Early pregnancy bleeding

Created by: AL
Created on: 06-02-13 14:13

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Bleeding in Early pregnancy
- Spontaneous miscarriage
  - Prior to 24 weeks most common before 12 wks after 24 weeks= viable foetus so intrapartum haemorrhage
  - Most common cause of early bleeding
  - Incomplete
    - Lower abdo pain
    - Heavy vaginal bleeding
    - Shock + uterine tenderness
      - blood transfusion if needed
    - Use forceps to remove remainder
      - On scan still see parts left behind/ empty/ foetus at cervix
    - Cervix open
    - On scan still see parts left behind/ empty/ foetus at cervix
    - FH -ve
  - Inevitable
    - FH +ve
    - Similar to incomplete
    - Bleeding and pain worse
    - Cervical os can be beginning to open
    - Nothing to be done. can give oxytoxic to contract uterus
  - Complete
    - No Tx- spontaneous- conservation
  - Threatened
    - Pain -ve
    - Bleeding not profuse + settles
    - Cervix closed
    - Uterus size= gestational age
    - FH +ve
    - Conservative mment and usually good outcome
    - Reassurance+ rest. Remove IUCD if present. Aspirin low dose
      - Conservative mment and usually good outcome
  - Septic
    - Rare in UK
    - All features of miscarriage + sepsis- eg from back street abortion
    - Empty uterus + abx
  - Aetiology
    - Uterine abnormalities
      - bicornuate uterus, uterine septae, fibroids (esp if protruding into uterine cavity), incompetent cervix
    - Acquired disease
      - Infections (TORCH)
        Toxoplasmosis, others, rubella, cytomegalovirus, herpes simplex
      - listeria, malaria, influenza virus, hypertension, renal, DM, thyroid
    - Abnormal conceptus- chromosomal
    - Toxins
      - Alcohol, smoking, anti-metabolites, chemotherapy, anaesthetic cases
    - Endocrine- deficient corpus luteum and progesterone production, high LH
    - Trauma: amniocentesis, abdo surgery
    - FB- IUCD
    - Immunological- antiphospholipid syndrome, lupus anticoagulent
    - Psych
  - Ix
    - Hb, blood group and Rh typing ( risk of rh iso immunisation), group and save.
    - b-hCG pregnancy test
    - serum b-hCG if hydratiform mole is suspected
      - Tracking disease. Also for ectopic
    - ECS and blood culture if sepseis
      - Swab + blood culture
    - USS
      - Transvaginalscan. Do need chaperone + more invasive. Gives superior picture
      - Transabdominal scan/ probe. Less clear in early pregnancy. Can't do without full bladder
      - Amniotic sac present from about 5 weeks. FH from 7 weeks
- Ectopic pregnancy
  - Aetiology
    - Chlamydial/ gonococcal salpingitis
    - Previous tubal surgery (narrowing)
    - IUCD
    - Previous tubal ligation
  - Implantation of conceptus outside uterine cavity
  - Most 1st trimester, fallopian tube
  - 10-15% recurrent
  - Clinical features
    - Amenorrhea
    - Lower abdo pain
    - Vaginal bleeding
      - Shoulder tip pain if irritating diaphragm/ adnexal tenderness if in pouch of douglas
  - Outcomes
    - Tubal abortion
    - Tubal rupture
  - Sites
    - Isthmal, ampullary, interstitial, ovarian, peritoneal, cervical
  - Mment
    - 1) pregnancy test 2) scan. cannot always see pregnancy. If more than 7 weeks, should see something in uterus
    - Ix
      - Urine b- hCG pregnancy test
      - Paired serum b- hCG
        Should more than double, if falling- not viable, if small increase- ectopic
      - transvaginal uss
      - Diagnostic laparoscopy
        risky for patient + pregnancy try to avoid!
    - Tx
      - Laparoscopic salpingectomy
        ok if not wanting more pregnancies. Can use IVF after. best.
      - laparoscopic salpingotomy
        only remove part with pregnancy
      - IM methotrexate
        inj to avoid surgery. does not eliminate risk of rupture
      - Intratubal methotrexate
      - Conservative mment
      - laparotomy if ruptured
- Hydratiform mole
  - Developmental anomaly of trophoblas or placenta. local or general vesicular change in chorionic villi
  - Amenorrhea, vaginal bleeding, uterus larger than dates , FH -ve, haemoptysis, pleuritic chest pain (spread)
    - No as much pain as in miscarriage
    - spread to lung/ breast
  - may see part of pregnancy but always not viable
  - Outcome
    - 1) tumor gone
    - 2) hCG doesn't fall so tumor cells somewhere in body. Not malignant- but "persistent" mole
  - Ix
    - Urinary and serum hCG
      - 2000-1000 IU in normal pregnancy. Mole= 100 000's
    - USS- snowstorm appearance, theca-lutein ovarian cysts
    - CXR
  - Tx
    - Evacuation of uterus. More difficult to empty due to tissue
    - Prolonged follow-up of urinary + serum b-hCG
    - Avoid pregnancy 1 yr (dont know if increased hCG is due to new pregnancy or mole)
    - Hysterectomy if no desire for further childbearing.
    - Persistent mole= chemo
  - Poss malignant change to choriocarcinoma
- Lower genital tract causes
- Cervical incompetence
  - cervical dilation in abscence of abdo pain
  - Aetiology
    - Cervical dilatation during TOP
    - Cone biopsy of cervix
    - cervical amputation during Manchester repair
    - Exposure to DES
    - Idiopathic
  - Cervical cerclage- suture at 14 weeks.
    - Risk of ROM and infection
    - removed at 36 wks
Recurrent miscarriage
- On 3 or more consecutive occasions
- Probability of live birth with next pregnancy 40-50%
- Ix
  - GTT, T4, TSH
  - Karyotyping of both parents + foetal tissue
  - Hysteroscopy, HSG (fibroids/ shape), IVT (renal)
  - Most couples: all normal
- Tx
  - Any underlying cause
  - TLC
Isthmal, ampullary, interstitial, ovarian, peritoneal, cervical

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Early pregnancy bleeding

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