Bleeding in Early Pregnancy Flashcards
What are the seven variations of pregnancy loss
1) Threatened miscarriage 2) Inevitable miscarriage 3) Incomplete Miscarriage 4) Complete miscarriage 5) Missed miscarriage 6) Ectopic Pregnancy 7) Molar pregnancy
How common are miscarriages?
How many miscarriages occur in the first trimester?
Common with a rate of 20-40% in pregnancies
60-80% of these occur in 1st trimester. In fact 25% of pregnancies end so early that the are not even recognised.
Miscarriage: the definition is?
“spontaneous loss of pregnancy before 20 weeks gestation”
After 20 weeks it is considered stillbirth
Miscarriages <6weeks “chemical pregnancies” or “early pregnancy loss”
6-20 weeks “clinical spontaneous miscarriage”
Causes of Miscarriages are?
- Chromosomal anomalies (50%)
- Structural anomalies
- Maternal Factors; fibroids, adhesions, diabetes
What is a Threatened Miscarriage?
Minor vaginal bleeding no/little pain
Cervix closed
Pregnancy symptoms
no tissue passed
*if fetal heartbeat heard, 95% will continue to term
*puts these patients more at risk for miscarriage
What is an inevitable miscarriage?
Heavy vaginal Bleeding
Pain
No tissue passed
may still have vaginal symptoms
Open cervical os
Management is indicated, USS confirms non-viable pregnancy and reveals products of conception in utero
empty sac at 7+ weeks means miscarriage is inevitable
What is an incomplete miscarriage?
Passage of products has started but not complete.
Heavy bleeding/clots
pain/cramps
tissue passed
cervical os open
May have pregnancy symptoms
Complete Miscarriage
Has occured
Light brown spotting
minimal pain
no more tissue passing
Cervical os closing
symptoms of preg reducing
Missed Miscarriage
When pregnancy ends but uterus does not expel its contents.
Light brown spotting
minimal pain
no more tissue passing
Cervical os closed
symptoms of preg reducing
Management of incomplete, inevitable or missed miscarriage?
Expectant: wait and see, review 1/52, usually within 2-6/52 will have passed
Natural/private at home: successful in 65% of early miscarriage
Medical:
- Misoprostol (800micrograms) -
- if not complete 72/24 second dose may be required
- F/U day 8/7
Surgical:
- Suction curettage (ERPOC) under GA/LA
What is an ectopic pregnancy?
When embryo implants at a site other than the endometrium of the uterine cavity.
1/50 pregnancies, mainly in fallopian tube.
- Small amount of dark red blood
- if ruptured massive haemorrhage, pale, sweaty, unwell, possibly collapsed
- After rupture, entire abdo tense and tender
- Unilateral pelvic pain (shoulder tip if ruptured)
Management of Ectopic Pregnancy includes?
Surgical: gold standard.
- laparotomy if in shock, or if laprascopy going to be difficult (inc BMI, previous surgery)
- Salpingectomy if other tube looks normal.
- **give anti-D to all Rh neg women
Medical:
- IM Methotrexate: only if haemodynamically stable, bhcg <5000 and USS are within limits (no fetal HR, gestational sac in adnexum, not ruptured/no free fluid)
Expectant: occassionallly appropriate
What is a molar pregnancy?
When a non-viable fertilized egg implants in the uterus and will fail to come to term.
no bleeding
no pain
Sometimes “grape like” tissue (swollen chorionic villi)
Exaggerated pregnancy symptoms
closed cervical os
Management of a molar pregnancy
Surgical evacuation via suction curettage
- THis carries a risk of heavy bleeding
- FU required at specialist clinic
- FU serum bhcg every 1-2 weeks till non-detectable, then monthly for 6/12
- ANTI D for all Rh neg
What are Braxton Hicks Contractions, are they a cause of concern?
“false labour contractions” Occur <8 times/hour or <4 times/20 mins; these contractions are not accompanied by bleeding or vaginal discharge and are relieved by resting. No increased risk in preterm labour
What investigations need to be done before a termination can occur?
1) Positive B-hcg 2) Endocervical swab: Chlamydia, gonorrhoea 3) High vaginal swab: Trichomonas vaginalis, bacterial vaginosis or candida
When can medical or surgical terminations be offered up until?
Medical terminations offered up to 5-9 weeks Surgical Terminations offered up to 7-13 weeks
What does medical termination consist of How long does it take What are its side effects Success rate?
Woman takes 2 tablets 24-48 hours apart to induce abortion at home. Requires 2x clinic visits. Takes 4-6 hours Nausea, vomiting, cramp like pain, bleeding, diarrhoea Success rate >95%
What does surgical termination consist of? How long does it take? What are its side effects? Success rate?
Removes pregnancy tissue with a suction procedure under sedation (LA/GA). Requires 2x clinic visits, takes 5-10 mins Nausea, vomiting, cramp like pain, bleeding, diarrhoea 99% success rate
Medications for surgical termination?
Misoprostol 400 mcg (given buccally to soften cervix and increase uterine tone to stop bleeding) Midazolam may also be given Fentanyl + paracervical block given as analgesia
How does medical termination occur?
1) Mifesprostone (RU-486): 200mcg is given to sensitise the uterus to PG’s and block progesterone release 2) Misoprostol (PG analouge): 400mcg is given 24-48hours later either vaginally or buccally to induce uterine contractions/cervical dilation
What type of bleeding is normal after MTOP
Woman may experience light bleeding for up to 3/52 post-MTOP **1/100 woman will have severe bleeding or pain**
What is Cervical Shock?
Occurs when miscarriage is occuring and a clot or pregnancy tissue gets stuck in transit in the cervix
This causes a profound vagal response of hypootension + bradycardia
How do we treat cervical shock?
- Perform Speculum
- Remove the POC from the cervical os
Should we always assume miscarriage with early pregnancy bleeding or spotting?
No, as light bleeding/spotting is common in early pregnancy (25%).
Causes of spotting:
- Hormone induced breakthrough bleeding ~when a women would usually menstruate
- Implantation Bleed: from embryo imbedding, lasts 1-2 days
- Cervical inflammation
- uterine fibroids
- Polyps
- Cervical/vaginal infection
- Inherited disorders; von willebrands
- Trauma
Risk factors for miscarriage in early pregnancy
- Chromosomal abnormality
- Smoking
- Parental genetic abnormality
- Chlamydia/rubella
- Previous miscarriage
- HTN
What do we want to know about with a history /assessment of early pregnancy bleeding/pain
A woman presents acutely unwell with bleeding and/or pain in early pregnancy. What do you do in that acute situation?
- Perform Drs ABC’s
- Obtain IV access
- give O2
- Start continuously monitoring
- Give IV fluids
- Request urgent bloods + group&hold, if needed transfuse blood while finding/treating cause
