This document discusses first trimester bleeding, which occurs in 20-40% of pregnancies. The main causes are miscarriage (95%), ectopic pregnancy (2%), hydatidiform mole (<1%), and vanishing twin. Diagnosis involves history, examination, ultrasound to determine if the pregnancy is intrauterine, extrauterine, viable, or nonviable. Common ultrasound findings for miscarriage include no fetal heartbeat, subchorionic bleeding, or an empty gestational sac over 20mm. Ectopic pregnancies may appear as an adnexal mass. Rare causes are molar pregnancies, appearing on ultrasound as a "snowstorm" pattern of cysts in the placenta. First trimester bleeding

1. FIRST
TRIMESTER
BLEEDING
Aboubakr
Elnashar
Benha university Hospital
Egypt
Aboubakr Elnashar

2. CONTENTS
1. INCIDENCE
2. CAUSES
3. DIAGNOSIS
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3. 1. INCIDENCE
Vaginal bleeding is common in 1st T
 20-40% of pregnant women.
Source is virtually always maternal, rather than
fetal.
disruption of blood vessels in the decidua
discrete cervical or vaginal lesions.
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4. 2. CAUSES
Related to pregnancy:
Miscarriage (95%)
Ectopic pregnancy
Hydatidiform mole
Vanishing twin
Implantation bleeding.
Associated with
pregnancy:
unrelated to pregnancy
pre-existing or aggravated
during pregnancy.
Cervico-vaginitis
Vascular erosion
Polyp, fibroid
Ruptured varicose veins
Malignancy.
Trauma
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5. 1. Miscarriage:
most common
15 to 20% of pregnancies
±heavy:1%
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6. 2. Ectopic pregnancy
much less common
2% of pregnancies
most serious
{rupture of the extrauterine pregnancy is a life
threatening complication}
must be excluded in every pregnant woman with
bleeding.
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7. 3. Trophoblastic disease
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8. 4. Vanishing twin
Singleton pregnancy
{very early loss of one member of a multiple
gestation}.
often the product of ART
can be associated with vaginal bleeding
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9. 5. Physiologic or implantation bleeding
small amount of spotting or bleeding
10-14 days after fertilization (at the time of the
missed menstrual period)
{implantation of the fertilized egg in the decidua},
although this hypothesis has been questioned
 Diagnosis of exclusion.
No intervention is indicated.
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10. Vaginitis, trauma, tumor, warts, polyps, fibroids
Diagnosis
Visual inspection
Additional tests as indicated:
wet mount, pH of vaginal discharge,cytology
biopsy of mass lesions, US
Ectropion:
common and normal finding in pregnancy.
The exposed columnar epithelium is prone to light bleeding
when touched, such as during coitus, insertion of a
speculum, bimanual examination, or when a cervical
specimen is obtained for cytology or culture.
Therapy is unnecessary
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11. 3. DIAGNOSIS
History:
gestational age
character of bleeding:
light or heavy
associated with pain or painless
intermittent or constant
Examination
Laboratory:
TVS
confirm or revise the initial diagnosis.
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12. Speculum examination
:
1.3% change of management
4.2% change of diagnosis
: minority of management decisions.
The need for speculum examination
should be assessed on a case-by-case basis,
depending on whether the findings on bimanual
examination are conclusive.
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13. NICE, 2012
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14. Aboubakr Elnashar

15. Aboubakr Elnashar

16. TVS
Cornerstone of the evaluation of bleeding in 1st T.
Most useful
Intrauterine or extrauterine
Viable or nonviable.
Heterotopic pregnancy
Gestational trophoblastic disease
Loss of one fetus from a multiple gestation.
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17. It is vital to describe clinical and ultrasound
findings in early pregnancy using appropriate
terminology
Miscarriage
should replace ‘abortion’ in clinical practice.
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18. Pregnancy of unknown location: PUL
 should replace pregnancy of indeterminate
location
Positive pregnancy test but no signs of intra- or
extrauterine pregnancy or retained products of conception
Pregnancy of uncertain viability: PUV
Should replace pregnancy of indeterminate
viability
IUGS 20 mm mean diameter with no obvious yolk sac or
fetus, or
fetal echo 6 mm CRL with no obvious fetal heart activity.
In these circumstances a repeat scan at a
minimum interval of 1 week.
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19. Clinical correlates of ultrasound appearances.
RCOG; 2006
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20. TAS:
most useful for assessing
free fluid in the abdomen
abnormalities beyond the field of view of a high
frequency vaginal probe
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21. U/S findings of threatened abortion
1. Viable IU pregnancy (50 % )
Bad signs: slow heart beat <85/min, subchorionic
bleeding and small sac
2. Non viable IU pregnancy
Missed miscarriage (25 %)
Delayed miscarriage Blighted ovum (20 %)
Incomplete miscarriage (3 %)
3. Ectopic pregnancy (2 %)
4. Hydatiform mole (< 1 %)
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22. 1. PUL
Positive pregnancy test +
No IU pregnancy
No extrauterine pregnancy
No retained products of conception
NICE, 2012
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23. Aboubakr Elnashar

24. Condous, 2006 Aboubakr Elnashar

25. Most PULs are at low risk for an ectopic
pregnancy provided that US is sufficiently skilled
and uses US with acceptable image quality.
HCG at defined times in women with a PUL can
reliably predict immediately viability of a PUL, but
cannot predict its location.
An hCG ratio cut-off <0.87 can be used to identify
spontaneously resolving pregnancies in a PUL
population.
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26. 2. BLIGHTED OVUM
(Anembryonic pregnancy)
No fetal parts with sac diameters > 20 mm (TV)
30 mm (TA)
No yolk sac
Irregular sac contour
If unsure repeat in 1 week
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27. Aboubakr Elnashar

28. 3. MISSED ABORTION
CRL: 6 mm & no cardiac activity or
< 6 mm & no change at the time of repeat
scan 7 days later (embryonic growth rate is 1 mm/d)
Abnormal form of G S
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29. Aboubakr Elnashar

30. 4. INCOMPLETE ABORTION
The endometrial midline echo:
distorted
>15 mm in the anteroposterior plane
Hetrogenous & irregular tissues.
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31. 5. COMPLETE ABORTION
The endometrial thickness
<15 mm in the anteroposterior plane
No evidence of retained products of conception
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32. Aboubakr Elnashar

33. 6. INEVITABLE ABORTION
GS situated low in uterus or cervix
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34. Aboubakr Elnashar

35. 7. ECTOPIC PREGNANCY
A. Uterine
1. No IU gestational sac
Normally BHCG doubles/48h
Discrimination zone:
BHCG increasing by >60% in 48 h
if not and no considerable bleeding think of ectopic
pregnancy if uterus Is empty on scan
However 5% of normal pregnancies don’t behave
like that
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36. 2. Pseudo gestational sac (a fluid collection or
debris in the cavity)
10-20% of ectopic P.
No double decidual sac sign
No yolk sac or embryo
Not eccentric (within the cavity)
3. No yolk sac in a G. sac > 20 mm
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37. Aboubakr Elnashar

38. B. Adnexal
1. Non cystic mass:
(Blob sign) inhomogeneous small mass next to the
ovary with no sac or embryo.
By pressing the vaginal probe gently against the
ectopic it moves separately to the ovary.
The most appropriate sign. Sensitivity 84% & specificity
99%
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39. loop
Non cystic mass
D pouch
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40. complex mass.
The adjacent ovary is marked by the presence of
regular follicular structures in the ovarian
parenchyma.
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41. 2. Cystic mass:
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42. 3. Ring:
(Bagel sign) hyperechoic ring around the GS
Note the circular morphology and the strongly
echogenic appearance of the trophoblast.
The content is anechoic {accumulation of fluid in GS}
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43. Ring
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44. 4.Sac & embryo.
Only seen in 10-20% of ectopic pregncncies
Ipsilateral side: Corpus luteum: 85% of cases
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45. C. D. pouch:
Fluid with or without blood clots
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46. Cervical
pregnancy
Abdominal
pregnancy
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47. Aboubakr Elnashar

48. 8. HYDATIFORM MOLE
 1. Placenta with multiple small sonolucent areas
(snowstorm)
2. Ovarian theca lutein cysts
 D.D :
1.Missed abortion with hydropic degeneration
2 .Degenerating fibroid
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49. Definitive diagnosis is made by histological
examination.
U/S: Early detection reduced from 16 W (passage of
vesicles) to 12 w
βhCG levels > 2 multiples of the median
RCOG Guideline No. 38 ; 2010 Aboubakr Elnashar

50. Aboubakr Elnashar

51. The characteristic snowstorm pattern representing the
hydropic chorionic villi
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52. Increased flow
Complete hydatidiform mole. The classic "snowstorm"
appearance is created by the multiple placental vesicles.
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53. Complete hydatidiform mole. The classic
"snowstorm" appearance is created by the
multiple placental vesicles. Aboubakr Elnashar

54. Color Doppler Scan In A Patient With A Molar Gestation
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55.  In most patients
Cl and US diagnosis is usually
missed or incomplete abortion.
Thorough histopathologic evaluation of
all missed or incomplete abortions
Partial H .Mole
Disaia &Creasman Clinical Gynecological Oncologym 7th edd. 2007
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56. Classically:
 Placenta: Thickened, hydropic
 Fetal or embryonic tissue
 Multiple soft markers, including:
 Cystic spaces in the placenta
 Transverse to AP dimension a ratio of the GS of >
1.5, is required for the reliable diagnosis of a partial
molar pregnancy
RCOG Guideline No. 38 ; 2010
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57. Partial molar pregnancy
The placenta shows multiple small cystic lesions, suggesting a
molar change.
a viable fetus
-
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58. Multicystic
placenta
embryo
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59. Multicystic
placenta
Yolk sac
Dead
embryo
Partial Molar Pregnancy
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60. Theca lutein cysts
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61. 246 lectures
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