Bleeding In Early Pregnancy

Question 1

Causes of miscarriage maternal and fetus

Answer 1

Fetus:
Chromosome Abnormality:
1. Autosomal trisomy
2. Monosomy (45, X; turner):
3. Triploids.

Maternal
1. Immunological:
- alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of a normal pregnancy.
- autoimmune disease:
• antiphospholipid antibodies : lupus
anticoagulant (LA) and the
• anticardiolipin antibodies (ACL)
2. uterine abnormality:
- congenital: septate uterus → recurrent abortion.
- fibroids (submucus): → (1) disruption of implantation and development of the fetal blood supply, (2) rapid growth and degeneration with release of cytokines (3) occupation of space for the fetus to grow e.g polyp , fibroid - cervical incompetence: → second trimester abortions.
3 . Endocrine : - Poorly controlled DM(type 1/type 2).
- Hypothyroidism and hyperthyroidism.
- Luteal Phase Defect (LPD): a situation in which the endometrium is
poorly or improperly hormonally prepared for implantation and is
therefore unstatutable for implantation. (questionable).
4. Infections (maternal/fetal): TORCH infections, Ureaplasma urealyticum, listeria
5. Environmental toxins alcohol, smoking, drug abuse, ionizing radiation
6. Psychological conditions and Trauma
7 -Idiopathic

Question 2

Types of Miscarriage

Answer 2

• Threatened Miscarriage.
• Inevitable Miscarriage.
• IncompleteMiscarriage.
• CompleteMiscarriage.
• Missed Miscarriage.
• Septic Miscarriage: Any type of abortion, which is complicated by infection.
• Recurrent abortion: 3 or more successive spontaneous abortions

Question 3

Threatened Miscarriage

Answer 3

• Short period of amenorrhea.
• Corresponding to the duration.
• Mild bleeding (spotting).
• Mild pain.

Question 4

Threatened Miscarriage management

Answer 4

• P.V.: closed cervical os.
• Pregnancy test (hCG): + ve.
• US: viable intra uterine fetus.

Question 5

Threatened Miscarriage

Answer 5

• Reassurance.
• Rest.
• Repeated U/S
  • Progestogens.
  • Gonadotrophins may be of benefit in
  cases of (( luteal phase deficiency ))

Question 6

Inevitable Miscarriage
Clinical feature:

Answer 6

• Short period of amenorrhea.
• heavy bleeding accompanied
  with clots (may lead to
  shock).
• Severe lower abdominal pain.

Question 7

Inevitable Miscarriage manegment

Answer 7

• P.V.: opened cervical os.
• Pregnancy test (hCG): + ve.
• US: non-viable fetus and
  blood inside the uterus.

Question 8

Inevitable Miscarriage ttt

Answer 8

• fluids…..blood.
• ergometrinn & sentoyinon.
• evacuation of the uterus
  (medical/surgical). D&C

Question 9

Incomplete Miscarriage Clinical feature

Answer 9

• Partial expulsion of products
• Bleeding and colicky pain continue.

Question 10

In complete Miscarriage management

Answer 10

• P.V.: opened cervix…
  retained products may be
  felt through it.
• US: retained products of
  conception.

Question 11

Incomplete Miscarriage ttt

Answer 11

1. Fluid , blood
2. Ergometrinn , synto
3. D & C

Question 12

Complete Miscarriage c/f

Answer 12

• Expulsion of all
  products of conception.
• Cessation of bleeding
  and abdominal pain.

Question 13

Complete Miscarriage management

Answer 13

• P.V.: closed cervix.
• US: empty uterus.

Question 14

Complete Miscarriage ttt

Answer 14

Ab
Ergometrine

Question 15

Missed Miscarriage c/f

Answer 15

• gradual disappearance of
  pregnancy Symptoms Signs.
• Brownish vaginal
  discharge.
• Milk secretion.

Question 16

Missed Miscarriage management

Answer 16

• Pregnancy test: negative
  but it may be + ve for 3-4
  weeks after the death of
  the fetus.
• US: absent fetal heart
  pulsations.

Question 17

Missed Miscarriage complication

Answer 17

• Infection (Septic abortion)
• DIC

Question 18

Missed Miscarriage ttt

Answer 18

• 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.( D&C)
• Uterus > 12 weeks :
  try Oxytocin or PGs.
• Vacum aspiration

Question 19

Septic Abortion

Answer 19

General examination:
Pyrexia and tachycardia.
Rigors suggest bacteraemia.
A subnormal temperature with
tachycardia is ominous and mostly
seen with gas forming organisms.
Malaise, sweating, headache, and joint
pain
Abdominal examination:
Suprapubic pain and tenderness.
Abdominal rigidity and distension indicates
peritonitis. Local examination:
OAensive vaginal discharge. Minimal
inoAensive vaginal discharge is often
associated with severe cases.
Uterus is tender.
Products of conception may be felt.
Local trauma may be detected.
Fullness and tenderness of Douglas pouch
indicates pelvic abscess which will be
associated with diarrhoea.

Question 20

Septic Abortion ttt

Answer 20

Isolate the patient . Bed rest in semi-sitting
position
•An intravenous line is established for therapy. •Observation for vital signs: •A cervico-vaginal swab is taken for culture
and sensitivity,
•Fluid therapy:
• Surgical evacuation of the uterus can be done after 6 hours of commencing IV therapy but may be earlier in case of severe bleeding or deteriorating condition in spite of the previous therapy.
•Hysterectomy may be the last choice
safe life

Question 21

Septic Abortion complication

Answer 21

• Infection. • Haemorrhage. • Uterine perforation (and rarely intraperitoneal injury). • Retained products of conception. • Intrauterine adhesions. • Cervical tears. • Intra-abdominal trauma.
(Uterine and cervical trauma may be minimized by administering prostaglandin (misoprostol) before the procedure)
•Psycological

Question 22

Risk factors Ectopic pregnancy

Answer 22

• Prior Tubal surgery (including tubal ligation)
• Current Intrauterine device
• In vitro fertilization
• Prior ectopic pregnancy
• Tobacco use
• History of infertility
• Prior PID
• Advanced maternal age

Question 23

Ectopic pregnancy site 8

Answer 23

1. Ampullary
2. Isthmic
3. Fimbrial
4. Cornual
5. Caserean scar
6. Abdominal
7. Cervical
8. Ovarian