Bleeding in early pregnancy by Prof. Athula Kaluarachchi

1. Bleeding in early pregnancy
Athula Kaluarachchi

2. Presentation
Usually presents with bleeding after period of
amenorrhoea
Important to consider regularity of periods

3. Last Normal Menstrual
Period
 Patients do not always remember LRMP (especially when
presenting late for care) - Reliability
 May be mistaken for implantation bleeding
 Irregular periods
 May be difficult to determine for Depo - provera and
implant users
 Delayed Period
 Recent pregnancy

4. What should you ask regarding
LRMP
 Can You remember ?
 Was it similar to your previous periods ?
 Are the periods regular ?
 Are you on hormonal contraception ?
 Have you had a recent pregnancy ?

5. Differential diagnosis – Bleeding after
POA(Negative pregnancy test)
 Delayed Period
 Irregular menstrual cycles
 Hormonal Therapy – eg DMPA,Implants
 Recent pregnancy

6. Positive Pregnancy Tests
 Both urine and serum will become positive within 7-10
days of conception
Urine pregnancy test
 Early morning sample
 Sensitivity of the test
 Serum ß HCG level doubles every 48 hours when the
pregnancy is intrauterine

8. hCG
Oestrogen
Blood levels of hormones during gestation, 40 weeks
0 10 20 weeks 30 40
Bloodconcentration
End of period Parturition
Progesterone
hPL
Next slide

10. Ultrasound features of a viable pregnancy
Regular Sac Fetal Echo
Yolk Sac Fetal Heart
A pregnancy sac that is seen in-utero on ultrasound scan
when the HCG is
> 1000 IU/L Transvaginal
> 1800 IU/L Transabdominal

11. Characteristics of a viable
intrauterine pregnancy
 A yolk sac will be seen transvaginally when the
gestational sac is > 8mm (5.3 weeks)
 A fetal pole should be seen transvaginally when
the gestation sac > 20mm (5.5 weeks)
 A fetal heart will be seen with the CRL > 4mm
 The normal fetal heart rate at 6 weeks is 70-100
beats/min.

12. Ultrasound
 Confirmation
 Fetal number
 Dating
 Growth patterns
 Fetal health
 Fluid volume

13. TVS- Sagittal section of uterus
Secretory cycle

14. Differential diagnosis – Bleeding
after POA(Positive pregnancy test)
 Miscarriage
 Ectopic pregnancy
 Trophoblastic disease
 Desidual Bleeding
 Incidental causes – Cervical Polyp etc.

15. Causes of early bleeding in pregnancy
Miscarriage Ectopic pregnancy Hydatidiform mole
Local Cervical
Lesions
Decidual Bleeding

16. Clinical subgroups of miscarriages
Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Missed Miscarriage
Septic Miscarriage

17. Features of Miscarriages
conceptus Vaginal abdominal Cervix os Uterine
Subgroups expulsion bleeding pain dilation enlargement
Threatened no ＋ －＋ Closed compatible
miscarriage
Inevitable no ＋ ＋ ＋ ＋ Open compatible or
miscarriage smaller
Incomplete part ＋ ＋ ＋ ＋ Open smaller
miscarriage
Complete all ＋ － － Closed normal
Miscarriage

18. Complete miscarriage

19. Missed Miscarriage
Expulsion of the conceptus does not
occur despite a prolonged period
after embryonic death.
Symptoms of pregnancy regress
Pregnancy test becomes negative
No fetal heart motion is detected
Uterine enlargement ceases
Clinical Features
•Mild bleeding
or brown
discharge
•Uterus smaller
•Cervix closed

20. Missed miscarriage
Blighted Ovum
No Fetal echo seen
(Empty Sac)
Early Fetal demise
Fetal echo seen
No Fetal heart

21. Septic miscarriage
Any type of spontaneous miscarriage is
complicated by infection
Endometritis, parametritis, peritonitis
Fever, abdominal tenderness, uterine
pain
Septicemia, septic shock

22. Recurrent miscarriage
Three or more consecutive spontaneous
losses of pregnancy
First-trimester: hypothyroidism, chromosomal
abnormalities, immunologic factors
Second-trimester: uterine malformations,
cervical incompetence, myomas

23. Options for the management of early
pregnancy failure
 Surgical evacuation of the uterus
 Medical evacuation of the uterus
 Wait and see

24. Surgical management is recommended
when...
 The patient is febrile (>37.50 C)
 After appropriate antimicrobial management
 If there is significant bleeding
 Failed medical induction

25. Medical management is recommended
when
 There are fetal parts >14 weeks in size
 Missed Miscarriage
 Incomplete Miscarriage

27. Medical management of early pregnancy failure
or incomplete miscarriage
 2 x 200 mcg Misoprostol into the posterior
fornix
 Repeat in 4-6 hrs if required
 Must scan or evaluate clinically to confirm
that evacuation is complete
 In general echogenic material >16 mm in AP diameter is required for the
US diagnosis of retained products of conception

28. Conservative management of early pregnancy
failure or incomplete miscarriage
 Repeat clinical and USS evaluation after 3
days
 Then 7 days and weekly
 Must come in at any hour if pain or
bleeding is unacceptable or fever occurs

29. Other aspects of management
 Anti-D is required for EP bleeding if Rh Neg
 Send all tissue for histology
 Provide or arrange psychological support
Patients want an explanation for the loss
And advice about the future
Or contraceptive advice
Offer referral to GP, counsellor or a Support Group

30. Ectopic Pregnancy

31. Definition:
 An ectopic pregnancy occurs when the
conceptus implants either outside the uterus
(Fallopian tube, ovary or abdominal cavity)
or in an abnormal position within the uterus
(cornua, cervix).
 Combined tubal and uterine
(heterotopic) pregnancies are
uncommon.

32. Epidemiology and risk
factors
The incidence of ectopic
pregnancy is about 1 %.
 Between 95 and 98 percent of
ectopic pregnancies occur in
the Fallopian tube.

33. Ectopic pregnancy
 Pregnancy outside the uterine corpus
 Ampulla
 Cornu
 Ovary
 Abdominal
 High index of suspicion if
 previous ectopic
 IUD
 infertility

34. Site of ectopic pregnancy:
 Site of tubal ectopic pregnancy are:
 1.More than 50 % of tubal pregnancies are
situated in the ampulla.
 2. approximately 20 % occur in the isthmus.
 3. around 12 % are fimbrial .
 4.approximately 10 % are interstitial

35. Pathogenesis
 Sites of Implantation
 Fallopian tube – most common site (ampulla) – 95%
 Ovary
 Uterine cornu
 Cervix
 Broad ligament
 Spleen 5%
 Liver
 Retroperitoneum
 Diaphragm
 Cesarean scar

36. Risk factor for ectopic pregnancyRisk Factors for an Ectopic
Tual Sterilization
Previous Ectopic Pregnancy
Assisted reproduction & infertility
Intrauterine Device
Documented Tubal Pathology
Infertility
Previous Genital Infection
Multiple Partners
Previous Pelvic/Abdominal Surgery
Smoking
Caesarean section
Tubal Corrective Surgery

37. Clinical features
 Compared to the other forms of early pregnancy disorders,
there is no pathognomonic pain or findings on clinical
examination that are diagnostic of a developing extrauterine
pregnancy.
 Vaginal bleeding (usually old blood in small amounts) and
chronic pelvic pain (iliac fossa, sometimes bilateral) are the
most commonly reported symptoms.

38. General examination
 This must include a record of pulse rate and blood
pressure.
 Shoulder pain, which may occur secondary to blood
irritating the diaphragm .
 vascular instability characterized by low blood pressure,
fainting, dizziness and rapid heart rate may be noted.
 These symptoms are present in more than 50 % of patients
and are most typical of patients whose ectopic pregnancy
has ruptured (intra-abdominal bleeding).

39. Signs & Symptoms
 Often subtle, or even absent
1.Pain :Pelvic and abdominal pain – sharp, stabbing or tearing in
character, rectal pain.
Pleuritic chest pain – from diaphragmatic irritation caused by the
hemorrhage
2.Abnormal Menstruation
Amenorrhea
Vaginal bleeding – may be scanty, dark brown, intermittent or
continuous
3.Abdominal and pelvic Tenderness
 Tenderness on abdominal and vaginal
examination especially on motion of the cervix
– ruptured or rupturing tubal pregnancies

40. Signs & Symptoms
4. Uterine changes
 In 25% of women, the uterus enlarges due to hormonal stimulation of
pregnancy.
5. Blood pressure and pulse
 Before rupture vital signs are generally normal. Hypotension and
tachycardia – if bleeding continues and hypovolemia becomes
significant
6. Pelvic Mass
 Almost always either posterior or lateral to the uterus, and typically
soft and elastic
 The mass may be firm with extensive infiltration of blood into the
tubal wall.

41. Tubal Ectopic Pregnancy
Ultrasound Features of
Ectopic Pregnancy
•Empty uterus
•Adnexal mass
+/- FHR
Ring of blood flow
on doppler
Free fluid especially
POD

43. Gynaecological examination:
 Speculum or bimanual examination must be performed in
an environment where facilities for resuscitation are
available,
 as this examination may provoke the rupture of the tube.

44. Laparoscopy
Laparoscopy should be considered in
women with hCG above the discriminatory
level and absence of an intrauterine
gestational sac on ultrasound

45. Management
 Ectopic pregnancy can be treated :
1. conservative (expectant ).
2. medical.
3. surgical .
According to:
1. Clinical presentation.
2. Ultrasound finding.
3. B-HCG titer.

46. Expectant Management
 Criteria:
1.Decreasing serial β-hCG levels.
2.Tubal pregnancies only .
3.No evidence of intra-abdominal
bleeding or rupture as assessed by
vaginal sonography
4.Diameter of the ectopic mass not
greater than 3.5 cm

47. Medical Management:
METHOTREXATE
 An anti-neoplastic drug that acts as a folic
acid antagonist, and is highly effective
against rapidly proliferating trophoblasts.
 Success is greatest if
 The gestation is <6 weeks
 The tubal mass should be <3.5 cm in diameter
 The fetus is dead
 Β-hCG is <5,000 mIU/mL

48. Medical Management:
METHOTREXATE
 Contraindications:
 Intra-abdominal hemorrhage
 Breast feeding
 Immunodeficiency
 Alcoholism
 Liver or renal disease
 Blood dyscrasias
 Active pulmonary disease
 Peptic ulcer

49. Surgical Management:
CONSERVATIVE
 Salpingostomy
 Used to remove a small pregnancy
usually <2 cm in length.
 A 10-15 mm linear incision is made on
the antimesenteric border immediately
over the ectopic pregnancy, and is left
unsutured to heal by secondary intention
 Readily performed through a laparoscope
 Gold standard surgical method used for
unruptured ectopic pregnancy

50. Surgical Management:
CONSERVATIVE
Salpingotomy
Procedure is the same as
salpingostomy except that the
incision is closed with a suture

51. Surgical Management:
RADICAL
 Salpingectomy
Tubal resection May be used for
both ruptured and unruptured
ectopic pregnancies Performed
if the fallopian tube is
extensively diseased or
damaged

52. Gestational Trophoblastic disease
 Abnormal placental development
 Usually no recognizable fetus
 Exaggerated symptoms of pregnancy
 Hyperemesis
 Thyroid hormone abnormality
 Large theca-lutein cysts
 Can recur and rarely in malignant form

53. Gestational Trophobalstic
Disease
 Classification
 Hydatidiform Mole
Complete
Partial
 Invasive Mole
 Gestational Choriocarcinoma
 Placental site trophoblastic tumour

54. Gestational Trophoblastic
Disease
 Genetics
Complete Mole
46 XX --- 85%
46 XY --- 15%
Paternal origin
Partial Mole
Triploidy 69XXY

55. 46xx
23x
Proliferation of
monospermic
androgenetic
complete HM
Duplication
of haploid
sperm
Maternal DNA
lost from
ovum
46xy
23x
Proliferation of
dispermic
androgenetic
complete HM
Two paternal
genetic
contributions
Maternal DNA
lost from
ovum
69xxx
23x
Proliferation of
triploid
partial HM
Maternal and two
paternal genetic
contribution
69xxy

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