BLEEDING IN FIRSTTRIMESTER Prof. M.C.Bansal. MBBS; MS,. MICIOG; FICOG. Fonder Principal & Controller , Jhalawar Medical College & Hospital Jhalwar. Ex Principal & controller Mahatma Gandhi Medical College & Hospital . Sitapura, Jaipur.
Bleeding in First Trimester 20-25 % pregnant women present with the complain of bleeding per vagina in first trimester. 50% 0f them Miss carry . Incidence of spontaneous abortion varies from 15 – 25 %. This symptom maybe due to ---- Obstetrical cause ---more common. Non obstetrical cause.
Obstetrical causes of bleeding in First Trimester Bleeding with viable embryo –ascertained by USG. 1. Bleeding from un fused membranes ,shading of decidual parietilis as in accessory horn /no pregnant side of didelphus uterus, exposed blood vessels of decidua basalis by the in growing blastocoele ( rodent like activity of syncitial trophoblast at the site of implantation). 2. Embryos with karyotypical like triosomy ,monosomi , Robertsonian Traslocation may present as threatened abortion and continues to grow as IUGR foetus / hydrops fetalis or IUFD. 3. Low implantation of gestational sac. 4. Retrochorionic bleeding. 5. Multi fetal gestation . 6. Complete mole . Ectopic Pregnancy ---USG may show Fetal heart activity To be present in few cases of intact ectopic pregnancy as in cornual / accessory horn and cervical pregnancy .
Obstetrical causes Of Bleeding inFirst Trimester Bleeding with a non viable embryo ---USG scan needed--- 1. Blighted ovum . 2, Missed Abortion. 3. Ectopic Pregnancy . 4. compete mole. 5. Vanishing Twin syndrome. 6. Vase prevail.
Non Obstetrical causes of bleedingin First Trimester A. Cervical— Fibroid Polyps , Erosion , Ectropion , cervical carcinoma , Mucous polyp. B. Vaginal – Trichomonas vaginitis , Bacterial vaginosis , Foreign body in vagina , vaginal tumors , trauma , varicose veins . C. Bleeding Disorders –Thrombocytopenia , haemophilia , Von Wlebrand’s disease. D. drug induced –Heparin , Asprin ., warfein .Note bleeding from other sites like rectal / urethral or bleeding from haemangioma of vulva etc.
Diagnosis and Investigations--- Care full history taking local examination in good light will help a lot .in excluding most common non obstetrical causes of bleeding. TVS is gold standard to know the viability status of embryo . It help in diagnosis of all possible obstetrical causes , except due to karyotypic defects in embryo. It may give snapshot and may have limited value. If no local cause is found case needs to be investigated for bleeding disorders-- by tests such as BT, CT ,Clot retraction , platelet count, PBF and prothrombin Time (PT). Note all women should have their ABORh grouping done , if RH negative ; Anti D therapy in low dose 100mg is tube given with in 24 hours of her first bleeding episode.
Terminology of Abortion Threatened Abortion—Amenorrhea, small bleeding usually < then MC loss , little / no pain . Uterus soft, uterine size & shape corresponds to period of amenorrhea, so is closed. TVS ---FHA present., if absent ---early missed abortion .in early 6-8 weeks if only gestational sac present and no embryonic pole is identified ----it is Blighted ovum. Assurance bed rest, progesterone, HCG , anxiolytic drugs and wait and watch policy that is all needed --With hope that pregnancy will continue. Absent FHA / no embryonic pole– present evacuation of RPOC is needed.
Inevitable Abortion--- Pregnant woman presents with more bleeding and pain in lower abdomen . Bleeding is more then MC loss / leaking from ruptured amniotic sac ,Pain is more than dysmenorrheal as described by the woman. Uterine size corresponds with period of amenorrhea but its shape is changed uterus is flattened anterio- poseriorly and no more globular or spherical. It is contracting and irritable ,cervical canal is ballooned up as the separated sac descents down and is not expelled due to closed external so. The pregnancy will be aborted spontaneously , but often need to accelerate the process with the help of syntocinon drip so as to minimize the duration , blood loss and chances of infection.
Incomplete Abortion-- Pregnant women present with more pain like mini delivery , more bleeding ., passage of clots and few pieces of placental tissue or foetus. There is partial retention of RPOC .Uterus is smaller, os is open and RPOC is felt in uterine cavity with examining finger. Depending upon amount and rate of blood loss patient may develope hemorrhagic, hypo volumic shock . Immediate evacuation of RPOC under oxytocin , fluid replacement ( ringer / blood ) Prophylactic antibiotic therapy , tetanus toxoid are the basic requirements to treat such woman.
Spontaneous complete Abortion -- Complete expulsion of products of conception from the uterine cavity , reduction in size of uterus by contraction and retraction of myometrium , closure of cervical os , bleeding is stopped and pain subsides by it self. Prescribing T,Toxoid , prophylactic antibiotics, haematinics and contraceptive advice for spacing purpose must always be given .
Induced Medical Abortion -- When growth of embryo is disturbed as in blighted ovum , after expected treatment of threatened abortion , self medication or prescription for medical termination in early gestation period > 49 days. The conceptus is to be expelled out with medical method (Mifepriston and prostaglandin tabs ) or by— Surgical method ---Dilatation curettage / suction evacuation.
Septic Abortion-- Often induced / illegal incomplete abortion complicated by frank sepsis due to mixed ( aerobic gram +vet and -vet , anaerobic and sometime tetanus ) infection . Peritonitis, septicemia septic shock and DIC ----high % of maternal mortality and morbidity. Thanks to MTP law and wide availability of MTP facilities , the incidence of septic abortion has decrease significantly over last 3 decades in our country .
Light Bleeding Vaginal Bleeding expulsion of Severe pain , uterine size Mild pain H/O ( before 20Mild pain , No H/OExpulsion of products of products of conception, normal size ? Bulky , tender weeks)conception, Uterine size uterine size decreased , os cervical movements ,correspond to period of closed tender mass in fornixGestation, Os closedThreatened Abortion Complete Abortion Ectopic Pregnancy confirm by UPT and TVSUSG Observe and Follow up Mange as Ectopic Pregnancy. Fetus viable Vaginal Bleeding Persists Fetus not viable Repeat USG for fetal viability after 1week Threatened Abortion Missed Abortion reassure , rest and UT < 12 weeks Ut < 12 weeksabstinenceBleeding stops –routine Evacuation Misoprost 400mcg orally 4ANC hourly maximum 5 doses Check for completeness. If still bleeding -Evacuation
Heavy Bleeding h/o Expulsion of POC , Uterine size < period of gestation , Os may be open Diagnosis --- Incomplete Abortion Management---Immediate Resuscitation and BT if needed , start 10-20 Sintocinon drip in 500ml of RL /NS @ 40-60 drops / min. Evacuation & curettage. , injection syntomethergin 1 amp. / carboprost IM . Suitable antibiotics ( against anaerobic, graham – ve & +ve organism for a week and T. Toxoid .
Any bleeding with----H/o passage of vesicles Pain , fever , abdominal distension , H/o interference by quack / nurse or doctorVesicular Mole Septic AbortionSerum - HCG USG And flat plate abdomen in standingChest X-ray. position , Hb , CBC, Blood grouping cross TVs for Theca Lutein cysts matching , arrange 2 units of blood , Start brad spectrum antibiotics and metronidazole IV. T.Toxoid. Ryles tube suction , Iv fluid therapy, CVS monitoring and fluid electrolyte balance.Suction Evacuation --- send Tissue for Evacuate uterusHPR. Laparotomy if perforation of uterus / intestinal injury or Pyoperitoneum.Follow up of mole Medico legal reportingNote --- council all cases to avoid Too Advise Contraceptionearly pregnancy At least 6—12 months
Further Reading -- Coulam CB , Goodman C, Dorffmann A. Coparison of ultrasonic findings in spontaneous abortion with normal and abnormal karyotypes. Hum Reprod 1997 ;12 : 823-6