Bleeding in Early Pregnancy PDF

# Bleeding in Early Pregnancy ## **DRISYA.V.R.** ## **2nd Year PG Nursing** ## **Definition** Any vaginal bleeding before 20 weeks period of gestation is defined as early pregnancy bleeding. ## **Causes of bleeding in early pregnancy** - **Abortion** - **Ectopic pregnancy** - **Hydatidiform...

# Bleeding in Early Pregnancy ## **DRISYA.V.R.** ## **2nd Year PG Nursing** ## **Definition** Any vaginal bleeding before 20 weeks period of gestation is defined as early pregnancy bleeding. ## **Causes of bleeding in early pregnancy** - **Abortion** - **Ectopic pregnancy** - **Hydatidiform mole** ## **Related to pregnant state** - Abortion - Ectopic pregnancy - Molar pregnancy - Implantation bleeding ## **Associated with the pregnant state** - Cervical lesions like - Ruptured varicose veins ## **Cervical Erosion** An image of a uterus with a close-up view of the cervix, labeled 'cervix' and 'vaginal wall'. The cervix is highlighted and labeled 'cervical erosion'. The caption reads "View of cervix through a speculum, cervical erosion." ## **Cervical Polyp** An image with two close-up views of the cervix, both labeled 'cervical polyp'. The first image labeled 'as viewed through a speculum' shows a zoomed-in view of the cervix with a polyp. The second image is a 'sagittal view' showing a polyp at the opening of the cervix. ## **Cervical Malignancy** An image of a close-up view of the cervix with a large mass. The caption reads "Cervical malignancy." ## **Pathology** - Haemorrhage into the decidua basalis. - Necrotic changes in the tissue adjacent to the bleeding. - Detachment of the conceptus. - The above will stimulate uterine contractions resulting in expulsion. ## **If it isn't a baby, then you aren't pregnant, so what are you aborting? -Author Unknown** ## **Abortion** An image of a hand holding an aborted fetus. Termination of pregnancy before the fetus is capable of extra-uterine survival i.e. 20 weeks or 500gm birth wt. ## **Types of abortion** ### **Spontaneous** - Threatened abortion. - Inevitable abortion - Complete abortion. - Incomplete abortion. - Missed abortion - Septic abortion ### **Recurrent** ### **Induced** - Legal abortion - Illegal abortion ## **Etiology** - Genetic factors - Endocrine and metabolic abnormalities - Infections ## **Anatomic abnormalities** An image with four visual depictions of a uterus with various anatomic abnormalities. The anatomical anomalies are noted (A, B, C, D). - Immunologic disorders - Autoimmune disorders - Alloimmune disorders - Antifetal antibodies - Maternal medical illness - Blood group and incompatibility - PROM - Environmental factors - Unexplained ## **Mechanism of Miscarriage** Before 8 weeks- the ovum surrounded by the villi with the decidual coverings, is expelled out intact. Sometimes the external os fails to dilate so that the entire mass is accommodated in the dilated cervical canal and is called cervical miscarriage. ## **Blighted Ovum** An image of a sonogram of a blighted ovum. ## **8-14weeks- expulsion of the fetus commonly occurs leaving behind the placenta and its membranes** ## **Beyond 14th week - The process of expulsion is similar to that of a mini labour. The fetus is expelled first followed by the expulsion of the placenta after a varying interval.** ## **Threatened Miscarriage** It is a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible. ## **Clinical features** - Short period of amenorrhea. - Corresponding to the duration. - Mild bleeding (spotting). - Mild pain. - PV: closed cervical os. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus. - Serum progesterone ## **Management** - Reassurance. - Rest. - Drug – Diazepam 5 mg BD - Repeated U/S ## **Inevitable Abortion** ## **Clinical features:** - Short period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - P.V.: opened cervical os. - Pregnancy test (hCG): + ve. - US: non-viable fetus and blood inside the uterus. ## **Management:** - fluids.....blood. - methergin 0.2mg - evacuation of the uterus (medical/surgical). ## **Complete Abortion** - expulsion of all products of conception. - Cessation of bleeding and abdominal pain. - P.V.: closed cervix. - US: empty uterus. ## **Management** - U/S - Anti – D gamma globulin ## **Incomplete Abortion** An image depicting a sonogram of an incomplete abortion. The image is labeled "Incomplete abortion". ## **Complete Abortion** An image depicting a sonogram of a complete abortion. The image is labeled "Complete abortion." The image contains additional text: "ULTRASOUND&IMAGING CONSULTANT GR(LMP)= 9W3D P80 7MHz E721, 89, SAG ML, GE, CNO Scm DR78 G 82, +4:56:29, 00, Empty uterus, MI<8.4." ## **Missed Abortion** ## **Features:** - gradual disappearance of pregnancy Symptoms Signs. - Brownish vaginal discharge. - Milk secretion. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - US: absent fetal heart pulsations. ## **Complications** - Infection (Septic abortion) - DIC ## **Treatment** - Wait 4 weeks for spontaneous expulsion - evacuate if: - Spontaneous expulsion does not occur after 4 weeks. - Infection. - DIC. - Manage according to size of uterus - Uterus < 12 weeks : dilatation and evacuation. - Uterus > 12 weeks : try Oxytocin or PGs. ## **Septic Abortion** An abortion complicated by infection ## **Symptoms** - Abdominal pain - Fever - Vaginal discharge (foul smelling) ## **Signs** - Sick looking, febrile or jaundiced - Tender uterus - Offensive vaginal discharge or bleeding - Cervix is usually soft and may be dilated ## **Clinical grading** - Grade1- the infection is localized in the uterus - Grade2- the infection spreads beyond the uterus to the parametrium - Grade 3-generalized peritonitis or endotoxic shock or jaundice or acute renal failure ## **Complications of septic abortions** ### **Immediate** - Haemorrhage - Peritonitis - Pelvic abscess, endometritis, - Septicemia, - Septic/haemorrhagic shock ### **Late** - PID - Pelvic adhesions - 2° Infertility ## **Management** 1. Resuscitation - IV fluids: RL, NS 2. Insert urethral catheter - Monitor Input/output 3. Blood grouping & Cross matching 4. Antibiotics: - Preferably cephalosporins, if not available ampicilin and metronidazole 5. Prophylactic antigasgangrene serum of 8000 units and 3000 units of antitetanus serum 6. Evacuation 7. Haematenics ## **Recurrent Miscarriage** Defined as 3 or more consecutive pregnancy losses ## **Other names:** - habitual abortions - habitual miscarriage - recurrent abortions - recurrent miscarriages. ## **Aetiology:** Can be established in only 30% - Genetic Factors - Endocrine Factors - Anatomic Causes - Congenital anomalies, in competencies, - Infectious causes - Immunologic problems ## **Ectopic Pregnancy** Is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity. ## **Incidence** - Increased due to PID, use of IUCD, Tubal surgeries, and Assisted reproductive techniques (ART). - Ranges from 1:25 to 1:250 - Average range is 1 in 100 normal pregnancies. - Late marriages and late child bearing -> 2% - ART -> 5% - Recurrence rate - 15% after 1st, 25% after 2 ectopics ## **Diagram of the Anatomy of the Fallopian Tubes** An image of the fallopian tubes, labeled with the following: - Intraligamentous - Isthmic tubal - Interstitial - Uterus - Ovary - Ampullar tubal - Fallopian tube - Infundibular tubal - Ovarian - Abdominal - Intramural ## **Etiology** - Tubal Factors (salpingitis, previous tubal surgery) - Zygote Abnormalities (chromosomal abnormalities) - Ovarian Factors (ovum into contralateral tube) - Exogenous Hormone (oral contraceptives) - Other Factors (endometriosis, IUD) ## **Fate of tubal pregnancy** ### **1- Tubal mole:** The gestational sac is surrounded by a blood clot and retained in the tube. This may remain for long period in the tube and forms so called (chronic ectopic pregnancy), or they may be gradually absorbed (involution) ### **2-Tubal abortion:** This occurs more if ovum had been implanted in the ampullary portion of the tube. Separation of the gestational sac is followed by its expulsion into the peritoneal cavity through the tubal ostium. Rarely, reimplantation of the conceptus occurs in another abdominal structure leads to secondary abdominal pregnancy. ### **3-Tubal rupture:** More common if implantation occurs in the narrower portion of the tube which is the isthmus. Rupture may occur in the anti-mesenteric border of the tube. Usually profuse bleeding occurs → intraperitoneal haemorrhage. If rupture occurs in the mesenteric border of the tube, broad ligament haematoma will occur. An image depicts a series of four images of the uterus and fallopian tubes, depicting the different stages of tubal pregnancy. The first image explains the condition before pregnancy, the second image explains the condition before pregnancy, the third image explains the condition at eight weeks, and the last image explains the ultimate condition of ruptured ectopic pregnancy. ## **Clinical Features** - Acute ectopic - Unruptured - Subacute (chronic or old) ## **Presentation** Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. The most common presenting symptoms that are suggestive for EP are: ## **Clinical traid (3As)** - Amenorrhea - Abdominal pain - Abnormal vaginal bleeding ## **Signs** - The patient looks quiet and conscious, perspires and looks blanched - Pallor - Features of shock - Abdomen feels tense, tumid, and tender. No mass is usually felt, shifting dullness present - Pelvic examination reveals blanched white vaginal mucosa, uterus seen normal in size or slightly bulky - Extreme tenderness on fornix palpation or on movement of the cervix - No mass is usually felt through the fornix - The uterus floats as if in water ## **Unruptured tubal ectopic pregnancy** ## **symptoms** - presence of delayed period or spotting with features suggestive of pregnancy - uneasiness on one side of the flank which is continuous or at times colicky in nature ## **Signs** - uterus is usually soft - a pulsatile small, well circumscribed tender mass may be felt through one fornix separated from the uterus ## **Chronic or old ectopic** ## **Symptoms** - Amenorrhea - lower abdominal pain - vaginal bleeding ## **Signs** - the patient looks ill - Pallor - pulse persistently high even during rest - features of shock - temperature may be slightly elevated ## **On abdominal examination** - tenderness and muscle guard on the lower abdomen specially on the affected side is striking feature - mass in the lower abdomen may be felt which is irregular and tender - Cullen's sign- dark bluish discolouration, if found suggests intraperitoneal hemorrhage. ## **Diagnosis of ectopic pregnancy** - Pregnancy tests (postive-82.5%) - Hematocrit - White blood cell count - A negative test does not rule out an ectopic gestation ## **Subacute (chronic) ectopic** - Blood examination - Culdocentesis - Estimation of Beta HCG - Sonography - Colour Doppler Sonography - Combination of quantitative beta HCG values and Sonography Laparoscopy - Dilation and curettage - Serum progesterone - Laparotomy ## **MANAGEMENT** - **Emergency Treatment** - Immediate surgery, anti-shock(warm, oxygen) - **Surgical treatment** - laparoscopic techniques - **Medical treatment** - **Supportive treatment** - antibiotic, iron therapy, a high-protein diet ## **UNRUPTURED TUBAL PREGNANCY** ## **Expectant management** Only observation is done hoping spontaneous resolution. Indications are: - Initial serum HCG level less than 1000IU/L and the subsequent levels are falling - Gestational sac size <4 cm - No fetal heart beat on TVS - No evidence bleeding or rupture ## **Conservative management** Either medical or surgical ## **Medical management** The drugs commonly used for salphingocentesis are methotrexate, potassium chloride, prostaglandin (PGF2a) or Actinomycin. ## **Conservative surgery** - Linear salphingostomy - Linear salphingotomy - Segmental resection - Fimbrial expression - salphingectomy ## **CERVICAL PREGNANCY** Clinical diagnostic criteria (Rubin – 1983) for cervical pregnancy are : - Soft enlarged cervix equal to or larger than the fundus - Uterine bleeding following amenorrhoea, without cramping pain - Products of conception entirely confined within and firmly attached to endocervix - A closed internal cervical os and a partially opened external os - Sonography - Confirmation is done by histological evidence of the presence of villi inside the cervical stroma. ## **Gestational Trophoblastic Disease** ### **GTD** ## **Definition** It is a term commonly applied to a spectrum of inter-related diseases originating from the placental trophoblast. ## **Classification** The conventional histological classification includes: 1. Hydatidiform mole (complete or partial) 2. Invasive mole 3. Choriocarcinoma 4. Placental site trophoblastic tumour ## **Modified WHO classification on GTD is** - Hydatidiform mole;- complete, partial - Invasive mole - Placental site trophoblastic tumour - Choriocarcinoma - nonmetastatic disease - metastatic disease ## **Risk factors for GTD** 1. **Low risk (good prognosis)** - Disease is present <4 months duration - Initial serum hCG level <40,000 mIU/ml - Metastasis limited to lung and vagina - No prior chemotherapy - No preceding term delivery 2. **High risk (poor prognosis)** - Long duration of disease >4 months - Initial serum hCG >40,000 mIU/ml - Brain or liver metastasis - Failure of prior chemotherapy - Following term pregnancy ## **Complications** An image depicts a black circle with the word 'Death' written inside. - About 1 in 1000 ectopic pregnancies result in maternal death - Untreated or mistreated ruptured ectopic tubal pregnancy 8-12% of all materal deaths - The majority of these deaths are preventable ## **Tubal damage** An image depicts a black circle with the word 'Tubal damage' written inside. - Chronic salpingitis - Infertility or sterility - Intestinal obstruction may develop after hemoperitoneum and peritonitis ## **HYDATIDIFORM MOLE** An image depicting a close-up view of a hydatidiform mole. ## **An image of a uterus with a hydatidiform mole inside.** The image includes the following labels: - Uterine wall - Uterine cavity - Hydatidiform mole - Uterine wall ## **Definition** It is an abnormal condition of the placenta where there are partly degenerative and partly proliferative changes in the young chorionic villi. ## **Types** - Complete - Incomplete ## **Features Of Partial and Complete Hydatidiform Moles** | Feature | Partial mole | Complete mole | |--------------------------|----------------------|-----------------------| | Karyotype | Most commonly 69, XXX or - XXY | Most commonly 46, XX or -,XY | | Pathology | | | | Fetus | Often present | Absent | | Amnion, fetal RBC | Usually present | Absent | | Villous edema | Variable, focal | Diffuse | | Trophoblastic proliferation | Focal, slight-moderate | Diffuse, slight-severe | | Clinical presentation | | | | Diagnosis | Missed abortion | Molar gestation | | Uterine size | Small for dates | 50% large for dates | | Theca lutein cysts | Rare | 25-30% | | Medical complications | Rare | 10-25% | | Postmolar CTN | 2.5-7.5% | 6.8-20% | **Disaia &Creasman Clinical Gynecological Oncology 2007** **Cunningham et al Williams Obsterics 23rd 2010** ## **Table comparing complete and partial hydatidiform moles.** | Feature | Complete | Partial | |------------------------|-----------|-----------| | Gestational age | 8 to16 wk | 10 to 22 wk | | Uterine size | | | | Large for gestational age | 33% | 10% | | Small for gestational age | 33% | 65% | | Diagnosis by ultrasonography | Common | Rare | | Theca lutein cysts | 25 to 35% | Rare | | Human chorionic gonadotropin (mIU/mL) | >50,000 | <50,000 | | Malignant potential | 15 to 25% | <5% | | Metastatic disease | <5% | <1% | ## **Complete Mole** - Gross findings include massively enlarged, edematous villi that give the classic grape-like appearance to the placenta and lack embryonic tissue. - Pathologic features include - hydropic swelling in the majority of villi, accompanied by a variable degree of trophoblastic proliferation. ## **Sonogram of a Complete Hydatidiform Mole.** An image depicts a sonogram of a complete hydatidiform mole. The caption reads: "Complete hydatidiform mole. The classic "snowstorm" appearance is created by the multiple placental vesicles." ## **Clinical features** - Vaginal bleeding - Varying degrees of lower abdominal pain - Constitutional symptoms - Expulsion of grape like vesicles per vaginum is diagnostic of vesicular mole - History of quickening is absent. ## **Signs** - Features suggestive of early months of pregnancy are evident - The patient looks ill - Pallor is present - Features of pre-eclampsia - hypertension, oedema, or proteinuria - Per abdomen-The size of the uterus is more than the expected period of amenorrhoea. The feel of the uterus is firm elastic, Fetal parts are not felt, Absence of fetal heart sound - Vaginal examination-Internal ballottement cannot be elicited. Unilateral or bilateral enlargement (theca lutein cyst) of the ovary. Findings of the vesicle in the vaginal discharge. ## **INVASIVE MOLE** Invasive mole is the most common sequela of hydatidiform mole, representing 70% to 90% of cases of persistent GTD. The disorder occurs when hydropic chorionic villi are present within the myometrium, its vascular spaces, or at distant sites. This lesion has been known as chorioadenoma destruens, penetrating mole, malignant mole, and molar destruens. Up to 20% of invasive moles metastasize to extrauterine pelvic and distant sites (e.g., lungs, vagina, vulva, or broad ligament). ## **Sonogram of an Ectopic Pregnancy** An image depicts a sonogram of an ectopic pregnancy. The image contains additional text: "3, B/C5, st Med, pt:Res, te:Max, 6 Pg0, Pg0, LT, UT, UNSW Embryology, -0, ECTOPIC, 7, We Care, LOV, 1, -2". ## **Sonogram of a Hydatidiform Mole** An image depicts a sonogram of a hydatidiform mole. The caption reads: "Hydatidiform mole (Snow storm appearance)." ## **Thank You** An image depicts a drawing of a mother holding her child. #