First trimester bleeding is common, occurring in 25% of pregnancies. While often resulting from miscarriage, it can also be caused by ectopic pregnancy, molar pregnancy, or non-obstetric conditions. Miscarriage is the spontaneous loss of pregnancy before 24 weeks gestation or fetal weight under 500 grams. Risk factors for miscarriage include increased maternal age, smoking, alcohol, caffeine, obesity, toxins, radiation, prior miscarriages, uterine defects, and infections. Diagnosis involves pregnancy tests, ultrasound, and bloodwork. Complications can include infection, shock, and anemia. Treatment depends on the type and severity, ranging from observation to medication and surgical evacuation. Follow up care and family planning counseling

1. FIRST TRIMESTER BLEEDING
BY
Mr. HITAYEZU Jean Bosco Henri, RM, BScM,
PGCLTHE, MSN(Neonatology)-Student

2. Expectations
• Describe the pathophysiology, diagnosis and
management of miscarriage
• Describe the spectrum of psychological
reactions to early pregnancy loss, and early
interventions that may reduce long-term
sequelae.

3. Introduction
• First trimester bleeding is common
• 25% of women are facing first trimester bleeding
• 8-15% ended by miscarriage
• However, it is not only miscarriage
– Ectopic pregnancy
– Trophoblastic disease
– Non-obstetric conditions

4. Key terms
• Bleeding in early pregnancy: Vaginal bleeding
that happens within the first 20 weeks of
gestation
• Miscarriage: Loss of the pregnancy before to
viability (<24 weeks of gestational/<500
grams)
(MOH, 2020)

5. Type of miscarriage Definitions
Spontaneous Involuntary loss of pregnancy before 24 weeks or<500 grams
Early spontaneous Spontaneous miscarriage occurring at or prior to 12 weeks of
gestational age
Complete Complete passage of all products of conception. Usually defined as
endometrial thickness < 15 mm
Incomplete Some, but not all, of the products of conception have passed
Inevitable Bleeding in the presence of a dilated cervix; indicates that passage of
the conceptus is unavoidable
Septic Incomplete miscarriage associated with ascending infection of the
endometrium, parametrium, adnexae or peritoneum
Threatened Uterine bleeding any time in the first half of pregnancy, in the
presence of an embryo with cardiac activity
Missed/delayed Minimal or absent bleeding, with a gestational sac diameter of ≥ 25
mm with no fetal pole or yolk sac (also called an embryonic
pregnancy) OR a fetal pole ≥ 7 mm with no cardiac activity
Recurrent Three or more consecutive miscarriages

6. Pathophysiology
• Difficult to diagnose
• Chromosomal abnormality
• 50% of spontaneous miscarriage related to
chromosomal anomaly (trisomy, triploid, ….)

7. Risk factors
• Increased maternal age
• Maternal smoking, environmental tobacco smoke
exposure and paternal smoking
• Alcohol consumption
• Caffeine intake > 100 mg/day
• Obesity
• Exposure to chemical toxins
• Exposure to radiation
• Illicit drug use

8. Risk factors cont…..
• History of previous repeated miscarriage
• Uterine anatomic defects
• Endocrine disorders
• Immunological causes
• Maternal infection
• medications

9. DIAGNOSIS (MOH, 2019)

10. Investigations
• Pregnancy test positive
• Ultrasound
• CBC, Blood Group and Rhesus

11. Complications
• Infection
• Hypovolemic shock
• Septic shock
• Anemia

12. Complete abortion
• All products of conception are out of uterus
and cervix
• Cervix is closed
• Uterus is small and well-contracted
• Vaginal bleeding
• Mild pain or absent

13. Investigation
• In case of Ultrasound is available to be used
for confirmation

14. Management
• Assess woman general status
• No need of medical or surgical treatment in case woman
is stable
• If woman is clinically stable:
– Reassure the woman
– Advise the woman to report any danger signs
• In case woman is unstable:
– Manage hypovolemic shock
– Vital signs monitoring
• Provision of FP
• Provide Anti-D 300 microgram IM once a woman has
Rhesus negative

15. INCOMPLETE ABORTION
• Open cervix (dilated cervix)
• Visible/felt conception products/partial
expulsion of conception products
• Heavy bleeding
• Light bleeding
• Smaller fundal height compared to LMP
• Lower abdominal pain or cramps

16. Nursing management
• Pregnancy <16 WA
– Light bleeding
• With fingers or forceps, remove visible products of
conception and observe
• No further action to be taken if bleeding remain light
– Uterine evacuation in case of heavy bleeding with
Manual vacuum aspiration
– Provide Misoprostol 400 microgram in sublingual
while waiting MVA

17. Nursing management cont,…
• In case pregnancy has >16 WA
– Provide Misoprostol 400 microgram every 3 hours
– Or Provide Oxytocin 40IU in 1L of NS/RL every 8 hours
until expulsion of conception products
– Or Provide Misoprostol 200 microgram every 6 hours.
Don’t exceed 800 microgram
– Examine uterus then any remained products proceed
to evacuate
– Continue follow-up

18. INEVITABLE ABORTION
• Vaginal bleeding increases
• Cervix dilated
• Cramping of lower abdominal pain

19. Nursing management
• In case of pregnancy of <16 WA:
– Evacuation of uterus as first option
– Provide Misoprostol 400 microgram PO every 4 hrs
during preparation of evacuation of uterus
– Follow-up after receiving care
• In case pregnancy is >16W:
– Expectant management until spontaneous expulsion
– If not succeeded plan for uterus evacuation
– Provide 40UI Oxytocin in 1 litter of NS/RL within 8 hrs
until expulsion
– Follow-up

20. Missed abortion
• Pregnancy in not viable
• No products of conception expelled
• No Hx of bleeding
• Absence of abdominal pain
• Cervix is closed
• Loss of pregnancy sign

21. Investigations
• BG&Rh
• FBC
• Ultrasound for final confirmation

22. Nursing management
• Assessment
• Hospitalization
A. Medical care
– If pregnancy is <13 weeks
• Give Misoprostol 800 vaginally or 600 mcg Sublingual every 3 hrs
– If pregnancy is 13-24 weeks
• Give Misoprostol 400 mcg every 6 hrs Sublingual, PO, vaginally if
no bleeding until delivery or 200 mcg every 4-6 hrs
– If pregnancy is 24-28
• Provide Misoprostol 200 mcg per vaginal every 4 hrs until delivery
– Pretreatment with Mifepristone 200 mg per os prior 2 days
before Misoprostol

23. Nursing management
B. Surgical treatment:
• MVA as first option
– Cervical ripening with misoprostol 400 mcg every
2-3 hrs
– Second trimester dilatation and evacuation
– Bereavement counseling
– FP; to be started immediaterely

24. Threatened abortion
• Vaginal bleeding slight spotting or heavy
• Cervical os is closed
• Lower abdominal pain or cramp
Nursing assessment:
• Uterus size is appropriate to gestational age
• Speculum ex: closed cervix, bloody stained in
introitus but no conception product

25. How can it be diagnosed?
• Hx of amennorhea
• Ultrasound reveals intrauterine pregnancy
plus cardiac activity
• CBC
• BG&Rh

26. Nursing management
• Take vitals signs
• Medical/surgical treatment is not needed
• Patient admission not mandatory
• Counsel the woman to reduce or stop excessive
activities and any sexual activity
• Bed rest not indicated
• Continue/resume ANC as planned once bleeding
stops
• Further investigation in case bleeding continues

27. SAFE AND UNSAFE ABORTION
• Unsafe abortion:
– Termination of pregnancy by
• Unskilled personnel
• Unconformity with minimal medical standards
• Notice: it is leading to sepsis
• Safe abortion:
– Done under limits of the law (discuss Rwandan
law)
– Managed at DH or referral hospital

28. SEPTIC ABORTION
• Induced abortion
– By untrained practioners
– Using nonsterile techniques
– It is illegally induced
– It causes infections; escherichia coli, enterobacter
aerogenes,…..

29. What to expect to see?
• Appear within 24-48 after abortion
• Presence of chills, fever, foul smelling vaginal discharge
• Associated with threatened or incomplete abortion
• Perforation of the uterus
• Septic shock
– Hypothermia
– Hypotension
– Oliguria
– Respiratory distress

30. Nursing management
• Rapid Assessment client and vital signs monitoring (ABC)
• Critically act as quick as possible and refer to the
appropriate health care setting
• Stabilize before transfer
• Fluid maintenance or replacement with two large IV
catheter then start RL/NS
• Provide ATBs, first dose prior transfer
– Ampicillin 2g IV every 6 hours
– Or cephalosporin: ceftriaxone 1 gr 6 hourly or cefotaxime IV 500
mg every 8 hrs
– In case of allergy to penicillin use Clindamycin IV 600mg 8 hourly
– Metronidazole 500 mg 8 hourly via IV

31. Nursing management cont,….
• Reduce the toxic load via surgical removal
after initiation of ATBs
• Determine shock type
• In case of shock(Pulse>systolic BP):
– Provide 1l of RL over 20 minutes
– Continue resuscitation if BP increases and Pulse
rate (think hypovolemic shock)
– No response repeat with another litre of RL
– IF no response again think about septic shock

32. POST ABORTION FOLLOW-UP
• Spontaneous miscarriage is common
• Occur 1/7 pregnancies
• Reassure for next pregnancy
• Plan next pregnancy once is fully recovered
• Immediate FP provision
• Delay implants, IUCD and surgery
• In case of presence of infection treat first
• In case of anemia (Hb<7g/dl) delay until anemia
resolved
( MoH, 2019)

33. ECTOPIC PREGNANCY
• Implantation of pregnancy out of uterine
cavity

34. Implantation site of Ectopic pregnancy
• Ampula: 80%
• Isthmus: 15%
• Cornua/intertitial : 2%
• Extra tubal
• Ovary
• Cervix
• Abdomen

35. Types
• Ruptured
• Unruptured

36. Risk factors
• Prior ectopic pregnancy
• Tubal surgery
• PID
• Endometriosis

37. What to expect during assessment?
• Hx of amenorrhea
• Vaginal bleeding
• Abdominal/pelvic pain
• Sometimes asymptomatic

38. UNRUPTURED Vs RUPTURED Ectopic
Pregnancy (MoH, 2020)
Unruptured ectopic pregnancy Ruptured ectopic preganncy
Early pregnancy symptoms Collapse and weakness
Abdominal and pelvic pain Fast,weak pulse
Hypotension
Hypovolemia
Acute abdominal and pelvic pain
Rebound tenderness
Pallor

39. Investigations
• Perform pregnancy test
• FBC
• BG&Rh-cross match
• Ultrasound

40. IF untreated what to expect?
• Hypovolemic shock
• Anemia
• Death

41. Nursing management
• If it is diagnosed:
– Immediately start resuscitation
– Stabilize the patient hemodynamically
– Laparotomy/laparoscopy
– Medical treatment
• Methotrexate 50mg/m2 IM single dose in case of:
– Not ruptured
– Beta HCG<5,000 mlU/MI
– Mass <3cm
– Absence of embryo cardiac activity
• Follow up of Beta HCG
– Give another dose of methothrexate if on 4 and 7 day <15%
– Repeat the dose if after one week no decreasing if no
improvement plan for surgical management.

42. Recommendations
• Keep the patient in hospital for at least three
days if on single dose of Methotrexate due to
rupture may occur
• Delay pregnancy at least 3 months after
receiving methotrexate
• FP to be discussed

43. MOLAR PREGNANCY
• Pregnancy pathology due to
– Cystic degeneration of the placenta
• Translucent visicles
– 1-2 cm in diameter
– Connected by filaments like a cluster of grapes
• There is neither foetus nor amniotic sac

44. Image

45. Complete Molar pregnancy

46. Etiology
• Chromosomal abnormality

47. Risk factors
• Prior molar pregnancy advanced maternal age

48. Types of molar pregancy
Complete mole Incomplete mole
Fetal /embryonic tissue Absent Present
Hydatidiform swelling of
chorionic villi
Diffuse Focal
Karyotype 46XX; 46XY; all
chromosomes are paternal
in origin
69XXY;69XYY;69XXX;extra
set of chromosomes is
paternal in origin
Risk of gestational
trophoblastic neoplasia
15-20% 1-5%

49. Signs and symptoms
• Amenorrhea
• Vaginal bleeding
• Expulsion of molar vesicles
• Exacerbated hyperemesis gravidarum
• Soft uterus and larger than gestational age

50. Investigations
• Quantitative beta-hCG levels
• Complete blood cell count with platelets:
Anemia could be present and coagulopathy
could occur.
• Liver function tests
• Renal function tests
• Blood type and Rh factor
• Thyroid function tests (TSH, T3, T4)

51. If untreated
• Choriocarcinoma
• Invasive mole
• Placenta site trophoblastic tumor
• Hypertensive disorders of pregnancy
• Hyperthyroidism

52. Management
• Aspiration under Ultrasound guidance
• Cross match and book blood for possible transfusion
• Administer Oxytocin during aspiration
• Products of evacuation should be sent for Histology
Examination
• Hysterectomy
• Signs of trophoblastic proliferation
• serum human chorionic gonadotropin [hCG]levels
>100,000 milli-international units/mL
• ovarianthecaluteincysts>6cmindiameter
• Age>40years

53. POST MOLAL SURVEILLANCE
• Monitor levels of ß hcg every 48hrs for the 1st
week, then weekly till ß HCG is normal for
3weeks,then test every month for 6months.
• If ß HCG is persistently high within 10% within
2weeks or increase,refer to a higher centre to
rule out possible GTN
• More likely persistent trophoblastic diseases
require chemotherapy
• Test renal and liver function prior and during
treatment
• Staging of the disease prior to treatment

54. Recommendations
• Immediate contraception during 1year of
post molar monitoring.
• Review if any Vaginal bleeding problem
• If blood group Rhesus negative(Rh-):GiveAnti-
D300µgIM
• Consider prophylactic
Chemotherapy(methotrexate) in case of
unreliable patient for follow-up and baseline
QuantitativeB-HCG>100000mUI/

55. REFERENCES
• Cunningham, F.G. et al. (2014). Williams
Obstetrics: 24th Ed. Mc Graw Hill Medical
.NewYork.
• ALSO Asia Pacific (2013) Advanced Life Support in
Obstetrics Course Manual. 2nd Edition. ALSOAsia
Pacific Ltd, Sydney.
• Ministry of Health. (2020). Obstetrics Care
Protocol. Kigali-Rwanda