The document discusses the differential diagnosis and workup for first trimester bleeding. It describes various types of first trimester pregnancy loss including abortion (spontaneous or induced), ectopic pregnancy, trophoblastic disease, and cervical or vaginal lesions. It provides details on history, examination, investigations, diagnosis and management for each type of early pregnancy bleeding/loss.

1. Early pregnancy bleeding Dr. Muhabat Salih Saeid MRCOG-London-UK

4. History Examination Investigations Diagnosis Management Assessment

7. Subserosal Fibroid

11. threatened inevitable incomplete missed

13. 2-Inevitable Abortion: O/H :lower abdominal pain similar to dysmenorrhoea which persist/worse O/E:Cervix is open Abortion will take its course Management: as incomplete abortion

14. 3. Incomplete abortion: * OH: as inevitable i,.e. abdominal pain and passage of clots and tissues * O.E: Cervical os open - If bleeding is severe, the patient may be shocked - Suprapubic tenderness, the uterine size is corresponding to expected gestational age - Bimanual examination: products of conception may be left in the os or in vagina * Ultrasound : remnant of conception in the uterus * Management: - Treatment of shock (plasma expanders and blood transfusion) - Evacuation of retained products under general anaesthesia

15. 4. Complete abortion: * History of abdominal pain and vaginal bleeding as well as passage of clots and tissues * On examination: The uterine size is smaller than expected for gestational; the cervical os is closed (the uterus expelled its contents) * Ultrasound shows empty uterus * Management : Patient usually well and fit to go home Threatened - ※Inevitable ※Incomplete ※ Complete Preg. Continues (majority)

16. Complete miscarriage Bleeding and cramps which are usually settling

17. 5. Septic abortion: * If abortion is associated with infection, it is called septic abortion * It is usually associated with incomplete induced abortion * History of abdominal pain, vaginal bleeding and may have foul vaginal discharge * On examination: the patient usually looks unwell; pyrexia with tachycardia If severe; the patient might have septic (endotoxic) shock Lower abdominal tenderness and enlarged tender uterus on bimanual examination

20. Missed miscarriage Spotting only usually. Expected to be 6-12 weeks by LMP. Fetal pole seen

21. Missed Miscarriage

22. 6. Missed abortion - Embryo dies and the uterus does not expel its contents - Loss of pregnancy symptoms - Uterine size is smaller than expected - Ultrasound showed: *no fetal heart * Embryo / Fetus size is smaller than expected for gestational age Management: If uterus size <12 weeks - evacuation under general anaethesia (suction currtage) bec. Risk of perforation if use sharp one as the uterus in this condition is soft. If uterine size >12 weeks - Extra-amniotic prostaglandins

24. RECURRENT MISCARRIAGE Definition: Three or more consecutive pregnancy loss before viability Incidence 1% Etiology: * Genetic * Anatomical * Infective * Systemic * Immunological * Endocrine

25. 1. Genetic: - Rare (5% of recurrent abortion will have paternal abnormal chromosomes) - usually cause early trimester abortion - Parental karyotyping: * Balanced reciprocal translocation * Invertions & mosaisms Management: Genetic counseling Karyotyping the product of conception Prenatal diagnosis Preimplantation diagnosis

26. 2. Anatomical Causes: - Abnormal mullerian development (Bicorneate uterus, septate uterus, unicorneate uterus) - Uterine Fibroid (submuscous fibroid) - Uterine Synechae (intrauterine adhesion due to previous curettage - Cervical incompetence These causes usually lead to midtrimester miscarriages/preterm deliveries

28. 3. Infective causes: - Rare - TORCH screen unhelpful (reinfection rare in these cases) - Bacterial Vaginosis may lead to recurrent late losses and preterm labour

29. *Normal uterus at laparoscopy *Normal HSG

32. 4. Immunological causes: Antiphospholipid syndrome (API) Definition: Presence of antibodies to patient`s own phospholipids and associated with thrombosis, thrombocytopenia and recurrent abortions. Incidence upto 40%of recurrent abortion. Theory: Disordered platelet function: release of thromboxane. Disordered endothelial function: reduce prostacyclin release  Altered ratio of thromboxane /prostacycline ratio

33. Complications: Obstetrics complications : Fetal losses (early and late); Abruptio placentae; intrauterine growth restriction Vascular complications: arterial and venous thrombosis. Neurological: TIA Diagnosis Lupus Anticoagulant (LA) Positive prolonged APTT Positive anticardiolipin antibodies (ACA) Treatment: Baby Aspirin Heparin Immunoglobulins (under investigations)

35. In Conclusion: Patients with recurrent abortion needs to be investigated by the following tests For all: * Chromosomal analysis of both partners * Serum LH (day 5) for PCO * Antiphospholipid Antibodies (LA, ACA) * Pelvic ultrasound * Rubella antibodies (if negative, vaccinate) For selected patients: * Hysteroscopy/hysterosalpingography

36. Thank you Questions?