Bleeding Disorders in Pregnancy

• Bleeding disorders during pregnancy can occur in any trimester and can be serious.

First Trimester Bleeding

• Abortion
• Ectopic Pregnancy

Second Trimester Bleeding

• Hydatidiform mole
• Incompetent Cervix

Third Trimester Bleeding

• Placenta previa
• Abruptio Placent

Abortion Defined

• Termination of pregnancy before viability, which is before 20 weeks of gestation or a fetal weight of <500 grams.
• The generally preferred term for spontaneous loss is "miscarriage" rather than "abortion."

Spontaneous Abortion (Miscarriage)

• Pregnancy loss before 20 weeks' gestation.
• Most occur in the first 12 weeks and can be caused by infection, trauma, genetic, and autoimmune causes.
• Types include threatened, inevitable, incomplete, complete, and missed abortions.
• Diagnosed based on history, physical examination, and ultrasound findings.
• Management may be expectant, medical, or surgical.

Definition of Terms Related to Abortion

• Abortus: A fetus aborted weighing less than 500 grams.
• Blighted ovum: Small, macerated fetus, possibly without a fetus, and has fluid inside an open sac.
• Carneous mole: Zygote surrounded by a capsule of clotted blood.
• Maceration: Necrosis of a dead fetus.
• Fetus compressus: Dessicated fetus.
• Fetus papyraceous: Fetus so dry it resembles parchment.
• Lithopedion: calcified embryo.
• Early abortion: Termination of pregnancy before 16 weeks.
• Late abortion: Abortion occurring between 16 and 20 weeks gestation.
• Immature infant: Infant with a birthweight between 500-1000 grams.
• Full term infant: An infant born between 38 and 42 weeks.
• Occult pregnancy: Zygotes that were aborted before pregnancy was diagnosed.
• Clinical pregnancy: Pregnancies that were diagnosed.

Definition of Spontaneous Abortion

• The definition of spontaneous abortion is the noninduced loss of pregnancy at <20 weeks gestation.

Epidemiology of Spontaneous Abortion

• Common complication of early pregnancy
• Accounts for 10-20% of clinically recognized pregnancies.
• Incidence is higher in women >35 years.

Classification of Spontaneous Abortion

• Threatened.
• Inevitable.
• Incomplete.
• Complete.
• Missed.

Causes of Abortion

• Fetal causes: Abnormal development of the zygote, embryo, or fetus.
• Maternal factors: Congenital or acquired maternal conditions or environmental factors that adversely affected pregnancy.

Maternal Factors Contributing to Abortion

• Advanced maternal age (>35 years).
• Medical conditions: antiphospholipid syndrome, hypertension, diabetes, obesity, hyperthyroidism, coagulopathies, autoimmune conditions.
• Infections: cytomegalovirus, parvovirus B19, toxoplasmosis, malaria, Chlamydia trachomatis.
• Anatomic abnormalities: cervical insufficiency, submucosal leiomyomas, congenital uterine anomalies, intrauterine adhesions.
• Maternal chromosomal abnormalities.
• Recreational drug use.

Fetal, Paternal, and Miscellaneous Factors Contributing to Abortion

• Fetal factors:
  • Chromosomal abnormalities (account for 50% of spontaneous abortions).
  • Congenital anomalies.
• Paternal factors:
  • Increased paternal age.
  • Paternal chromosomal abnormalities.
• Miscellaneous:
  • Trauma.
  • Environmental exposure to toxins such as tobacco, chemotherapeutic agents, and certain industrial chemicals such as toluene and formaldehyde.

Clinical Presentation of Abortion

• Individuals may be asymptomatic.
• Vaginal bleeding is the most common symptom if present.
• Additional symptoms: vaginal discharge, abdominal pain, or menstrual-like cramping.

Diagnostic Evaluation of Abortion

• Requires review of history, physical examination, and an ultrasound.
• Evaluate for: -Vaginal bleeding: presence or absence. -Dilation of the cervical os. -Hemodynamic stability.
• Ultrasound assessment: -Presence of products of conception in the uterus. -Presence or absence of fetal cardiac activity. -Size of the gestational sac or fetus.
• Additional studies: -Maternal blood type and Rh factor. -Complete blood count to evaluate blood loss. -Beta-hCG levels.

Clinical and Ultrasound Findings in Abortion Types

• Threatened Abortion: -Vaginal bleeding is present. -Abdominal cramps or pain may be present. -Fetal cardiac activity is present. -The cervical os is closed. -Products of conception have not been expelled. -Generally self-limiting; prognosis is worse with heavier bleeding.
• Inevitable Abortion: -Vaginal bleeding is present. -Abdominal cramps and pain may be present. -Fetal cardiac activity may be present. -The cervical os is dilated. -Products of conception have not been expelled.
• Incomplete Abortion: -Vaginal bleeding is present. -Abdominal pain is present. -Fetal cardiac activity may be present. -The cervical os is dilated. -Products of conception (POC) are partially expelled.
• Complete Abortion: -Vaginal bleeding is often present. -Abdominal pain may be present. -The cervical os is closed. -Products of conception are completely expelled.
• Missed Abortion: -Vaginal bleeding may be absent. -Abdominal pain is often absent. -Fetal cardiac activity is absent. -The cervical os is closed. -Products of conception have not been expelled.

Types of Abortion and Key Characteristics

• Threatened abortion: Possible loss of product of conception, light vaginal bleeding, mild uterine cramping, bedrest, save all pads, and no coitus up to 2 weeks after bleeding stops.
• Inevitable abortion: Loss of the products of conception cannot be prevented, moderate to profuse bleeding, moderate to severe uterine cramping, open cervix, rupture of membranes, admission/hospitalization, dilatation and curettage, oxytocin, and sympathetic understanding and emotional support.
• Complete abortion: Spontaneous expulsion of the products of conception, light bleeding, mild uterine cramping, passage of tissue, closed cervix, and sympathetic understanding and emotional support.
• Incomplete abortion: Expulsion of some parts and retention of other parts of conceptus in utero, heavy vagina bleeding, severe uterine cramping, open cervix, passage of tissue, dilatation and curettage, oxytocin, and sympathetic understanding and emotional support.
• Missed abortion: Retention of all products of conception, no FHT, signs of pregnancy disappear; products have to be removed from the uterus to prevent DIC.
• Habitual abortion: Occurring in 3 or more successive pregnancies, treat the cause.
• Septic abortion: Complicated by infection, foul smelling vaginal discharge, uterine cramping, and fever.

Management of Abortion

• The appropriate therapy for spontaneous abortions depends on the type of abortion and hemodynamic stability of the individual.
• Rh(D)-negative women should receive Rh(D) immunoglobulin if vaginal bleeding is present.
• Main options are expectant, medical, or surgical management.
• Expectant management: -Appropriate for hemodynamically stable individuals. -Treatment of choice for threatened abortions. -May involve avoiding intercourse and decreasing strenuous physical activities. -Close follow-up with clinic visits and ultrasound is crucial. -May take weeks to resolve. -In certain situations, surgical intervention may become necessary if expectant management fails. -Medical management: -Appropriate for hemodynamically stable individuals and poor surgical candidates. -May be used for inevitable, incomplete, or missed abortions. -Involves pharmacological agents to aid in cervical dilation and expulsion of the products of conception. -Misoprostol: given orally or vaginally. -Prostaglandin E1 analog to promote uterotonic effects.
• Premedication may be given with mifepristone: -Increases efficacy and primes the cervix and uterus for misoprostol by competitively binding to the progestin receptor. -Pain control with NSAIDs. -Close follow-up is crucial for success, and may take days to weeks. -Surgical management may be required if medical treatment fails. -Surgical management: -Appropriate for hemodynamically unstable individuals, those who decline other options, can't adhere to follow-up, or have not fully expelled products of conception. -Dilation and curettage is preferred surgical intervention -Resolves immediately after surgery, but carries risks. -Risks include: uterine perforation, infection, hemorrhage, and subsequent formation of uterine adhesions (synechiae).

Ectopic pregnancy Defined

• Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity, due to disruption of the normal anatomy of the fallopian tube.

Ectopic Pregnancy Symptoms

• Affected patients may suffer from acute abdominal pain and vaginal bleeding.
• If tube ruptures, internal bleeding can cause hemodynamic instability and hemorrhagic shock.

Diagnosing Ectopic Pregnancies

• Diagnosis involves measurements of serum human chorionic gonadotropin (hCG) levels and transvaginal ultrasonography, often via serial assessments over days.

Treating Ectopic Pregnancies

• Treatment depends on the clinical situation; expectant, medical, or surgical management.
• Ruptured fallopian tube with hemorrhage is considered a medical emergency requiring immediate surgery.

Epidemiology of Ectopic Pregnancy

• Third-leading cause of maternal mortality.
• Accounts for 1-2% of all pregnancies.
• Diagnosed in ~10% of patients presenting with vaginal bleeding and abdominal pain in early pregnancy.

Etiology of Ectopic Pregnancy

• Occurs when the fertilized egg doesn't enter the uterine cavity via the fallopian tube by day 5-6 of gestation.
• May result due to: -Abnormal passage of the embryo through the fallopian tube. -Congenital anomalies. -Acquired tubal obstructions such as adhesions. -Disruption of ciliary activity or tube motility.

Risk Factors for Ectopic Pregnancy

• Pelvic inflammatory disease (increases risk 3-fold in 50% of cases).
• Adhesions after tubal surgery (25% of cases).
• Assisted reproduction such as in vitro fertilization (IVF).
• Prior EP.
• Abnormal endometrium such as endometriosis or fibroids.
• Congenital malformation of the uterus such as a bicornuate uterus.
• Smoking.
• Advanced age (>35 years old).
• Intrauterine device/oral contraceptives (if pregnancy occurs despite their use).

Potential Locations of Implantation

• 90-95% within the fallopian tube.
• 3% in the ovary.
• 1% in the peritoneal cavity (abdominal).
• 1% in a cesarean scar.
• <1% in the cervix.

Mechanical Factors Contributing to Ectopic Pregnancy

• Delay the passage of ovum in the oviducts and prevent it from reaching the uterus in time for implantation, such as; -Salpingitis. -Peritubal adhesions. -Developmental abnormalities. -Previous ectopic pregnancy. -Previous operations on the tube. -Tumors that distort the tube. -Past induced abortion.

Functional Factors Contributing to Ectopic Pregnancy

• External migrations of the ovum
• Menstrual reflux.
• Altered tubal motility.

Factors Related to Assisted Reproduction

• Ovulation induction.
• Gamete intrafallopian transfer.
• In vitro fertilization.
• Ovum transfer.

Failed Contraception and Ectopic Pregnancy

• IUD.
• Oral contraceptives.
• Traditional barriers methods.
• Tubal ligation.
• Hysterectomy.

Types of Ectopic Pregnancy

• Tubal: Implants in the fallopian tube, often the ampullary portion.
• Interstitial/cornual: Implants on the interstitial or intramyometrial portion of the fallopian tube.
• Ovarian: Symptoms similar to tubal pregnancy or bleeding corpus luteum (treat with cystectomy/oophorectomy).
• Cervical: Occurs due to in vitro fertilization and embryo transfer, painless vaginal bleeding, distended thin walled cervix, dilated external os, seldom goes beyond 20 weeks gestation.
• Abdominal: Rarest type, tubal abortion, embryo reimplants in the peritoneal cavity.
• Isthmic.
• Fimbrial.
• Others: Tubo-uterine, Tubo-abdominal, Tubo-ovarian, Heterotypic.

Clinical Presentation of Ectopic Pregnancy

• Can present before, during, or after rupture.
• Early symptoms (pre-rupture): mild, light bleeding or cramping.
• If the pregnancy does not spontaneously abort, it will eventually rupture, leading to a potentially massive internal hemorrhage.
• Common presentation: vaginal bleeding and/or pelvic pain with a positive pregnancy test (early in pregnancy). -Bleeding is often light. -Pain is menstrual-like cramping that may be unilateral or diffuse.
• Signs of ruptured ectopic pregnancy: -Acute abdomen: severe lower abdominal or pelvic pain, abdominal rigidity, rebound tenderness, and pain that may be more diffuse if there is blood in the abdominal cavity. -Hemodynamic instability: Rupture causes significant internal bleeding and may lead to hypovolemic shock. -General pregnancy symptoms: -Breast enlargement and tenderness. -Secondary amenorrhea. -Morning sickness.
• Pelvic exam findings: -Cervical motion tenderness. -Closed cervix. -Adnexal tenderness. -An adnexal mass may be felt in 10%-20% of cases.

Diagnostic Studies for Ectopic Pregnancy

• Ultrasonography is the imaging method of choice, performed immediately with a positive pregnancy test and symptoms (bleeding, cramping).
• Normal pregnancy: At 5-6 weeks gestation, a gestational sac and yolk sac are present within the uterus; fetal pole with a heartbeat seen around 5.5-6 weeks gestation.
• EP findings: -Empty uterine cavity. -Adnexal mass. -Visualization of a gestational sac or yolk sac outside the uterus is definitive of diagnosis.
• Tubal rupture: Free fluid (blood) is present in the pouch of Douglas.
• Possible to determine if the embryo is alive by the detection of a fetal heartbeat on ultrasound. -Pain, usually in the pelvic, abdominal, and cervical areas. -Amenorrhea -Hemorrhage: Cullen's sign, rigid/boardlike abdomen, signs of shock (cyanosis, pallor, cold clammy skin, rapid pulse, hypertension), hypotension, tachycardia, oliguria

Diagnostic Tests for Ectopic Pregnancy

• Rapid urine pregnancy test
• Serum hcg
• Ultrasound examination
• Serum progesterone
• Culdocentesis

Clinical Triad for Ectopic Pregnancy

• Amenorrhea
• Abdominal pain
• Abnormal vaginal bleeding

Symptoms of Ectopic Pregnancy

• Pain and discomfort: in lower back, abdomen, or pelvis, usually unilateral; may feel like a strong stomach pain, shoulder pain caused by free blood irritating the diaphragm (ominous sign); pain while urinating or having a bowel movement.

Bleeding Related to Ectopic Pregnancy

• External bleeding: Vaginal bleeding usually mild, a result of falling progesterone from the corpus luteum, with causes withdrawal bleeding.
• Internal bleeding: (hematoperitoneum) due to hemorrhage from the affected tube.
• Dizziness, headache, weakness, and fainting may occur due to bleeding.
• Signs of ectopic pregnancy, including early pregnancy symptoms and abdominal examination: acute, agonizing, or colicky pain in the lower abdomen.
• Referred shoulder tip pain (25%).
• Haemoperitoneum may be present (DANFORTH'S SIGN).

Diagnosis Tests for Ectopic Pregnancy

• Perform a pregnancy test on all women of reproductive age who present with abdominal pain!
• Typically start with a rapid urine hCG test.
• If the rapid urine hCG test is positive and the individual has symptoms, order a quantitative serum hCG.
• Type and screen: blood type and Rh factor (if negative, RhoGam is required).
• Complete blood count (CBC): to look for anemia/evidence of hemorrhage.
• Liver function tests (LFTs), basic metabolic panel (BMP), urinalysis (UA): to evaluate for other causes of acute abdomen and look for contraindications to methotrexate, a treatment for EP
• Determine or date the pregnancy based on the last menstrual period (LMP).
• After a positive urine pregnancy test, determine the gestational age based on the LMP.
• Note: pregnancy may be

Treatments for an Ectopic Pregnancy

• If not yet ruptured: Salpingostomy, Salpingotomy, Fimbrial evacuation, Medical management with Methotrexate
• If pregnancy has ruptured: Salpingectomy, Ipsilateral oophorectomy, sterilization
• Additional treatment for hemorrhage, infection, and need for contraception.

Preventative Treatment for Hemorrhaging

• Blood transfusion
• Administer fluids
• Prevent Shock

Emergency and Medical Treatments for for Hemorrhaging

• Unstable patients: Assess and stabilize ABCs and administer IV fluids, administer RhoGAM if blood type is negative.
• Medical treatment: for stable patients with unruptured and without contraindications, may administer Methotrexate, and monitor results.

Surgical for Ectopic Pregnancy

• Hemodynamic instability
• Contraindications to medical care Expectant management: -ONLY for women who are asymptomatic.
• No evidence of the pregnancy on ultrasound or physical.
• Decreasing HCG
• Close follow-up is required to monitor and follow to zero.

Differential vs Ectopic Pregnancy

• Ectopic pregnancy vs failed pregnancies
• Threathened, misscarriage, inevitable, incomplete or complete pregnancies
• Also check for any molar pregnancies and non-obstetric sources of bleeding
• Note: In cases of threatened abortion a subchorionic hematoma can be present (while the pregnancy can sill continue). Note: In cases of stone or appendicitis US may enlarge appencical diameter and HCG will rise properly.