1. The document provides guidance on diagnosing and managing bleeding during early pregnancy, including conditions like pregnancies of unknown location or viability, threatened miscarriage, and molar changes in a missed miscarriage. 2. Diagnosis involves a clinical examination and transvaginal ultrasound, noting features like a gestational sac size and presence of a fetal heartbeat provide clues to viability. 3. Management options for conditions like ectopic pregnancy or miscarriage are discussed, including expectant management, medication, or surgery depending on the situation. Serial ultrasounds and beta-hCG monitoring help guide treatment decisions.

1. BLEEDING DURING EARLY
PREGNANCY
A PRACTICAL GUIDE
Prof/ Mahmoud abdel-
aleem

2. ‫بالشكرعلي‬ ‫الكالم‬ ‫أبدأ‬
‫أسرة‬ ‫من‬ ‫الكريمه‬ ‫الدعوه‬
‫أمراض‬ ‫و‬ ‫التوليد‬ ‫قسم‬
‫النساء‬-‫االيمان‬ ‫مستشفي‬.

3. WHAT TO DISCUSS ?
We are here for
1- Pregnancy of unknown viability.
2- Pregnancy of unknown location.
3- Persistent pain/bleeding after “apparent” evacuation.
4- Early undisturbed Ectopic Pregnancy.
5- Missed miscarriage with molar changes.

4. WHAT NOT TO DISCUSS ?
And not for:
1- Inevitable miscarriage.
2- Tubal rupture or tubal abortion: EP
3- Molar Pregnancy.

6. WHY DO PROBLEMS ARISE?
PREGNANCY
Too early
Too anxious
Too disturbed
ICSI pregnancy.
OBSTETRCIAN
Too decisive
Too intervening.
Lab-oriented doctor.
Too old machine.

7. DIAGNOSISClinical:
 ABC: only “A”.
 Cervical motion tenderness.
Transvaginal ultrasound
Must be performed meticulously because of potential pitfalls in image interpretation: considerable
expertise is necessary
 Sensitivity 99.0%
 Specificity 99.9%
1- Adnexal mass: non-cystic : 50–60%.
2- Adnexal mass: cystic (gestational sac)
 Empty: 20–40%.
 Full: (YS, Embryo)15–20%.
3- Fluid in Douglas pouch
Anechoic fluid: non-specific: IUP and EP.
Echogenic fluid: 50 % of EP
Laparoscopy is no longer the gold standard for diagnosis. False-negative diagnosis when the

8. TUBAL ECTOPIC PREGNANCY
1- Transvaginal ultrasound is the diagnostic tool of
choice.
2- Tubal EP should be positively identified, if possible, by
visualizing an adnexal mass that moves separate to the
ovary (by inclusion not by exclusion).
3- A trilaminar endometrial pattern, although specific
(94%) for ectopic pregnancy, is associated with low
sensitivity (38%).
4- TVS colour Doppler is not better than TVS 2D
ultrasound but may be useful in showing enhanced

17. VALUE OF Β-HCG
1- A positive serum hCG= pregnancy. Very rare exceptions
2- A single β-hCG level isn’t useful alone to predict an ectopic
pregnancy.
3- No cut-off value for diagnosing IUP or EP.
4- It is useful for planning the management of an ultrasound
visualized ectopic pregnancy.
A serum progesterone level is not useful in predicting ectopic
pregnancy.

18. WHAT ARE THE OPTIONS FOR TUBAL
PREGNANCY?
Expectant management is an option for clinically stable women with an
ultrasound diagnosis of EP and a decreasing β-hCG level initially less than 1500
iu/l.
Systemic methotrexate: some suitable women with a tubal ectopic pregnancy.
It should never be given at the first visit, unless the diagnosis of ectopic pregnancy is absolutely
clear and a viable intrauterine pregnancy has been excluded.
A laparoscopic surgical approach is preferable to an open approach.
Salpingectomy should be performed in preference to salpingotomy in the
presence of a healthy contralateral tube.
Indications of salpingotomy: history of fertility-reducing factors
Previous ectopic pregnancy.
Contralateral tubal damage.
Previous abdominal surgery.
Previous pelvic inflammatory disease

19. POSTOPERATIVE CARE
Offer anti-D prophylaxis all RhD-negative women:
Surgical removal of an ectopic pregnancy.
Repeated, heavy bleeding.
Abdominal pain.
If a salpingotomy is performed, women should be informed
about the risk of persistent trophoblast with the need for
serum β-hCG level follow-up.
It is recommended that women treated with methotrexate
wait at least 3 months before trying to conceive again.

20. CAESAREAN SCAR PREGNANCY
1. Empty uterine cavity.
2. Gestational sac or solid mass of trophoblast located anteriorly at
the level of the internal os embedded at the site of the previous lower
uterine segment caesarean section scar.
3. Thin or absent layer of myometrium between the gestational sac
and the bladder.
4. Evidence of prominent trophoblastic/placental circulation on
Doppler examination.
5. Empty endocervical canal.

21. II. PREGNANCY OF
UNKNOWN LOCATION

22. There is no sign of either intra- or extra-uterine pregnancy
or retained products of conception on TVS, despite a positive
pregnancy test.
 The sonographer’s experience influences the prevalence of PUL
 A pregnancy site will not be visualized in 8–31% of early pregnancy
scans, although a lower incidence (8–10%) has been observed in
specialized scanning units.

23. DISCRIMINATORY ZONE
A defined level of hCG above which the gestational sac of an intrauterine
pregnancy should be visible on ultrasound with sensitivity approaching
100%.
The current recommended value ranges from 1000–2400 iu/l.
In multiple pregnancies, hCG levels should be interpreted with caution as
they are a little higher, requiring an extra 2 or 3 days for the sacs to
become visible.
In women with an hCG result above the discriminatory level but no
intrauterine gestational sac on ultrasound, steps must be taken to
determine whether the pregnancy is ectopic.
high discriminatory level minimises the risk of intervening
inappropriately before an intrauterine pregnancy has become apparent
but at the expense of delaying the diagnosis of ectopic pregnancy by a
few days.

24. Urine pregnancy test +ve
TAS: IUP visualized: OK
IUP not visualized TVS: not visualized: PUL =Serum β-hCG
< 2000 mIU/mL: 3 possibilities: EP, normal IUP, failing IUP.
Wait for 48 hours
 Reaching 2000: should visualize IUP
 Not reaching 2000:
 > 66% rise: mostly IUP.
 < 66% rise:
 Failing IUP
 Ectopic pregnancy.
≥ 2000 mIU/mL:
 Should visualize IUP
 If not visualized:
 +ve adnexal mass: ectopic pregnancy.
 No adnexal mass: ?? Failing IUP.
There are always
exceptions (RARE).
So always look at
the uterus and the
adnexa

25. I- THREATENED MISCARRIAGE
• Live intrauterine gestation
• Cervix is closed.
• ± subchorionic haemorrhage.

26. THREATENED MISCARRIAGE

27. GOOD PROGNOSIS
• FHR> 90 bpm
• Yolk sac < 7 mm
• Small or irregular gestational
sac: MSD/CRL >5 mm
• Small subchorionic haemorrhage <
1/5 of gestational sac
• Small mean gestational sac diameter
• Normal amnion size.
• Normal decidual reaction.
BAD PROGNOSIS
• Fetal bradycardia: <80-90 bpm
• Large and calcified yolk sac of > 7
mm
• Small or irregular gestational
sac: MSD/CRL <5 mm
• Large subchorionic haemorrhage>
2/3 of gestational sac
• Small mean gestational sac diameter
• Expanded amnion sign (an
abnormally large amniotic cavity)
• Absent or poor decidual reaction

29. PREGNANCY OF UNCERTAIN VIABILITY

30. •An intrauterine pregnancy with no enough
criteria (usually on ultrasound grounds) to
confidently categorize an intrauterine
pregnancy as either viable or a failed
pregnancy.
•Intrauterine GS with an embryo with CRL <7
mm with no fetal cardiac activity.
•Gestational sac with MSD <25 mm containing

31. GESTATIONAL SAC

33. TVS
Embryo +ve
≥ 7mm
-ve pulsation
????
< 7mm
-ve pulsations
Rescan 7 days
No embryo
MSD <12 mm
Rescan 14
days
MSD 12-25
mm
Rescan 7 days

34. •Findings suspicious but not diagnostic
of pregnancy failure: action: wait 7-14
days.
• Single scan:
• CRL: of <7 mm and no heartbeat
• Mean sac diameter (MSD) of 16-24 mm and no embryo
• Serial scan:
• No pulsating embryo 7-13 days after a scan that showed a gestational sac without a yolk
sac
• No pulsating embryo 7-10 days after a scan that showed a gestational sac with a yolk sac
• Absence of embryo ≥ 6 weeks after last menstrual period.
• Amnion seen adjacent to yolk sac, with no visible embryo (empty amnion sign)
• Enlarged yolk sac (>7 mm)

35. MOLAR CHANGES IN A MISSED
MISCARRIAGE.

36. • Definitive diagnosis by ultrasound is often difficult.
• Described sonographic features include
• Greatly enlarged placenta relative to the size of the uterine cavity.
• Cystic spaces within the placenta ("molar placenta"), which may not
always be present
• An amniotic cavity (gestational sac), either empty or
containing amorphous small fetal echoes which may be
surrounded by a relatively thick rim of placental echoes with
intermingling cystic spaces