declined after legalization of abortion. Death now
occurs in less than 1 per 100,000 abortions.
The risk of death from septic abortion rises with
the progression of gestation.

Clinical Feature-
History: Any woman of childbearing age presenting
with fever, abdominal pain, vaginal discharge, or vaginal
bleeding should be evaluated for a possible septic
abortion.
Patients with septic abortion usually present with
complaints including the following:
Fever
Abdominal pain
Vaginal discharge
Vaginal bleeding
History of recent pregnancy

Physical:

Perform an abdominal examination with
attention to guarding, rebound tenderness,
and bowel sounds.
Perform a pelvic examination to assess
vaginal discharge, bleeding, cervical
motion tenderness, uterine and adnexal
tenderness, and masses.

Clinical grading
Grade I- The infection is localised in
uterus.
Grade II-The infection spreads
beyond the uterus to the
parametrium,tubes and ovaries or
pelvic peritoneum.
Grade III-Generalised peritonitis
and/or endotoxic shock or jaundice or
acute renal failure.
Causes:
Two major factors contribute to development of septic
abortion.
Retained products of conception due to incomplete
spontaneous or therapeutic abortion
Introduction of infection into the uterus - Pathogens causing
septic abortion usually are mixed and derived from normal
vaginal flora and sexually transmitted bacteria. These
organisms include the following:
Escherichia coli and other aerobic, enteric, gram-negative
rods,
Group B beta-hemolytic streptococci,Staphylococcal
organisms
Bacteroides species,Neisseria gonorrhoeae,Chlamydia
trachomatis,Clostridium perfringens,Mycoplasma hominis
Haemophilus influenzae


Lab Studies:
Complete blood count
Erythrocyte sedimentation rate
Beta-human chorionic gonadotropin; quantitative
levels may provide a basis for future comparison
Electrolytes, glucose, BUN, and creatinine
Blood type and screen
Endocervical cultures (eg, aerobic, anaerobic,
gonorrheal, chlamydial) and Gram stain
Blood cultures

Treatment
Hospitalisation.
Investigation,high vag /cervical swab for culture.
Monitor vital signs.Assess clinical grade.
Objective of tt-
*to control sepsis
*to remove the source of infection
*stabilise homeostasis.
*prevent complications
Grade-1
Early antibiotic treatment , but broad-spectrum coverage is
recommended
Antibiotics-Start Ampicillin, Gentamycin,
metronidazole.
Change after C&S report.
Prophylactic AGS/ATS if h/o interference.
BT,analgesic,sedative as required.
Perform evacuation of retained tissues from the uterine cavity,
preferably by dilation and curettage (D&C). If D&C is not
immediately available, high doses of oxytocin can be used.
Grade II
Antibiotics
Evacuation of uterus after 48 hrs of
antibiotic.
Posterior colpotomy in pelvic
abscess(spiky rise of temp,rectal
tenesmus,frequent loose stools,boggy
mass/fullness in posterior fx)
Laparotomy may be needed if the above measures elicit
no response.

Grade III
Stabilize with IV fluids through a large-bore
angiocatheter.(eg, normal saline, Ringer lactate).
For patients who are unstable, administer oxygen and
insert a Foley catheter.
Administer aggressive antibiotic therapy.
Monitor temperature, vaginal discharge, and bleeding.
Laparotomy indicated in-injury to the uterus/gut,FB in
abd,peritonitis pyoperitonium,septic shock not
responding to tt. Drainage of pus & lavage if nothing
found.
A hysterectomy may be necessary in cases of uterine
perforation, bowel injury, clostridial myometritis, and
pelvic abscess.












Prevention
Contraception to prevent unwanted pregnancies
Safe and legal abortions
Easy access to prenatal care
Prompt diagnosis of septic abortion
Timely treatment with IV antibiotics
Prompt evacuation of retained tissue from the
uterus


Complications:


Pelvic inflammatory disease
Peritonitis
Hemorrhage
Sepsis
Septic shock
Inferior vena cava thrombosis

Pathology

When looking for gross or microscopic
pathologic symptoms of miscarriage,
one looks for the products of
conception. Microscopically, these
include villi, trophoblast, fetal parts,
and background gestational changes
in the endometrium. Genetic tests
may also be performed to look for
abnormal chromosome arrangements.

Psychological aspects

Although a woman physically recovers from a
abortion quickly, psychological recovery for
parents in general can take a long time. People
differ a lot in this regard: some are 'over it' after
a few months, others take more than a year.
Still others may feel relief or other less negative
emotions.
Interaction with pregnant women and newborn
children is often also painful for parents who
have experienced abortion. Sometimes this
makes interaction with friends, acquaintances
and family very difficult.


Recurrent spontaneous abortion

Recurrent pregnancy loss (RPL)
(medically termed habitual
abortion) is the occurrence of 3
consecutive abortions. A large
majority (85%) of women who
have had two abortion will
conceive and carry normally
afterwards, so statistically the
occurrence of three abortions is
regarded as "habitual".