Early bleeding in pregnancy can be caused by ectopic pregnancy, abortion, or hydatidiform mole. Abortion, also called miscarriage, is the spontaneous loss of a fetus before 24 weeks gestation and can be caused by fetal chromosome abnormalities in 50% of cases, uterine abnormalities like fibroids, endocrine issues like diabetes, infections, or environmental factors. The types of abortion include threatened, inevitable, incomplete, complete, and missed. Missed abortion features the gradual disappearance of pregnancy signs and symptoms despite an empty uterus seen on ultrasound. Management depends on the type but may include medication, dilation and evacuation, or expectant management.

1. Bleeding in early pregnancy
Dr.Sushma Sharma

2. Causes of early bleeding in pregnancy
Ectopic pregnancy
Abortion
Hydatidiform mole

3. Abortion/Miscarriage
Definition: any fetal loss from conception until the time of
fetal viability at 24 weeks gestation.
OR:
Expulsion of a fetus or an embryo weighing 500 gm or less
 Incidence: 15 - 20% of pregnancies total reproductive losses
are much higher if one considers losses that occur prior to
clinical recognition.
 Classification:
1. spontaneous:
occurs without medical or mechanical means.
2. induced abortion


4. Pathology




Haemorrhage into the decidua basalis.
Necrotic changes in the tissue adjacent to
the bleeding.
Detachment of the conceptus.
The above will stimulate uterine
contractions resulting in expulsion.

5. Causes of miscarriage

Fetal causes:

Chromosome Abnormality:
- 50% of spontaneous losses are associated with fetal chromosome
abnormalities.
- autosomal trisomy (nondisjunction/balanced translocation): is the
single largest category of abnormality and → recurrence.
- monosomy (45, X; turner): occurs in 7% of spontaneous abortions
and it is caused by loss of the paternal sex chromosome.
- triploids: found in 8 to 9% of spontaneous abortions. it is the
consequence of either dispermy or failure of extrusion of the
second polar body,

6. Causes of miscarriage
Maternal causes:
1. Immunological:
- alloimmune response: failure of a normal immune response in the
mother to accept the fetus for a duration of a normal pregnancy.
- autoimmune disease: antiphospholipid antibodies especially lupus
anticoagulant (LA) and the anticardiolipin antibodies (ACL)
2. uterine abnormality:
- congenital: septate uterus → recurrent abortion.
- fibroids (submucus): → (1) disruption of implantation and
development of the fetal blood supply, (2) rapid growth and
degeneration with release of cytokines, and (3) occupation of space
for the fetus to grow. Also polyp > 2 cm diameter.
- cervical incompetence: → second trimester abortions.


7. Causes of miscarriage

Maternal causes:
3. Endocrine :
- poorly controlled diabetes (type 1/type 2).
- hypothyroidism and hyperthyroidism.
- Luteal Phase Defect (LPD): a situation in which the endometrium is
poorly or improperly hormonally prepared for implantation and is
therefore inhospitable for implantation. (questionable).
4. Infections (maternal/fetal): as TORCH infections, Ureaplasma
urealyticum, listeria

Environmental toxins: alcohol, smoking, drug abuse, ionizing
radiation……

8. Types of abortion


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
Threatened abortion.
Inevitable abortion.
Incomplete abortion.
Complete abortion.
Missed abortion
Septic abortion: Any type of
abortion, which is complicated by
infection

Recurrent abortion: 3 or more
successive spontaneous abortions

9. Clinical features/management


-
Threatened abortion:
Short period of amenorrhea.
Corresponding to the duration.
Mild bleeding (spotting).
Mild pain.
P.V.: closed cervical os.
Pregnancy test (hCG): + ve.
US: viable intra uterine fetus.
Management
reassurance.
Rest.
Repeated U/S

10. Inevitable abortion

-
Clinical feature:
Short period of amenorrhea.
heavy bleeding accompanied
with clots (may lead to shock).
Severe lower abdominal pain.
P.V.: opened cervical os.
Pregnancy test (hCG): + ve.
US: non-viable fetus and blood
inside the uterus.

-
Management:
fluids…..blood.
ergometrinn & sentocinon.
evacuation of the uterus
(medical/surgical).

11. Incomplete abortion

Clinical feature:
- Partial expulsion of
products
- Bleeding and colicky pain
continue.
- P.V.: opened cervix…
retained products may be
felt through it.
- US: retained products of
conception.

Treatment
as inevitable abortion

12. Complete abortion
-
expulsion of all products of conception.
Cessation of bleeding and abdominal pain.
P.V.: closed cervix.
US: empty uterus.

13. Missed abortion
Feature:
- gradual disappearance of
pregnancy Symptoms Signs.
- Brownish vaginal discharge.
- Milk secretion.
- Pregnancy test: negative but
it may be + ve for 3-4 weeks
after the death of the fetus.
- US: absent fetal heart
pulsations.
 Complications
- Infection (Septic abortion)
- DIC


Treatment
Wait 4 weeks for spontaneous
expulsion
- evacuate if:
 Spontaneous expulsion does not
occur after 4 weeks.
 Infection.
 DIC.
- Manage according to size of
uterus
- Uterus < 12 weeks : dilatation
and evacuation.
- Uterus > 12 weeks : try
Oxytocin or PGs.
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