Hemorrhage (Bleeding) in Early Pregnancy PDF

Hemorrhage (bleeding) in early pregnancy: Dr. Kadra.A.Omar MBBS/AU, Mmed/UoN, Consultant Obstetrician and Gynecologist.  Introduction: Vaginal bleeding during pregnancy has many causes. Some are serious and others are not. Bleeding can occur early or later in pregnancy. Bleeding in ear...

Hemorrhage (bleeding) in early pregnancy: Dr. Kadra.A.Omar MBBS/AU, Mmed/UoN, Consultant Obstetrician and Gynecologist.  Introduction: Vaginal bleeding during pregnancy has many causes. Some are serious and others are not. Bleeding can occur early or later in pregnancy. Bleeding in early pregnancy is common. In many cases, it does not signal a major problem. Bleeding later in pregnancy can be more serious ( obs/gyn must evaluate this condition).  Cont.. Bleeding in the first trimester happens in 15 to 25 in 100 pregnancies. Light bleeding or spotting can occur 1 to 2 weeks after fertilization when the fertilized egg implants in the lining of the uterus (implantation bleeding). The cervix may bleed more easily during pregnancy because more blood vessels are developing in this area. It is not uncommon for a pregnant women to have spotting or light bleeding after sexual intercourse or after a Pap test or pelvic exam.  Causes: Implantation bleeding Abortion ( miscarriage) Ectopic pregnancy Molar pregnancy Local gynaecological lesions e.g. cervical ectopy, polyp, dysplasia, carcinoma and rupture of varicose vein. Implantation bleeding: This is when the fertilized egg implants in the wall of your uterus and causes light bleeding. It’s considered a normal part of early pregnancy. It may spare some women. Miscarriage(abortion):  DEFINITION:  Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 g or less when it is not capable of independent survival (WHO).  This 500 g of fetal development is attained approximately at 22 weeks (154 days) of gestation.  The expelled embryo or fetus is called abortus. The word miscarriage is the recommended terminology for spontaneous abortion. Incidence: About 10 to 20 percent of known pregnancies end in miscarriage. But the actual number is likely higher because many miscarriages occur very early in pregnancy — before women might even know about a pregnancy. Causes of miscarriage:  Chromosomal abnormalities: cause at least 50% of early abortions e.g. trisomy, monsomy X (XO) and triploidy.  Blighted ovum (anembryonic gestational sac): where there is no visible foetal tissues in the sac.  Maternal infections : Listeria monocytogenes, mycoplasma hominis, ureaplasma urealyticum, cytomegalovirus,rubella, and malaria,toxoplasma gondii which causes abortion if there is acute infection early in pregnancy.  Acute fever for whatever the cause can induce abortion. Cont.. Trauma: external to the abdomen or during abdominal or pelvic operations. Endocrine causes: Luteal phase defect (LPD) results in early miscarriage as implantation and placentation are not supported adequately. Progesterone deficiency ( causes abortion between 8-12 weeks). Diabetes mellitus. Thyroid abnormalities Cont.. Anatomical: Septum , Asherman's syndrome (intrauterine adhesions) and submucous myomas. Immunological causes: Systemic lupus erythematosus (SLE). Antiphospholipid antibodies that are directed against platelets and vascular endothelium leading to thrombosis, placental destruction and abortion. Histocompatibility between the mother and father and in turn the foetus. Cont…  Drugs and environmental causes: Quinine , ergots, severe purgatives, tobacco, alcohol, arsenic, lead, formaldehyde, benzene and radiation.  Maternal anoxia and malnutrition.  Overdistension of the uterus: i.e. acute hydramnios.  Ageing sperm or ovum.  Stress, psychological conditions and maternal exhaustion.  Smoking, alcohol.  Idiopathic. Types of miscarriages: 1. Spontanous: Isolated(sporadic) and Reccurent: Threatened, inevitable, complete, incomplete, missed, septic(less common) 2. Induced: Legal (MTP), illegal(unsafe)--- septic—common. Threatened miscarriage:  A threatened miscarriage refers to vaginal bleeding that occurs during the first 20 weeks of pregnancy. It does not necessarily mean that pregnancy will end in a miscarriage — around half of threatened miscarriages result in a live birth.  Signs and Symptoms: Other symptoms of threatened miscarriage include lower back pain and abdominal cramps.  In a threatened miscarriage, the cervix will remain closed. However, if an examination reveals the cervix has opened, a miscarriage is much more likely.  Pregnancy test is positive, on ultrasonography it shows alive fetus. Management: Bed rest and pelvic rest ( no sexual intercourse as it may trigger the miscarriage). Progestroge can be prescribed and may help most of the patients. Folic acid should be prescribed if not already. Inevitable miscarriage: Inevitable miscarriage refers to unexplained vaginal bleeding and abdominal pain during early pregnancy. Signs and Symptoms: Bleeding is heavier than with a threatened miscarriage and abdominal cramps more severe with passage of clots. Unlike threatened miscarriage, an inevitable miscarriage is also accompanied by dilation of the cervical canal. Management: Attempting to retain this type of pregnancy is not possible. Resuscitate the patient right after admission. Use of uterotonics ( misoprostol or oxytocin),ergoterine can also be used if the patient has no known hypertension. E&C ( Evacuation and curettage), or D&C ( Dilatation and curettage if there is retained product of conception). MVA ( manual vacuum aspiration can also be used, whichever available. Incomplete miscarriage:  Retention of a part of the products of conception inside the uterus. It may be the whole or part of the placenta which is retained.  Clinically patient usually noticed the passage of a part of the conception products. Bleeding is continuous.  On examination, the uterus is less than the period of amenorrhoea but still large in size.  The cervix is opened and retained contents may be felt through it.  Ultrasonography: shows the retained contents. Management: Manage like inevitable miscarriage. Complete miscarriage:  A complete miscarriage, refers to a miscarriage in which all of the pregnancy tissue is expelled from the uterus.  Signs & Symptoms: A complete miscarriage is characterized by heavy vaginal bleeding, severe abdominal pain, and passage of pregnancy tissue.  With a complete miscarriage, the bleeding and pain should subside quickly.  Complete miscarriages can be confirmed through an ultrasound, finding that uterus is empty. Missed miscarriage: Is when the fetus is dead and retained inside the uterus for a variable period, it is called missed miscarriage or early fetal demise,(dark vaginal discharge rather than bright red). Symptoms may resemble like those of threatened miscarriage. Pregnancy symptoms reduce or may even subside. Cont… Fundal height may not increase or may even reduce. Fetal movements are absent or may subside if present earlier. Milk secretion from the breasts( especially in the 2nd trimester). On examination: cervix is closed there may/may not be a dark colored vaginal discharge stained gloved fingers. Ultrasonography examination confirms the diagnosis. Management: Expulsion of the fetus+POC can occur spontaneously with in a 4 weeks without intervention. Evacuation of the product of conception must take place if uterine size is upto 12 weeks if gestation. If it is >12 weeks then uterotonics must be used(i.e misorpstol or oxyticin and some times combination). Septic miscarriage: Any abortion associated with clinical evidences of infection of the uterus and its contents is called septic abortion. Common causative organisms includes : E.Coli,bacteroids, anaerobic streptococci, clostridia, streptococci and staphylococci. Clinical presentation: Fever and tachycardia, rigors suggest bacteraemia. Malaise, sweating , headache, and joint pain. - Jaundice and /or haematuria is an ominous sign, indicating haemolysis due to chemicals used in criminal abortion or haemolytic infection as clostridium welchii. On examination: there is abdominal tenderness, especially suprapubic tenderness, rigid abdomen with diffuse tenderness may suggest peritonitis. Cont.. Pelvic examination: foul smelling vaginal discharge, trauma may be seen locally. Uterus is boggy and tender on bimanual examination. Product of conception may be felt at the cervix. There is also fullness at the fornices. Management: Admit the patient to an isolation room/area. Large i.v cannula should be inserted for antibiotic and possible resuscitations if needed. Withdraw blood sample for evaluation ( i.e for culture). Urine analysis Cervico-vaginal swap for culture and sensitivity. Cont.. Monitor vital signs closely ( BP,PR.Temp,B/sugar). I.v fluids crystatiod and colloids. i.v antibiotcs: broad specturum of antibiotics is recommended ( penicilis,cephalosporins, metronidazole). Blood and or blood products may be needed. Anti gas gangrene and antitetanus should be prescribed. Cont.. Uterotonics ( oxytocin), to help expulsion of the POC. Surgical evacuation can be done after 6 hrs from the treatment. Hysterectomy may be needed in the cases of endotoxic shock. Treatment of the complications in a multidisciplinary form. Induced (MTP): Mostly this type of miscarriage is done by trained medical personnel, and it is done because of medical condition ( maternal/fetal). Illegal miscarriage: mostly ends up with complication ( septic or perforation of the adjacent organs or even death). Recurrent miscarriage (RPL): Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks. Some, however, consider two or more as a standard. It may be primary or secondary (having previous viable birth). A woman procuring three consecutive induced abortions is not a habitual aborter Etiology: First trimester: Genetic factors ( from parents or fetus). Endocrine abnormalities including: poorly controlled DM, thyroid abnormalities, PCOS,LPD. Infections: - Toxoplasma, Mycoplasma hominis, Ureaplasma urealyticum, Listeria monocytogenes, Brucella, Chlamydia, Syphilis. Cont… Inherited thrombophilia : I:e protein C resistant or deficiency. Immunological: autoimmune factors, antiphospholipid antibodies such as SLE. Miscellaneous: Chronic malnutrition, chronic anaemia, chronic cardiac and renal diseases, smoking and alcohol. Unexplained: In the majority, the cause remains unknown. Second trimester miscarriage: Anatomic abnormalities are responsible for 10– 15% of recurrent abortion. The causes may be congenital or acquired. Congenital anomalies may be due to defects in the Müllerian duct fusion or resorption (e.g. unicornuate, bicornuate, septate or double uterus). Congenital cervical incompetence is rare. Acquired anomalies are: intrauterine adhesions, uterine fibroids and endometriosis and cervical incompetence. Cont... Chronic maternal illness—such as uncontrolled diabetes with arteriosclerotic changes, hemoglobinopathies, chronic renal disease. Inflammatory bowel disease, systemic lupus erythematosus. Infection—Syphilis, toxoplasmosis and listeriosis may be responsible in some cases. Unexplained. Causes of cervical incompetence:  Congenital Uterine anomalies.  Acquired (iatrogenic)— common, following:  D and C operation.  Induced abortion by D and E (10%).  Vaginal operative delivery through an undilated cervix.  Amputation of the cervix or cone biopsy of trachelectomy.  Others—multiple gestations, prior preterm birth. Cervical incompetence is considered as a biological continuum of spontaneous preterm birth syndrome Clinical presentation:  History of previous obs/gyn procedures i:e D&C  Usually miscarriage occurs between 16—28 weeks of gestation.  Spontaneous rupture of membranes, and miscarriage time is shorter.  History of mild pain, and bleeding preceding expulsion of the fetus.  There may be history consanguinity between the couple.  History or may be an evidence of infection may be there. On examination:  Clinically patient may have sings of respective disease that she has.  In between pregnancies:  The cervix can admit easily No. 8 Hegar’s dilator without resistance or pain.  A 2 ml (6 mm diameter) Foley’s balloon catheter can be withdrawn through the cervical canal with minimal resistance.  Hysterosalpingogram: demonstrates cervical funnelling.  Extensive old cervical lacerations may be detected Cont.. During pregnancy: The membranes are bulging through the os. Ultrasonography shows shortened cervix with funneling sign. Investigations: Evaluate based on your diagnosis + basic investigations. Management: Medical: Treat underlying medical conditions accordingly. Surgical management:  Cervical cerclage:  It means encircling the cervix at or as near as possible to the internal os by a non-absorbable suture.  The best time for the operation is about 12-14 weeks, so that the placenta is formed and there is no possibility of abortion due to congenital anomalies of the early embryo.  The suture is removed at 38 weeks or if labour started at any time.  Ultrasonography is done before operation to: - confirm foetal viability, - exclude congenital anomalies, - measure the internal os. Cont.. Vaginal cerclage: Mc Doland procedure. Shirodkar operation. Cont.. Mc Donald operation: It is the commonest operation. The cervix is surrounded from outside by a nylon or silk purse- string suture. The suture takes bites of cervical tissue at 4—5 times then tied anteriorly or posteriorly. This operation is easier and gives nearly the same results as Shirodkar. Mc Donald: Cont.. Shirodkar operation: Two incisions at the reflection of the vaginal wall on the cervix are done anteriorly and posteriorly and bladder is dissected upwards. A nylon or silk suture or a dacron (mersilene) tape is applied around the internal os under the cervical mucosa. Shirodkar: Abdominal cerclage: In case of previous high amputation of the cervix extensive cervical laceration or repeated failure of vaginal cerclage. The isthmus uteri is encircled by a non- absorbable suture and the patient should be delivered by caesarean section. Ectopic pregnancy: It is implantation of the fertilised ovum outside the normal uterine cavity. Sites of ectopic pregnancy: Common sites: fallopian tubes 95% Rare sites (5%) : The ovaries, a rudimentary horn of a bicornuate uterus , broad ligaments, peritoneum and cervix. Sites of ectopic pg: Etiology: PID Previous pelvic surgeries. Previous ectopic pregnancy(increases 10—15%). IUCD Progesterone only contraceptives ( E.pills). ART Previous induced abortion. Premature implantation of fertilized ovum. Clinical presentation: History of amenorrhea usually shorter. Lower abdominal pain, sharp pain if ruptured Shoulder pain when there is hemapretonium (rupture ectopic). Bladder and rectal irritability in pelvic haematocele. Slight vaginal bleeding. O/E:  Generally patient is in pain ( severe pain when ruptured).  May have signs of hypovolemia, as well as signs of anemia.  Abdomen :  There is abdominal tenderness severe, may be localized at one side, at the iliac fossa, there is also rigidity.  Vaginal examination shows signs of pregnancy, there is also positive cervical motion tenderness ( cervical excitation).  There is blood stained gloved fingers. Investigations: CBC Blood grouping and cross-matching Beta hCG (serum). Culdocentesis Ultrasonography: In general, a positive b -hCG test with empty uterus by sonar indicates ectopic pregnancy. This is true if the ß-hCG is at or above the threshold level in which an intrauterine gestational sac can be detected. Management of ectopic pg: Acute Principle: The principle in the management of acute ectopic is resuscitation and laparotomy and not resuscitation followed by laparotomy. Antishock treatment: Antishock measures are to be taken energetically with simultaneous preparation for urgent laparotomy. Ringer’s solution (crystalloid) is started, if necessary with venesection. Arrangement is made for blood transfusion. Cont.. Even if blood is not available, laparotomy is to be done desperately. When the blood is available, it is better to be transfused after the clamps are placed to occlude the bleeding vessels on laparotomy, as it is of little help to transfuse when the vessels are open. After drawing the blood samples for grouping and cross matching, volume replacement with colloids (hemaccel) is to be done. Cont.. Laparotomy: Indications of laparotomy are: Patient hemodynamically unstable. Laparoscopy contraindicated. Evidence of rupture. Salpingectomy is the definitive management. Oophrectomy if ovary damaged beyond repair. In rare case hysterectomy may be performed. Cont.. CHRONIC ECTOPIC: All cases of chronic or suspected ectopic are to be admitted as an emergency. The patient is kept under observation, investigations are done and the patient is put up for laparotomy at the earliest convenient time. Usually a pelvic hematocele is found. Blood clots are removed. The affected tube is identified and salpingectomy is commonly done as described previously. uncommon types of ectopic pg: Cervical pregnancy: Implantation in the substance of the cervix below the level of uterine vessels. May cause severe vaginal bleeding. Treatment : Evacuation and cervical packing with haemostatic agent as fibrin glue and gauze. If bleeding continues or extensive rupture occurs hysterectomy is needed Pregnancy in a rudimentary horn:  Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.  As such a horn is capable of some hypertrophy and distension, rupture usually does not occur before 16-20 weeks.  Treatment:  Excision of the horn.  During operation, pregnancy in a rudimentary horn can be differentiated from interstitial cornual tubal pregnancy by finding the attachment of the round ligament lateral to the first and medial to the later. Cornual angular pregnancy: It is implantation in the interstitial portion of the tube. It is uncommon but dangerous because when rupture occurs bleeding is severe and disruption is extensive that it needs hysterectomy. In some cases, the pregnancy is expelled into the uterus and rupture does not occur. Ovarian pregnancy: Causes: a)Pelvic adhesions. b)Favourable ovarian surface for implantation as in ovarian endometriosis. Pathogenesis: Fertilisation of the ovum inside the ovary or , Implantation of the fertilised ovum in the ovary. Cont.. Spiegelberg‘s criteria in diagnosis of ovarian pregnancy are: 1. Tube on the affected side must be intact. 2. The gestation sac must be in the position of the ovary. 3. The gestation sac is connected to the uterus by the ovarian ligament. 4. The ovarian tissue must be found on its wall on histological examination Cont.. Treatment: Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the ovary if possible. Removal of the affected ovary is indicated if it is damaged beyond repair. Abdominal (peritoneal) pregnancy:  Types: 1. Primary: implantation occurs in the peritoneal cavity from the start. 2. Secondary: usually after tubal rupture or abortion. Intraligamentous pregnancy: is a type of abdominal but extraperitoneal pregnancy. It develops between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border or lateral rupture of intramural (in the myometrium) pregnancy. Diagnosis: History: like any other pregnancy, history of amenorrhea, Braxton-Hicks contraction is absent in abdominal pregnancy. O/E: fetal parts can easily be felt in the abdomen, uterus may be palpable differently. Vaginal examination may reveal soft cervix, no fetal presentation is felt. Investigations: USG: shows absent of uterine walls around fetus, fetus is in high position. MRI: Can confirm the diagnosis and may be very accurate. Computed tomography is diagnostic and is superior to MRI. CT has the risk of radiation. Plain X-ray : shows abnormal lie. In lateral view, the foetus overshadows the maternal spines. Management:  Laparotomy: The ideal surgery is to remove the entire sac-fetus, the placenta and the membranes.  This may be achieved if the placenta is attached to a removable organ like uterus or broad ligament. If, however, the placenta is attached to vital organs, it is better to take out the fetus and leave behind the placenta and the sac, after tying and cutting the cord flushed with its placental attachment. In such a situation, placental activity is to be monitored by quantitative serum b-hCG level and ultrasound.  Complete absorption of the left behind placenta occurs through aseptic autolysis. Complications include secondary hemorrhage, intestinal obstruction and infection. Gestational trophoblastic disease (GTD): Gestational trophoblastic disease (GTD): encompasses a spectrum of proliferative abnormalities of trophoblasts associated with pregnancy. Persistent GTD (persistently raised b-hCG) is referred as gestational trophoblastic neoplasia (GTN). Cont..  Gestational trophoblastic disease (GTD) is a general term that includes different types of disease:  Hydatidiform Moles (HM)Complete HM,and Partial HM.  Gestational Trophoblastic Neoplasia (GTN)Invasive moles.  Choriocarcinomas.  Placental-site trophoblastic tumors (PSTT; very rare).  Epithelioid trophoblastic tumors (ETT; even more rare). Hydatidiform mole (HM):  HMs are slow-growing tumors that look like sacs of fluid. An HM is also called a molar pregnancy. The cause of hydatidiform moles is not known.  HMs may be complete or partial:  A complete HM forms when sperm fertilizes an egg that does not contain the mother’s DNA. The egg has DNA from the father and the cells that were meant to become the placenta are abnormal, karyotipically it contains Paternal 46 XX (96%) or 46 XY (4%).  A partial HM forms when sperm fertilizes a normal egg and there are two sets of DNA from the father in the fertilized egg. Only part of the fetus forms and the cells that were meant to become the placenta are abnormal, karyotypicaly it contains Paternal and maternal 69 XXY or 69 XYY. Cont..  Most hydatidiform moles are benign, but they sometimes become cancer. Having one or more of the following risk factors increases the risk that a hydatidiform mole will become cancer:  A pregnancy before 20 or after 35 years of age.  A very high level of beta human chorionic gonadotropin (beta-hCG), a hormone made by the body during pregnancy.  A large tumor in the uterus.  An ovarian cyst larger than 6 centimeters. Cont.. High blood pressure during pregnancy. An overactive thyroid gland (extra thyroid hormone is made). Severe nausea and vomiting during pregnancy. Trophoblastic cells in the blood, which may block small blood vessels. Serious blood clotting problems caused by the HM. DIAGNOSIS: Symptoms: Amenorrhoea: usually of short period (2-3 months). Exaggerated symptoms of pregnancy especially vomiting. Vaginal bleeding which is usually dark brown and may be associated with passage of vesicles.  Abdominal pain : may be , - dull-aching due to rapid distension of the uterus, - colicky due to starting expulsion, - sudden and severe due to perforating mole. O/E:  Pre-eclampsia develops in 20% of cases, usually before 20 weeks’ gestation.  Hyperthyroidism develops in 10% of cases manifested by enlarged thyroid gland, tachycardia and elevated plasma thyroxin level.  Breast signs of pregnancy.  The uterus is larger than the period of amenorrhoea in 50% of cases, corresponds to it in 25% and smaller in 25% with inactive or dead mole.  The uterus is doughy in consistency.  Foetal parts and heart sound cannot be detected except in partial mole. Vaginal examination: Passage of vesicles (sure sign). Bilateral ovarian cysts (5-20 cm) in 50% of cases. Partial mole: Investigations: CBC, cross matching, LFT’s, RFT’s, TFT. Urine for pregnancy test. Serum beta Hcg ( Quantitative). Ultrasonography reveals: The characteristic intrauterine " snow storm" appearance, no identifiable foetus, bilateral ovarian cysts may be detected. Complete and partial mole: Snow storm +ovarian cyst: Management: Initial stabilization of the pt, give i.v flids As soon as the diagnosis of vesicular mole is established the uterus should be evacuated. The selected method depends on the size of the uterus, whether partial expulsion has already occur or not, the patient's age and fertility desire. It is carried out under general anaesthesia(sedation). Cont..  Hysterectomy is indicated in:  Patients with age over 35, completed her family.  Patient completed her family irrespective of age.  Uncontrolled hemorrhage or perforation during surgical evacuation. Hysterectomy reduces the risk of GTN by fivefold.  Hysterotomy is rarely done these days. It may be done in cases with  profuse vaginal bleeding,  cervix is unfavorable for immediate vaginal evacuation and  accidental perforation of the uterus during surgical evacuation. FOLLOW-UP: Routine follow-up is mandatory for all cases for at least 1 year. The occurrence of choriocarcinoma is mostly confined to this period. The prime objective is to diagnose persistent trophoblastic disease (20–30%) that is considered malignant. However, hCG levels following evacuation should regress to normal within 3 months time. Cont…  Intervals: Initially, the checkup should be at an interval of one week till the serum hCG level becomes negative.  This usually happens by 4–8 weeks. Once negative within 56 days, the patient is followed up at every one month interval for 6 months.  Women who undergo chemotherapy should be followed up for one year after hCG has been normal.  The patient must not become pregnant during the period of follow-up. Complications: Hemorrhage and shock. Sepsis Perforation of the uterus Pre-eclampsia Acute pulmonary insufficiency: due to metastasis of the vesicles to the lungs. Coagulation failure due to pulmonary embolization of the vesicles choriocarcinoma