Bleeding in early pregnancy Flashcards
Benign causes of bleeding in early pregnancy
- Infection: cervix, vagina or STI
- Cervical changes: progesterone influence
- Sex
- Implantation bleed
Serious causes of bleeding in early pregnancy
- Miscarriage
- Ectopic
- Gestational trophoblastic diseases
How can miscarriage be classified?
Threatened: body shows signs that indicate miscarriage may occur, os closed
Inevitable: heavy vaginal bleeding and cramping, os open
Complete/ incomplete: all pregnancy tissue has been expelled/ pregnancy tissue remains in uterus but no foetus or no viable foetus (no heartbeat)
Missed/ silent: baby died in uterus, signs of pregnancy may have faded but otherwise nothing unusual
Definition and epidemiology of micarriage
Spontaneous loss of the pregnancy before foetus reaches viability
- Up to 20% of all clinically recognised pregnancies (80% within 1st trimester)
- 50,000 admissions in the UK annually
- Significant distress to patient
- UK viability is 23+6 weeks
Causes of miscarriage
- Foetal chromosomal abnormalities (trisomy 21 - Down’s, trisomy 12, Patau’s, trisomy 18 - Edward’s)
- Hormonal factors: PCOS, inadequate luteal function, diabetes, thyroid dysfunction
- Immunological causes: auto or alloimmune
- Uterine anomalies: septated, Asherman syndrome, fibroids
- Infections
- Environmental factors: alcohol, smoking
- Unexplained
Management of miscarriage
- Emotional time so sensitive empathic approach
- Medical or surgical management or expectant management which entails waiting for the miscarriage to complete spontaneously
- Woman’s preference takes precedence
- Expectant management is an option for women who aren’t bleeding heavily but this can take weeks
- Medication: miscarriage is induced by prostaglandins e.g. misoprostol oral or vaginal. Use of progesterone antagonist mifepristone administered 12-48hr before prostaglandin increases success rate
- Surgery: dilation of the cervix and suction of uterus
- Emergency surgery required if: profuse bleeding, tachycardia, anaemia, need for immediate fluid resuscitation
Viable pregnancy
- Reassure
- If bleeding getting worse or >14 days - reassess
- Continue or start antenatal care
- Anti-D if required
Confirmed incomplete, missed or inevitable miscarriage
- First line is expectant management over 7-14 days if accepted by mother
- Exclude complicated factors
- Reassess after 14 days if no bleeding
Complete miscarriage
Pregnancy test at home in 3 weeks and return for assessment if +
Retained products of conception
If small and minimal bleeding can be managed conservatively
Medical management of miscarriage
- Misoprostol - synthetic prostaglandin E1
- Evacuation of retained products of contraception
Epidemiology of ectopic pregnancy
1/100 pregnancies
1/30 in high risk population
Risk factors:
- Pelvic infection
- Previous ectopic
- Previous surgery
- Endometriosis
- IVF
50% occur with no risk factors
What is a heterotopic pregnancy?
Combined intrauterine and ectopic - rare
Define recurrent miscarriage
3+ miscarriages in a row
Investigations and management for recurrent miscarriage
Investigations
- Antiphospholipid antibodies: anticardiolipin
- Cytogenic analysis
- USS to check uterine anatomy: fibroids, congenital uterine anomaly
- Inherited thrombophilia screen
- Parental karyotype
Treatment
- Low dose aspirin + heparin]genetic counselling
- Assisted conception
- Surgery
What is the most common cause of bleeding in early pregnancy?
Miscarriage
What is the evidence for intervention in the reduction of incidence of miscarriage?
- Little evidence to suggest that any intervention reduces incidence
- Women with antiphospholipid syndrome: low dose aspirin and low molecular weight heparin improves live birth rate of future pregnancies to 70%
- Cases of excessive shortening of the cervix can be alleviated by placement of a cervical suture
What investiations are done if a woman presents with suspected miscarriage?
- Urinary pregnancy test - serial measurements of hCG are more useful than a single measurement, decreasing levels generally indicates miscarriage
- USS - is foetal heartbeat not heard of pregnancy <12 weeks a USS is done
Aetiology of ectopic pregnancy
- Damage to Fallopian tube = key risk factor
- Common risk factors: PID, previous ectopic, tubal surgery, IUD, smoking, IVF failed emergency contraceptive
- Key to maintain high index of suspicion
Clinical features of ectopic pregnancies
- Unilateral lower abdo pain is most common presenting complaint
- Often vagina bleeding
- Irritation of diaphragm >> innervated by phrenic nerve can cause shoulder tip pain
- Fainting or collapse suggest intra-abdo bleeding
- Examination: unilateral tenderness, cervical excitation &/ adenexal mass
- Clinical signs of haemodynamic compromise or peritoneal irritation, tachycardia, hypotension, abdo guarding suggest tubal rupture and haemorrhage
Diagnosis of ectopic pregnancy
Empty uterus + positive pregnancy test = ectopic until proven otherwise
Investigations for ectopic pregnancy
- Transvaginal USS: empty uterus, adnexal mass and free fluid in rectouterine pouch. If live, the adnexal mass might have a heartbeat.
- Serial hCG measurements: in a viable uterine pregnancy levels double every 48hrs. If levels rise slowly or remain static this suggests ectopic
Management of ectopic pregnancy
- Expectant management providing pain is minimal and serum hCG is falling and the ectopic isn’t visible on USS - women are monitored to make sure hCG levels fall
- Medication: if pain is minimal, adnexal mass is <4cm and hCG = <1500IU/L. Methotrexate causes tubal abortion before tube ruptures. Given as single IM injection. hCG levels initially rise and then fall. 15% require second dose. Women must avoid pregnancy for 3mo because methotrexate is teratogenic
- Surgery: if haemodynamic compromise, salpingectomy
**Expectant management of methotrexate are only given if woman can attend for follow up**
Gestational trophoblastic disease
- Rare in UK - 0.1% of pregnancies
- South east Asia - 1% of pregnancies
Gestational trophoblastic disease includes:
- Benign disorders of trophoblastic proliferation such as complete or partial hydatidiform moles
- Neoplastic trophoblastic disease does example invasive moles, choriocarcinoma and placental site trophoblastic tumours
Trophoblastic disease more common in teenagers and >45
What is a hydatidiform molar pregnancy?
- A complete hydatidiform mole is created when two separate spermatozoa fertilise an empty ovum (an egg with no functional DNA). Makes a diploid conceptus 46 XX. Mass forms but no foetus
- Partial hydatidiform mole results when two spermatozoa fertilise a normal egg. Makes a triploid conceptus 69 XX. Abnormal foetus forms but cannot survive or develop into baby
Clinical features of a molar pregnancy
- Vaginal bleeding in first or second trimester in often the only the presenting complaint
- USS: multiple cystic areas are visible within placental mass and contain either no recognisable foetus (complete mole) or grossly abnormal foetus (partial mole)
- Serum hCG extremely high
Management of molar pregnancy
- Surgical evacuation of pregnancy is recommended
- Follow up carried out at regional trophoblastic screening centres where hCG levels are monitored until undetectable
- Persistent trophoblastic disease warrants chemo
What is hyperemesis gravidarum?
Can cause dehydration and malnutrition which can cause hyponatremia and thiamine deficiency which can cause Wernicke’s encephalopathy
35% of women have symptoms that reduce their QoL
1% have hyperemesis gravidarum wand require hospital treatment for dehydration
Clinical features of hyperemesis gravidarum
Persistent vomiting accompanied by weight loss exceeding 5% of pregnancy body weight is diagnostic of hyperemesis gravidarum
Epidemiology of hyperemesis gravidarum
- More common in 1st pregnancy
- More common in women who experience nausea related to other things e.g. migraine
Investigations if woman has hyperemesis gravidarum
- Exclude other causes of nausea and vomiting and assess severity
- Urinalysis: patients with ketonuria are usually admitted for rehydration. Signs of infection may indicate precipitating factor
- Bloods: electrolyte imbalance due to vomiting
- Ultrasound: hydatidiform molar pregnancy and multiple pregnancies are associated with hyperemesis
Bloods:
- FBC: anaemia
- U&E: hyponatremic, hypokalaemic, hyochloraemic
- Metabolic acidosis indicates severe disease
- LFTs: increased bilirubin, AST and ALT but frank jaundice is rare
Management of hyperemesis gravidarum
Mainly supportive, IV fluid, antiemetics, vitamins
Prevention of DVT if dehydration is severe and mobility limited
Bleeding in pregnancy with repsect to trimester
- 1st trimester: miscarriage, ectopic, hydatidiform mole
- 2nd trimester: miscarriage, hydatidiform mole
- 3rd trimester: bloody show, placental abruption, placenta praevia, vasa praevia
- Also consider STI, cervical polyps
Symptoms of placental abruption
- Constant lower abdo pain and
- shock greater than expected
- tense tender uterus with normal lie and presentation
- coagulation problems
- foetal heart may be distressed
- consider pre-eclampsia, DIC, anuria
Causes of abdominal pain in pregnancy
Early: miscarriage, ectopic
Abruption
Symphysis pubis dysfunction: ligament laxity increases due to hormona changes and pain can raidate to groins and thighs, causes a waddling gait
Pre-eclampsia/ HELLP
Appendicitis
UTI
What is gestational trophoblastic disease?
AKAmolar pregnancy
Can be benign or malignant
0.1% pregnancies in the UK
1% pregnancies SE Asia
Chromosomally abnormal pregnancies that have the potntial to become malignant
Risk factors for molar pregnancies
Maternal age extremes
Previous molar pregnancy
Outline the two types of molar pregnancies
1) Complete: chromosomally empty egg fuses with a normal sperm and sperms genetic material doubles forming a mass but no foetus
- Placenta secretes huge amount of B-hCG - BhCG can mimic TSH causing tachycardia, anxiety, insomnia and palpitations, abdo grows rapidly so uterus too large for dates
2) Incomplete mole: normal egg fertilised by 2 sperm forming an organism w/ 69 chromosomes and non-viable foetal parts
- More BhCG than normal but less than complete moletherefore no symptoms of hyperthyroidism
Clinical features of molar pregnancy
Vaginal bleeding in 1st/2nd trimester
USS; multiple cystic areas within placenta, no recognisable foetal parts (complete), grossly abnormal foetus (incomplete), snow storm/ swiss cheese
Extremely high BhCG
*Moles = pre-malignant conditions
Management of molar pregnancies
Surgical evacuation or pregnancy
Follow up at trophoblastic screening centres and monitor until BhCG levels fall
If levels don’t fall may suggest residual tissue or malignancy
What is choriocarcinoma?
Malignant transformation of the placenta, can develop following normal pregnancy or molar pregnancy
Persistent trophoblastic disease is malignancy related only to molar pregnancies and not normal pregnancies
