Bleeding in early pregnancy: Miscarriage Flashcards
Bleeding in early pregnancy
- 30% of mothers p/w bleeding in early pregnancy
- Women in reproductive age group with abnormal vaginal bleeding: Think of pregnancy!!!
Causes of bleeding in 1st trimester
- Intrauterine pregnancies
- Blighted ovum
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Complete miscarriage
- Missed miscarriage
- Trophoblastic miscarriage: molar pregnancy, partial mole - Ectopic pregnancies
- Non-pregnancy causes
- Cervical polyp, cancer, ectropion
- Infection
- Implantation bleeding
What causes miscarriage?
Fetal causes
- Chromosomal anomalies account for 80% of spontaneous miscarriages due to aberrations in maternal gametogenesis
- Trisomy 13, 18, 21, Turner’s
- Infections: TORCHes
Maternal causes
- Poorly controlled DM / thyroid disease
- SLE / APS
- Renal disease
- Excessive alcohol/caffeine
- Uterine abnormality
Patient pregnancy test positive with BLEEDING and NO PAIN differentials
- Threatened miscarriage
- Missed miscarriage
- Inevitable miscarriage
- Molar pregnancy (next chapter)
- Ectopic pregnancy (next chapter)
Features of threatened miscarriage
Small amount of vaginal bleeding
+/- Abdominal pain
Pregnancy symptoms present
Pelvic examination of threatened miscarriage
Cervical os CLOSED
Uterus size expected to date
Ultrasound findings of threatened miscarriage
Fetus with CRL corresponding to dates
Fetal heart present
Management of threatened miscarriage
Ultrasound to check viability of intrauterine pregnancy:
- Fetus with CRL corresponding to dates
- Fetal heart present
Reassure, bed rest
Investigate blood group +/- Anti-D
Oral/IV progesterone (to stabilise)
Repeat scan in 1-2 weeks to determine is fetus is alive
Features of missed miscarriage
Fetus fails to develop and dies in utero:
Vaginal bleeding - Nil or staining
NIL abdominal pain
NIL pregnancy symptoms
Pelvic examination of missed miscarriage
Cervical os CLOSED
Uterus size smaller than expected
Ultrasound findings of missed miscarriage
- Non-viable Intrauterine fetus
- CRL > 7mm but NO fetal heart
- Gestational sac > 2.5cm but NO fetal pole
Management of missed miscarriage
Ultrasound to check viability of intrauterine pregnancy
- Non-viable Intrauterine fetus
- CRL > 7mm but NO fetal heart
- Gestational sac > 2.5cm but NO fetal pole
Investigate blood group +/- Anti-D
Misoprostol (vaginal or oral) or cervagerm pessaries
Evacuation of uterus
Features of inevitable miscarriage
Large amount of vaginal bleed
Can lead to:
- Spontaneous complete miscarriage OR
- Incomplete miscarriage OR
- Viable pregnancy (rare since os open)
Pelvic examination of inevitable miscarriage
Cervical os OPEN
*regardless of state and viability of fetus
Ultrasound findings of inevitable miscarriage
Fetus with CRL corresponding to dates
Fetal heart present
Management of inevitable miscarriage
Ultrasound to check for viability
Misoprostol (prostaglandin) to hasten miscarriage
Send products of conception for histology -> partial mole
Patient pregnancy test positive with bleeding, cramps, passage of blood and possibility some tissue differentials
- Incomplete miscarriage
- Complete miscarriage
- Septic miscarriage
- Ectopic pregnancy
Features of incomplete miscarriage
Large amount of vaginal bleed
Abdominal pain
Vasovagal syncope (if POC @ cervical os)
Other sx - dizziness, hypotensive, tachycardic, pale
Pelvic examination of incomplete miscarriage
Cervical os OPEN
POC seen at cervical os, genital tract
Uterus smaller than expected size
Ultrasound finding of incomplete miscarriage
Thick endometrium suggestive of retained products of conception
Management of incomplete miscarriage
Haemodynamically unstable patient:
Secure ABCs
Remove POC from cervical os using sponge forceps
Blood tests - FBC, GXM
Investigate blood group +/- Anti-D
Evacuation of uterus
- Use uterotonic agents during surgery
If infected POC: Abx cover
Features of complete miscarriage
Small amount of vaginal bleed
+/- abdominal pain
(bleeding and cramps decrease)
NIL pregnancy symptoms
Pelvic examination of complete miscarriage
Cervical os CLOSE
Uterus is smaller than expected
Ultrasound findings of complete miscarriage
Empty uterine cavity
Thin endometrium
No adnexal masses
Management of complete miscarriage
Ultrasound to check for viability
No treatment required
Follow up in 1-2 weeks to ensure bleeding has stopped
Features of septic miscarriage
Vaginal bleeding
Abdominal pain
Prior instrumentation of uterus
Fever
Pelvic examination of septic miscarriage
Cervix os OPEN
Purulent vaginal discharge
Cervical motion tenderness
Uterus smaller than expected
Adnexal tenderness
Ultrasound findings of septic miscarriage
Non-viable intrauterine pregnancy
Thick endometrium suggestive of retained products of conception
Management of septic miscarriage
Ultrasound to check for viability
Investigate blood group +/- Anti-D
IV Abx
Evacuation of uterus
Differentials for CLOSED cervical os
Threatened miscarriage
Missed miscarriage
Complete miscarriage
Differentials for OPEN cervical os
Inevitable miscarriage
Incomplete miscarriage
Septic miscarriage
Differentials for uterus of expected size
Threatened miscarriage
Inevitable miscarriage
Differentials for uterus smaller than expected size
Missing miscarriage
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Implantation bleeding
- Occurs in 1st trimester during implantation
- When the fertilized egg embeds to the uterine lining, light bleeding/ spotting can occur
- Cannot differentiate it from threatened miscarriage
- Diagnosis of exclusion
