A guide to midwives to discover early warning signs

1. EARLY
PREGNANCY
BLEEDING
DR DOBGIMA W. PISOH
OB/GYN
REGIONAL HOSPITAL BAMENDA
1

2. Scope
1. Definition
2. Causes
3. Abortions
4. Molar Pregnancies
5. Ectopic pregnancies
6. Conclusions

3. DEFINITION
 Bleeding from the lower genital tract during the first two
trimesters of pregnancy (ie before fetal viability).
 The concept of viability
 baby can survive out of the womb with or without support.
 Generally 28 weeks in our context

4. CAUSES
• Obstetrical
• Abortions
• Molar pregnancy
• Ectopic
•Non – Obstetrical
• Cervicitis
• Trauma of the lower genitalia
• Cervical polyps
• ectropion
4

5. I. Abortions
1. Definition
2. General causes
3. Classification
4. Symptoms
5. Signs
6. Diagnoses
7. Management
8. Complications

6. Definition
•Termination of pregnancy before the viability of the
fetus i.e. before 28 completed weeks of pregnancy
in our context.

7. General Causes
1. Chromosomal anomalies ( 60-70% of cases)
2. Trauma: Road Traffic Accidents, Falls, Fights,
3. Infections: Bacterial, Protozoan, viral
4. Anatomical disorders: Embryological anomalies,
uterine myoma, cervical incompetence
5. Febrile conditions: Malaria, Urinary Tract
Infections, Chest infections etc
6. Certain medications/ Ingestion of abortificients.

8. CLASSIFICATION
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Missed abortion
6. septic abortion
8

9. THREATENED ABORTION
•Symptoms:
• Painless vaginal bleeding
•Signs:
• Vital signs are normal
• No abdominal tenderness
• Cervical os is closed
• Uterine size = Gestational Age

10. THREATENED ABORTION
(CONT’D)
•Management:
• Bed rest
• Sedation
•Outcome/ Complications:
• Spontaneous regression
• Clinical deterioration: Inevitable abortion

11. INEVITABLE ABORTION
•Symptoms:
• Bleeding increasing in quantity
• ± Lower abdominal pain
•Signs:
• Slight lower abdominal tenderness
• More severe vaginal bleeding.
• Cervical os is open
• Uterine size = Gestational age

12. INEVITABLE ABORTION
(CONT’D)
•Management:
• Uterine evacuation
• Antibiotherapy
• Analgesics
• Sedation
•Outcome/ Complications:
• Incomplete abortion/ Complete abortion

13. INCOMPLETE ABORTION
•Symptoms:
• Severe lower abdominal pains
• Very severe vaginal bleeding
• ± Symptoms of hypovolemia
•Signs:
• Severe lower abdominal tenderness
• Cervical os is open
• Products of conception are visible
• Uterine size < gestational age of pregnancy

14. INCOMPLETEABORTION
(CONT’D)
•Management:
• Uterine evacuation
• Antibiotherapy
• Analgesics
• Sedation
• Family Planning
•Outcome/ Complications:
• Complete abortion, Septic abortion
• Endometritis, Salpingitis, PID, Infertility

15. COMPLETE ABORTION
•Symptoms
• None or mild per vagina bleeding
•Signs:
• No or mild pv bleeding
• Cervical os closed
• Uterine size normal
• ± Normal vital signs

16. COMPLETE ABORTION
(CONT’D)
•Management
• Antibiotherapy
• Reassurance
• ± Family Planning
•Outcome/ Complications:
• ± Discuss risk of recurrence

17. SEPTIC ABORTION
•Syptoms
• Lower or generalised abdominal pains
• Persistent vaginal bleeding
• ± Offensive vaginal discharge
•Signs:
• Signs of constitutional disturbance – altered vital
parameters
• Signs of pelvi-peritonitis.- abdominal tenderness,
distention, guarding
• ± Malodorous PV discharge

18. SEPTIC ABORTION (CONT’D)
•Management
• Hospitalisation/ IVI line/ Parenteral antibiotherapy
• Septic work up
• Uterine evacuation
• Intensive continuous monitoring and evaluation
•Outcome/ Complications:
• Pelvic infection and sepsis (PID)
• Pelvic abcess/ peritonitis
• Infertility

19. MISSED ABORTION
•Symptoms:
• Cessation of pregnancy symptoms
• Slight spotting (altered blood)
• ± Recent febrile illness
•Signs:
• ± None
• No abdominal tenderness
• Os uteri closed
• Uterine size < Gestational age

20. MISSED ABORTION (CONT’D)
•Management:
• Hospitalize and sedate.
• NFS, TP, TCK, GS & x-match
• Uterine evacuation
• Subsequently investigate possible causes
•Outcome/ Complictions:
• Incomplete evacuation
• Uterine perforation
• Coagulation failure, Anemia ± sepsis

21. MISSED ABORTION (CONT’D)
•Management:
• Investigate and treat possible causes
• Uterine evacuation
•Outcome/ Complictions:
• None
• Depression

22. 2. MOLAR PREGNANCIES
•Definition:
• Vesicular degeneration of the placenta
• With the presence of an embryo or fetus or not

23. 2. MOLAR PREGNANCIES
(CONT’D)
Types:
1. Hydatidiform mole
2. Invasive mole
3. Chorio-carcinoma
4. Placenta site trophoblastic disease

24. 2. MOLAR PREGNANCIES
Symptoms:
1. Exagerated symptoms of pregnancy
2. Accelerated increase in uterine size
3. Painless vaginal bleeding
4. Passage of vesicular substances through the vagina

25. MOLAR PREGNANCIES
(CONT’D)
Signs:
 Uterine size > Gestational age
 Signs of dehydration and electrolyte imbalance
 Elevated B.P.
 Vesicular materials emanating from cervix on speculum
examination.
 Proteinuria

26. MOLAR PREGNANCIES
(CONT’D)
Management:
 Hospitalisation and uterine evacuation
 Medical treatment with Methotrexate should be
considered in order to prevent subsequent
invasive mole and choriocarcinoma
 Avoid pregnancy for at least 12 months with
serial ß-hCG estimations

27. MOLAR PREGNANCIES
(CONT’D)
Outcome/ Complications:
 Subsequent chorio-carcinoma
 Elevated risk of recurrence

28. ECTOPIC PREGNANCY
28

29. INTRODUCTION
Definition:
◦Any pregnancy where the fertilised ovum gets implanted &
develops in a site other than uterine cavity.
Ectopic - out of the normal site of implantation
Extrauterine - at any site other than the endometrial cavity
Heterotopic – one in normal site and the other extrauterine
Incidence: 0,5 à 1,25%

30. RISK FACTORS cont.
•Past history of ectopic
•Pelvic infection: Chlamydiae
•Narrowing of the tube - Congenital defects, such as diverticuli, Benign tubal
tumors and cysts, Uterine fibroids at the utero-tubal junction, Endometriosis of
the tube, Peritubal adhesions secondary to appendicitis, pelvic or abdominal
surgery, Surgical repair of the tube (tuboplasty).
Transmigration of the fertilized ovum:IVF
Intrauterine Device (IUD) usage
Hormonal factors: Progestin oral contraceptives

31. ETIOPATHOGENY
1. Delayed capture of the fertilised egg
2. Arrest or slow migration of the zygote in the tube
3.Transmigration

32. ETIOPATHOGENY
Localisation of extrauterine pregnancies
•Tubal (95 – 98%) :
• Ampulla : 70 – 75% (ruptures at 8-12wks)
• Isthmic : 10 – 20% (rupture à 6-8 wks)
• Interstitial : 4% (rupture 12-16 wks)
• Infundibular : 5%
•Ovarian : 0.5 – 1%
•Abdominal : 1 – 2% (diagnosis is often late. Could be primary or
secondary.

33. SIGNS AND SYMPTOMS OF ECTOPIC
PREGNANCY
Bleeding: Metrorragia, spotting. May occur at the time of the
expected menses and interpreted as menses
Missing period - amenorrhea
Pain: Usually unilateral pelvic pain, which may be Knife-like and
stabbing Or dull and less well defined
Signs of pregnancy might be present

34. SIGNS AND SYMPTOMS OF ECTOPIC
PREGNANCY
Physical exam:
◦ Hypotension/normal; Tachycardia
◦ Pale conjunctivae
◦ Abdominal tenderness; localised or generalised
◦ Speculum: bluish color of cervix
◦ V/E: uterus might be increase slightly; annexial mass;
cervicalmotion tenderness unilat

35. DIAGNOSIS
Ectopic pregnancy is suspected in pregnant patients:
◦ Who present with abnormal bleeding and pelvic pain or
◦ Who have one of the above risk factors esp PID or Pelvic surgery
etc

36. DIFFERENTIAL DIAGNOSIS
patient with amenorrhea, symptoms of pregnancy, pelvic pain, and
bleeding can also have:
◦ Adnexal torsion or
◦ Acute appendicitis
◦ Abortion of intrauterine pregnancy (external bleeeding is much more
severe than the pain)
◦ Bleeding corpus luteum of a normal intrauterine pregnancy (pain and
shock are usually less severe than in ectopic. Uterine bleeding is absent).
◦ PID/ Tubo ovarian abscess

37. DIAGNOSTIC TESTS
•Serial beta-HCG
•Ultrasound
•Culdocentesis/ Paracentesis
•

38. EVOLUTION
Fissuration → rupture
Tubo abdominal abortion
Resorption
Hematosalpinx
To term under strict monitoring (abdominal preg) .

39. TREATMENT
Objectives:
◦ Removal of the ectopic ovum
◦ Hemostasis
◦ Elimination of trophoblastic activity (medical treatment)
Means
◦ Abstention
◦ Surgery: radical or conservative
◦ Medical: methotrexate, expectant management

40. FERNANDEZ SCORE
Elements 1 2 3
Gestational age (in days) >49 49-42 <42
hCG values (mUI/ml) <1000 1000-5000 >5000
Progestérone serum levels (ng/ml) <5 5-10 >10
Abdominal pain Absent Provocked Spontaneous
Hematosalpinx (cm) <1 1-3 >3
Hemoperitoneum (ml) 0 1-100 >100

41. FERNANDEZ SCORE
Score < 11 => Abstention
Score : 11 – 13 => Medical treatment
Score > 13 => surgical treatment.

42. SURGICAL TREATMENT OF EP
Laparotomy:
◦ Indications: ruptured ectopic pregnancy, unruptured EP with
contraindications to (or unavailability of) laparoscopy or medical
treatment
◦ Radical: salpingectomy, salpingo-oophorectomy (rare)
◦ Or conservative: salpingostomy, fimbrial evacuation by digital
expression ; segmental resection of the tube (in view of anastomosis
of tubal ends)

43. CONCLUSION
Ectopic pregnancy is a complication of pregnancy in our
milieu
The risk factors are known and must be identified.
Early diagnosis, less invasive management
Diagnosis is sometimes quite cunning!!!!!!!!

44. THANK YOU