ABNORMAL MIDWIFERY

(Bleeding in early Pregnancy) by: Florence Wambua

First Trimester
Any bleeding in pregnancy is abnormal and is of concern to any mother. To the midwife, this is something to be taken very seriously even if there has not been any history of previous fetal loss. The midwife should establish the following through history taking:

Cont.
At what obstetrical age the bleeding occurred. How much blood was lost. The color of the blood. Was it associated with any pain? Have the symptoms subsided since then.

Cont.
After taking history, the next step should be to do fetal assessment to determine the condition of the baby. The best method to do this would be ultrasound because even in very young pregnancies, the viability of fetus can be determined even before the establishment of fetal heart sounds loud enough to be heard over the fetal-scope.

Causes of bleeding in early pregnancy

Implantation bleeding Cervical eversion Carcinoma of the cervix Abortions/Miscarriages Ectopic pregnancy Hydatidiform mole (gestational trophoblastic disease.) Retroversion of the uterus

Implantation bleeding
This bleeding occurs as part of the normal implantation process. It is not a cause of alarm, the bleeding is small and occurs around the time of expected menstruation and may be mistaken for a period and makes calculation of the EDD false.

Cervical Eversion
This is not the same as cervical erosion and requires no treatment in pregnancy. The cervix is composed of 2 types of cells: columnar epithelium in the canal reaching the external os and stratified squamous cells that cover the vaginal side of the cervix.

Cont
High levels of oestrogen in pregnancy cause the junction to be everted into the vagina and bleeding may occur especially after intercourse. This is because this cells at the junction are highly vascularised and may cause intermittent blood loss in addition to the spontaneous blood loss after sexual acts.

Carcinoma of the cervix

This is the most diagnosed cancer in pregnancy. Most are discovered in the first and second trimesters. This condition is treatable if discovered early in pregnancy. It is caused by HPV type 16(human papillomavirus).

Risk factors
Sexual behaviour: women who become sexually active at an early age, many partners and unprotected sex. Smoking: women smokers are 2 times at risk. Pregnancy: women with a late 1st pregnancy have a lower risk. Risk also increases with parity. Social class: women in manual social class have an increased risk.

Clinical Signs and investigations

Bleeding is the most common symptom. Investigation is mostly through a papanicolaou smear test (pap smear). When changes are detected through the pap smear then colposcopy is done and a cone biopsy taken for subsequent tests.

Treatment
This depends on the stage of the disease and gestation. Laser treatment or cryotherapy following colposcopy can be carried out as outpatient. Cone biopsy is done under general anasthesia and may be dangerous to the mother. There is risk of severe hemorrhage and miscarriage.

Delaying treatment until the end of pregnancy is an option for women with early changes in cervical cytology. If the changes are advanced and diagnosis is done in the 1st or 2nd trimester, the mother may have to choose between treatment and keeping the baby. In later pregnancy, the decision to deliver the fetus may be taken to allow mother to start treatment.

Abortion/ Miscarriage
a.) Spontaneous miscarriage This is the involuntary loss of the products of conception before 26 weeks. Loss before 12 weeks is early miscarriage whereas after 13 weeks its called late miscarriage.

Causes
Fetal causes: chromosomnal abnormalities. Maternal causes: advanced maternal age, structural abnormalities of the genital tact, infections, maternal medical conditions, excessive use of alcohol, coffee and cigarette smoking.

Types of Spontaneous miscarriages

Spontaneous abortion

Threatened

Inevitable

Pregnancy progress

Missed

Incomplete

Complete

Birth of viable infant

Blood mole

Septic

Threatened Miscarriage
Any vaginal bleeding during pregnancy should be treated as threatened miscarriage until proven otherwise. Blood loss may be little with or without back pain and cramp like pains. The cervix remains closed and the uterus soft. symptoms may continue for sometime then stop. Out come?

Inevitable Miscarriage
Patient is usually admitted in the hospital. A urine sample is taken for a pregnancy test and vital signs taken. Blood taken to confirm Rhesus factor and anti-D given within 72 hours if she is negative. A transvaginal ultrasound is taken to confirm if any products of conception remain.

Vaginal bleeding may be heavy with clots or gestational sac containing the embryo or fetus. The uterus if palpable may be smaller than expected. The membranes can rupture at this time, and amniotic fluid will be seem. The cervix dilates and tissue or clots may be seen in the vagina or cervical os. Blood loss may be excessive and oxytocin 20 units IV may be given.

Cont
Dilatation and curretage are now not the only method for treating this form miscarriage. some patients may present with shock that is inconsistent with the blood loss because some of the POCs may be trapped in the cervix and will resolve with their removal.

Pain may be a lot and adequate analgesia should be provided to the mother. The mother and partner should be informed of the outcome of the abortion and proper support, dignity and care accorded to them. Sometimes a live fetus is born especially in the 2nd trimester, in that case the baby should be resuscitated and a pediatrician informed. Mother should hold this baby.

Incomplete Miscarriage
In this case POCs remain within the uterine cavity making bleeding heavy and profuse. Oxytocin may be given to control the bleeding, evacuation should be done under General anasthesia. Blood loss estimates is poor so treat hypovolemia before anasthesia.

Complete Miscarriage
In this case, all the POCs have been expelled completely from the uterus. The pain stops and signs of pregnancy regress. On palpation, the uterus is contracted and firm and on ultrasound an empty uterus is seen. No further treatment is needed unless patient develops pyrexia or bleeding.

Missed Miscarriage
Also known as silent or delayed. In this case the fetus dies despite the presence of a viable placenta but is not expelled from the uterus. Death occurs at 8wks gestation but the body does not recognise it. A brown loss is seen as the placenta degenerates. Symptoms of pregnancy cease and uterine growth stops.

Management
Administration of prostagladins is done and in some cases that is all the intervention required. Evacuation of the uterus under general anasthesia. Use of prostaglandins before surgery help to dilate the cervix gently. Blighted ovum should be avoided.

Septic Abortion
This is a complication of missed abortion or induced abortion because of ascending infection. In addition to the signs of miscarriage, mother reports feeling unwell may have a headache, nausea and high temperature. Blood culture and vaginal swabs identify the bacteria and its antibiotics.

b.) Induced Abortion

This is termination of pregnancy as a choice of the mother up to 12 weeks gestation. It may be legal or illegal depending on the laws of ones country or circumstances surrounding the pregnancy.

Assignment 2
Is induced abortion legal in Rwanda? What is the role of the midwife in Rwanda if he/she encounters a case of induced abortion? Research and write a report.

Ectopic Pregnancy
This is when implantation takes place in a site other than the uterine cavity e.g uterine tube, ovary, cervix and the abdomen. Midwives must consider that ectopic pregnancy is the cause in unexplained abdominal pain and bleeding in early pregnancy.

Risk Factors for Ectopic pregnancy

Previous history of ectopic pregnancy. Previous surgery on the uterine tube. Exposure to diethylstilboestrol in utero. Congenital abnormalities of the tube. Previous infection including chlamydia, gonorrhea, and pelvic inflammatory disease. Use of intrauterine contraceptive devices. Assisted reproductive techniques.

Physiology of ectopic pregnancy

The blastocyst embeds in the decidua and the trophoblast erodes the maternal tissue anchoring the developing embryo. It rapidly grows distending the tube, exposing the maternal vessels and the pressure caused by the resultant blood flow can destroy the embryo.

outcomes
Tubal abortion the developing conceptus is expelled through the fimbriated end of the tube, especially in ampullary implantation. Tubal mole bleeding around the embryo results in its death. The blood clots around the conceptus enclosing it. Products are retained in the tube and may need to be removed.

Tubal rupture the wall is distended by the pregnancy and penetrated by the trophoblast to such an extent that it raptures. Abdominal pregnancy. Maternal death.

Clinical Picture
Rarely remains asymptomatic for more than 5 weeks. It may be difficult to diagnose but with each delay, the risk to losing the mother increases. Mother presents with vaginal spotting following a short period of amenorrhea, abdominal pain, dizzines, nausea and shoulder pain.

Pelvic pain when present is severe. N/B Acute symptoms are the result of tubal rupture and relate to the degree of hemorrhage there has been. Atypical signs such as unexplained abdominal pain due to bleeding into the peritoneal cavity causing distension can delay diagnosis fatally. Pleuritic chest pain can be a sign of diaphragmatic irritation. Vomiting with or without diarrhea.

Diagnosis and Treatment

Ultrasound is an accurate diagnosis. In a case of uterine rupture, shock may ensue therefore resuscitation would be followed by a laparatomy to try and stem the bleeding and repair the damaged tube as well as remove the products of conception.

Gestational trophoblastic disease

This term covers hydatidiform mole, trophoblastic tumor and choriocarcinoma. a.) Hydatidiform mole This is a malformation of the trophoblast in which the chorionic villi proliferate and become avascular. Found mostly in the uterus and rarely in the tubes.

Risk factors
Women who have had a molar pregnancy. Women under the age of 20 and over the age of 40. Women of Asian origin. NB. Accurate diagnosis is important as it can lead to the development of cancer; choriocarcinoma.

Types
There are 2 types of moles: a.) complete hydatidiform mole In this instance there is no evidence of embryo, cord or membranes. Death occurs prior to the development of the placental circulation. The chorionic villi change to form clear, hydropic vesicles which hang in clusters from pedicles like grapes.

Cont.
Hyperplasia occurs and the growth can mimic that of an advanced gestation. The trophoblast as usual will penetrate the myometrium to anchor the conceptus and can penetrate even beyond the uterus. Rupture of the uterus with massive hemorrhage is a possible outcome.

Cont
Complete moles have 46 chromosomes of paternal origin only. This happens because a sperm fertilises an empty egg, the maternal chromosomes being lost. Choriocarcinoma can develop from this type.

b.) Partial mole

In this case there is the evidence of an embryo, fetus or amniotic sac as death has occurred on the 8th or 9th week. Analysis reveal this to have 69 chromosomes; one maternal and 2 paternal. Risk to develop choriocarcinoma is slight.

Clinical presentation
Symptoms vary according to the type of mole:
Exagerrated signs of pregnancy by 6 8 weeks is due to a complete mole. Partial mole signs are less obvious. Vaginal bleeding after amenorrhea of light pink or brown. Sometimes a vesicle may detach and is then passed out allowing for diagnosis.

Cont
Anemia as a complication of the bleeding. Excessive nausea and vomiting due to high levels of Hcg lead to hyperemesis gravidarum. Pre-eclampsia early in pregnancy is suggestive of hydatidiform mole. On palpation, uterus exceeds expected date and feels doughy. Diagnosis is by ultrasound and Hcg level

Treatment
The aim is to remove all trophoblast tissue. This may occur as a spontaneous abortion or vacuum aspiration or dilatation and curettage may be necessary. Due to the risk of carcinoma development, suspected cases have a 2 year follow up program. IUCD family planning and hormonals

Cont
Method are contraindicated. In addition, women should avoid pregnancies over the 2 year period. Choriocarcinoma: It is a malignant neoplasm. Aside from hemorrhage, patient risks developing lung, hepatic and cerebral metastases if undetected. Can also occur after a normal pregnancy, an ectopic or abortion.

Retroversion of the uterus

This is when the long axis of the uterus is directed backwards during pregnancy.

Normally it would rise out of the pelvic cavity by the 14th week spontaneously but when it remains confined to the pelvis, pressure symptoms ensue.

Cont
Abdominal discomfort A feeling of pelvic fullness Low abdominal pain Back pain frequency of micturation, dysuria or paradoxical incontinence or retention. Urinary tract infections Rectal pressure and constipation with impacted faeces.

On examination
Bladder will be palpable abdominally. Fetal heart difficult to auscultate if the rectum is full. Way forward: midwife should refer patient to a gynecologist and gain consent for catheterization to drain urine and an indwelling to keep bladder empty, enabling the uterus to rise out of the pelvic cavity.

If untreated.
The lower portion of the uterus continues to expand and extend, forming a pouch to accommodate the growing fetus. Uterine rupture can result (leading to vaginal bleeding) and bladder rupture due to overextension or from necrosis of the bladder wall during manual correction.

Fibroids (Leiomyomas)
These are firm, benign tumors of muscular and fibrous tissue varying in size. Types of fibroid Intramural: they are embedded in the uterus separated from the myometrium by a capsule of connective tissue. They imitate a gravid uterus.

Cont
Subserosal: These lie below the perimetrium and may be irregular in shape and may become peduculated. Submucosal: these are found within the endometrium or decidua. Difficult to detect on examination, can cause bleeding and become both infected and necrotic.

Effect of pregnancy on fibroids

There is no evidence of increased fibroid growth during pregnancy. Most changes occur during the first 10 weeks of pregnancy. In pregnancy, the fibroids become softer, more vascular and edematous making it difficult to detect during pregnancy.

Effect of fibroids on pregnancy

Sub-mucosal fibroids are likely to cause early pregnancy loss. Mild abdominal pain that resolves spontaneously. Outcome of pregnancy is dependent on the position of the fibroids. Those situated in the lower uterine segment cause obstruction, so delivery should be by caesarian section.

THE END!