Bleeding in early pregnancy Flashcards
Is bleeding in pregnancy common? What is an implantation bleed? Is bleeding considered abnormal or normal in pregnancy? what are the 4 general causes of bleeding in early pregnancy?
Vaginal bleeding occurs in 25% pregnancy prior to 20wks. A small amount of bleeding may occur 5-7 days after fertilization (implantation bleed). Bleeding should always be considered as abnormal in pregnancy and investigated appropriately.
More common:
o Spontaneous miscarriage (most common)
o Ectopic pregnancy
Less common
o Hyatidiform mole
o Lower genital tract causes
What is a spontaneous miscarriage?
λ Expulsion or removal of the products of conception prior to 24 weeks of gestation
λ Most common cause of bleeding in early pregnancy
What type of spontaneous miscarriage exist?q
- threatened
- incomplete
- inevitable
- complete
- septic
What is a threatened miscarriage?
o This is when bleeding occurs but the pregnancy continues
o pain -ve; bleeding not profuse; cervix closed;
uterus = gestational age; Fetal heart (FH) +ve – (on ultrasound)
o Most women presenting with a threatened miscarriage will carry on with the pregnancy irrespective of method of management
What is an incomplete miscarriage?
o the patient develops abdo. Pain assoc. with increasing vaginal bleeding, the cervix opens and eventually products of conception pass through to vagina. However, if some of the products of conception are retained miscarriage is incomplete.
o lower abdominal pain; heavy vaginal bleeding with clots/tissues; shock +ve; tenderness +ve; cervix open; POC may be present in cervix; FH -ve
What is an inevitable miscarriage?
o similar to incomplete miscarriage; FH +ve
What is a complete miscarriage?
o an incomplete miscarriage may proceed to completion spontaneously when the pain will cease and vaginal bleeding will subside with involution of the uterus.
o Spontaneous completion of miscarriage is more likely in miscarriages over 16wks gestation
o history similar to incomplete abortion followed by cessation of bleeding; uterus < gestation age; cervix closed; FH -ve
What is a septic miscarriage?
o during the process of miscarriage – or after an abortion – infection may be introduced into the uterine cavity
o the clinical findings are similar to incomplete miscarriage with additional uterine and adnexal tenderness, vaginal loss may become purulent and the pt. may become pyrexial
o infection following a miscarriage
What are the 9 aetiologies of miscarriage?
Abnormal conceptus
λ Chromosomal (50%) – trisomy 16,22,21,15; monosomy 45 X0; tri and tetraploidy; balanced translocation
Uterine abnormalities
λ bicornuate uterus; uterine septae; marked uterine ante/retroflexion; fibroids; incompetent cervix
Acquired disease
λ Infections (TORCH), listeria, malaria, influenza virus; hypertension, renal; disease, diabetes mellitus, thyroid disorders
Toxins
λ alcohol; smoking; anti-metabolites, chemotherapy; anaesthetic gases
Immunological
λ antiphospholipid syndrome;
lupus anticoagulent
Endocrine
λ deficient corpus luteum and progesterone production; high preovulatory LH (> 10 IU/l)
Trauma
λ amniocentesis, abdominal surgery; coitus
Foreign body
λ intrauterine contraceptive device
Psychological
λ stress; anxiety
What is included in the examination and investigation for miscarriage?
Examination:
Examination of the patient includes gentle vaginal and speculum examination – ascertain cervical dilatation
-some women may prefer not to be examined due to worry of causing miscarriage
Investigations: λ Haemoglobin λ Blood group and Rh typing λ Group & save λ b-hCG pregnancy test λ Serum b-hCG if hydatidiform mole is suspected λ ECS and blood culture if sepsis is present λ Ultrasound
What is the treatment for: -threatened -inevitable -incomplete -complete -septic miscarriage
Threatened miscarriage
λ reassurance and rest; avoid coitus; remove IUCD if present; aspirin, heparin or prednisolone for APLS after 1st trimester
Inevitable miscarriage
λ allow uterus to evacuate itself; pain relief; oxytoxic; evacuation of uterus
Incomplete miscarriage
λ blood transfusion if shock is present (3-5%)
oxytoxic; removal of POC (products of conception); evacuation of uterus; biannual compression
Complete miscarriage
λ conservation management
Septic miscarriage
λ resuscitation if shock is present; antibiotics; evacuation of uterus
Recurrent miscarriage:
- what is this classified as?
- what investigations are done?
- what treatment is available?
λ Miscarriage on 3 or more consecutive occasions
λ Probability of live birth with next pregnancy
40-50%
Investigations
- karyotyping of both parents
- GTT, T4, TSH
- hysteroscopy, HSG, laparoscopy, IVP
Treatment
- TLC
- treat any underlying course
Ectopic pregnancy:
- what is this?
- what increases the risk?
λ Implantation of the conceptus outside the uterine cavity
Aetiology:
Chlamydial or gonoccocal salpingitis; previous tubal surgery; endometriosis; IUCD; previous tubal ligation
What are the clinical features of ectopic pregnancy?
- amenorrhoea 75%
- lower abdominal pain 95%
- vaginal bleeding 75%
- shoulder tip pain; shock and syncope; abdominal guarding and rigidity; cervical excitation; adnexal tenderness; bulky uterus
What are the outcomes of ectopic pregnancy?
- tubal abortion
- tubal rupture
What are the investigations of ectopic pregnancy?
- urine b-hCG pregnancy test
- paired serum b-hCG
- transvaginal ultrasound scan
- diagnostic laparoscopy
What is the treatment for ectopic pregnancy?
- laparoscopic salpingectomy
- laparoscopic salpingotomy
- IM methotrexate
- intratubal methotrexate injection
- Conservative management
- Laparotomy if ectopic pregnancy is ruptured
What is a hyatidiform mole?
Developmental anomaly of the trophoblast or placenta in which there is a local or general vesicular change in the chorionic villi
This is a premalignant lesion (choriocarcinoma) and is part of a group of disorders called gestational trophoblastic disease – it needs to be removed
Hydatidiform mole, or molar pregnancy, results from too much production of the tissue that is supposed to develop into the placenta. The placenta feeds the fetus during pregnancy. With a molar pregnancy, the tissues develop into an abnormal growth, called a mass.
¥ Complete mole is caused by a single (incidence is about 90%) or two (incidence is about 10%) sperm combining with an egg which has lost its DNA (the sperm then reduplicates forming a “complete” 46 chromosome set. Only paternal DNA is present in a complete mole.
¥ Partial mole occurs when egg is fertilized by two sperm or by one sperm which reduplicates itself yielding the genotypes of 69,XXY (triploid). Partial moles have both maternal and paternal DNA
¥ Complete hydatidiform moles have a higher risk of developing into choriocarcinoma (a malignant tumour of trophoblast) than partial moles.
What are the different types of hyatidiform mole?
complete and incomplete moles
What are the clinical features of hyatidiform mole?
Amenorrhoea; vaginal bleeding; uterus larger than dates; ‘doughy’ uterus; FH-ve; hyperemesis; pre-eclampsia
What investigations exist for hyatidiform mole?
urinary and serum b-hCG levels
Ultrsound: snowstorm appearance and theca-lutein ovarian cysts
CXR
What is the treatment of hyatidiform mole?
- evacuation of uterus
- prolonged follow-up with urinary and serum b-hCG
- contraception to avoid pregnancy during follow up
- hysterectomy if no desire for further childbearing
- persistent disease requires chemotherapy
what is cervical impotence?
-cervical dilatation in the absence of any abdominal pain
What are the aetiologies of cervical impotence?
- cervical dilatation during TOP
- cone biopsy of cervix
- cervical amputation during Manchester repair
- exposure to DES (diethylstilbestrol)
- idiopathic in 25% of cases
What is the management of cervical impotences?
Cervical cerclage
this is the placement of stitches in the cervix to hold it closed
- Shirodkar’s suture or McDonald suture
- performed usually at 14 weeks of gestation
- risk of ROM (rupture of membranes) and infection
- removed at 36 weeks of gestation or in early labour, whichever is earlier
