A 23-year-old woman who is 6 weeks pregnant has noticed slight vaginal spotting and her period is 2 weeks late. The differential diagnoses in this case are threatened miscarriage, ectopic pregnancy, or molar pregnancy. Ultrasound would be helpful to locate the pregnancy and assess viability. Serial beta-hCG levels and progesterone levels could also help predict the pregnancy outcome if the location is unknown. Surgical uterine evacuation may be needed if bleeding is excessive or the woman prefers it.

1. Bleeding in Early Pregnancy
Dr Irfan Ziad

2. CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.

3. WHAT IS THE LIKELY DIFFERENTIAL DIAGNOSIS?
Miscarriage
Ectopic Pregnancy
Molar Pregnancy

4. Six weeks of amenorrhoea and a positive pregnancy
test,after regular menstrual cycles,indicate an early
pregnancy . These small amount of bleeding is a sign
that the patient is threatening to have a miscarriage.

5. MISCARRIAGE
is a pregnancy loss under 24 weeks

6. ABORTION

7. Aetiology
Chromosomal abnormality
 Trisomies (Down’s syndrome)
 Triploidies and tetraploidies
 Monosomy X (Turner’s syndrome)
 Translocation (hereditary)

8. Aetiology
Endocrine Disorder
 Diabetes
 Hypothyroidism
 Luteal phase deficiency
 Polycystic ovarian syndrome

9. Aetiology
Abnormalities of the uterus
 Uterine septa (bicornuate uterus)
 Endometrial adhesions (post
curettage or Asherman’s syndrome)

10. Aetiology
Others
 Tobacco, anaesthetic gases, arsenic, benzene,
solvents, ethylene oxide, formaldehyde, pesticide,
lead, mercury, cadmium
 Psychological disorders
 Antiphospholipid syndrome
 Thrombophilia (hereditary)

11. CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.

12. What additional features in the history would
you seek to support a particular diagnosis?
How much blood?
How’s the pain?
Do you pass out anything?

13. What clinical examination would you perform
and why?
Haemodynamic status
General exam, vitals, conjunctival colour
Abdominal Exam
To assess uterine size, to exclude acute abdomen
Per Speculum
To see if os is open , any fetal tissues, cervix.
VE and bimanual exam
Assess os, Elicit cervical excitation and adnexal mass in
ectopic pregnancy

14. Threatened Miscarriage
Pain : None/ Slight
Bleeding : Slight-moderate
Os : Close
Ultrasound intrauterine gestational sac,
:
fetal heart activity, intrauterine
bleeding, haematoma

15. Inevitable Miscarriage
Pain : Considerable
Bleeding : Heavy
Os : Open
Ultrasound is important in determining the
:
absence or persistence of
conception products inside
uterine cavity

16. Complete Miscarriage
Pain : Slight
Bleeding : Slight-moderate
Os : Open, then close
afterwards
Ultrasound Empty uterus
:

17. Silent Miscarriage
Pain : Absent
Bleeding : Slight, chronic
Os : Close
Ultrasound failure to identify fetal heart beat
:
Gestational sac >20mm in diameter and
no embryonic/fetal part can be seen
6 mm embryo with no heart activity on
TVS

18. Molar Pregnancy
Pain : Slight/None
Bleeding : Slight-moderate
Os : Close
Ultrasound Classic “snow-storm”
:
appearance of vesicles
Honeycomb appearance

19. Ectopic Pregnancy
Pain : Present
Bleeding : Slight
Os : Close/tender
Ultrasound Empty uterus
:
May see adnexal mass

20. Summary

21. CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.

22. What investigations would be most helpful and
why?
Urine pregnancy test
A quick test but may be unreliable
FBC
To assess Hb, TWC
Blood group and GSH
To check rhesus status, and to prepare for tranfusion
Ultrasound
To locate the fetus, to assess viability and to look for POC
Histology
Any tissues expelled should be investigated to exclude
molar or ectopic pregnancy

23. Ultrasound assessment
Look for pregnancy within the uterus
Presence of fetal heart
 Should be present 6 weeks
 If CRL< 6mm or MSD<20mm with no yolk
sac/fetus – rescan
 Uncertain viability and unknown location
Presence of yolk sac
Adnexal masses
Free fluid/ endometrial thickness

24. 5.5 weeksGestation sac and contents

25. Yolk sac ( left)
6.5 weeks Fetus is 3mm long
A fetal heartbeat

26. 8.5 weeksYolk sac still visible

27. 12 weeksNow we can see the baby

29. “Evennot beexpert useto confirm if aagreed criteria, it
may
with
possible
of TVS using
pregnancy is
intrauterine or extrauterine in 8–31% of cases at the “
first visit.
Condous G, Okaro E, Bourne T. The conservative
management of early pregnancy complications: a
review of the literature. Ultrasound Obstet
Gynecol
2003;22:420–30

30. What is the role of serial B-hCG assessment in
predicting pregnancy outcome?

31. “ RCOG Study Group concluded thatisaccess
to serial serum B-hCG estimation essential, “
with results available within 24 hours.
Recommendations from the 33rd RCOG Study Group.
In: Grudzinskas JG, O’Brien PMS, editors. Problems in
Early Pregnancy: Advances in Diagnosis and
Management. London: RCOG Press; 1997. p. 327–31

32. B-HCG
Pregnancy hormone
Should approximately double in the first trimester
every 48 hours
>1500 iu/l Ectopic pregnancy will usually
be visualised with TVS
Plateau below Pregnancy of unknown
1000 iu/l location and miscarriage
are both possible outcomes

33. Does serum progesterone assay have a role in
predicting pregnancy outcome?

34. “ When ultrasound findings progesterone levelsof
unknown location, serum
suggest pregnancy
below 25nmol/l are associated with pregnancies “
subsequently confirmed to be non-viable
Hahlin M, Thorburn J, Bryman I. The expectant
management of early pregnancy of uncertain site.Hum
Reprod 1995;10:1223–7.
20. Banerjee S, Aslam N, Woelfer B, Lawrence A. Elson J,
Jurkovic D. Expectant management of pregnancies of
unknown location:a prospective evaluation of methods
to predict spontaneous resolution of pregnancy. BJOG
2001;108:158–63.

35. Should all women with early pregnancy loss
receive anti-D immunoglobulin?

36. Non-sensitised rhesus (Rh) negative women
Anti-D
should receive anti-D immunoglobulin in the
following:
ectopic pregnancy
All miscarriages over 12 weeks of gestation
(including threatened)
All miscarriages where the uterus is evacuated
(whether medically or surgically)
Royal College of Obstetricians and Gynaecologists. Use
of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.

37. Which women should be screened for genital
tract infection?

38. “ Screening forshould be considered in women
trachomatis,
infection, including Chlamydia “
undergoing surgical uterine evacuation.
Royal College of Obstetricians and Gynaecologists. The
Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.

39. When should surgical uterine evacuation be
used?

40. Indications for Surgical uterine evacuation :
Patient’s preference
Persistent excessive bleeding,
Haemodynamic instability,
Evidence of infected retained tissue
Suspected gestational trophoblastic disease
Royal College of Obstetricians and Gynaecologists. The
Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.

41. How should surgical uterine evacuation be
performed?

42. “ Surgical uterine evacuation forcurettage should
be performed using suction &
miscarriage “
Royal College of Obstetricians and Gynaecologists. The
Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.

43. A Cochrane review concluded that vacuum aspiration
is preferable to sharp curettage in cases of incomplete
miscarriage. The advantages include:
Decreased blood loss
Less pain
Shorter duration of procedure
Royal College of Obstetricians and Gynaecologists. Use
of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.

44. Complications of Surgical uterine evacuation :
Perforation
Haemorrhage
intrauterine adhesions
Intra-abdominal trauma
Royal College of Obstetricians and Gynaecologists. Use
of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.

45. “usingincidence of serious morbidity
The
a similar surgical technique in
induced abortion is 2.1% with a “
mortality of 0.5/100 000.
Joint Study of the Royal College of General Practitioners and
the Royal College of Obstetricians and
Gynaecologists. Induced abortion operations and their
early sequelae.J R Coll Gen Pract 1985;35:175–80

46. What is the advantages of prostaglandin
administration prior to surgical abortion?

47. “ significant reductions in
dilatation force,
haemorrhage and
“
uterine/cervical trauma.
There is no randomised evidence to guide practice in cases of first-
trimester miscarriage,particularly in the presence of an intact sac

48. Should prophylactic antibiotics be given prior
to surgical evacuation?

49. “ There is insufficient evidence to
recommend routine antibiotic
prophylaxis prior to surgical uterine “
evacuation.
Antibiotic prophylaxis should be given based on
individual clinical indications
A randomised trial of prophylactic doxycycline in curettage for incomplete
miscarriage did not demonstrate an obvious benefit

50. What are the alternatives to surgical uterine
evacuation for miscarriage?

51. Medical methods
are an effective alternative
in the management of
confirmed first-trimester
miscarriage.

52. Efficacy rates vary widely
from 13% to 96%,influenced
by many factors

53. Higher success rates were associated with
Incomplete miscarriage (70–96% success rate)
High-dose misoprostol (1200–1400 micrograms),
Prostaglandins administered vaginally
and clinical follow-up without routine ultrasound.
Hinshaw HKS. Medical management of miscarriage. In:
Grudzinskas JG, O’Brien PMS, editors. Problems in
Early Pregnancy: Advances in Diagnosis and
Management. London: RCOG Press; 1997. p. 284–95.

54. Misoprostol
prostaglandin analogue
cheap, highly effective
active orally and vaginally
No significant difference in successful outcome
May bleed up to 3 weeks
Used in combination with mifepristone
S/E: Diarhhoea, abd pain, nause, headache

55. Cervagem
Gameprost
Inserted into the vagina
S/E: vaginal bleeding or uterine pain
nausea, vomiting, lower abdominal pain, backache
headache, slight fever, flushing, chills

56. “Vaginal misoprostol for the termination of
second and third trimester of pregnancy “
appears as effective as cervagem, but
information about maternal safety is limited.

57. effective regimens for
missed miscarriages
•a higher dose of prostaglandin with longer duration of use
•or, alternatively, priming with antiprogesterone.

58. Incomplete miscarriage
Can be managed with prostaglandin alone
No statistical difference in efficacy between
surgical and medical evacuation for
incomplete miscarriage and for early fetal
demise at gestations less than 71 days or sac
diameter less than 24mm.

59. Threatened miscarriage
No specific management
Reassurance
Rest
Sedation
weekly ultrasound examination

60. Expectant management
is another effective method to use in
selected cases of confirmed first-
trimester miscarriage.

61. Expectant management
Watch and wait
Serial scans and HCG
More successful in incomplete miscarriage
28% success if intact sac
94% if incomplete
May have prolonged bleeding
Can convert at anytime to medical/surgical

62. Concerns have been raised about the
infective risks of non-surgical management
But published data suggest a reduction in
clinical pelvic infection and no adverse
affects on future fertility.

63. Septic miscarriage
Complicated by infection
- delayed evacuation

64. Septic miscarriage
Immediate complication
1.localized endometritis 9.septicaemia
2.spreading endometritis 10. septic shock
11. renal failure
3.salpingitis
12. DIC
4.salpingo-oophritis 13. tetanus
5.pelvic peritonitis 14. gangrene
6. pelvic abscess
7.tuboovarian abscess
8.generalized peritonitis

65. Septic miscarriage
Late complication
• Chronic pelvic inflammatory disease
• Pelvic adhesion
• Ectopic pregnancy
• infertility

66. Septic miscarriage
Genital swab
I/V broad spectrum antibiotics to cover g(+)ve, g(-)ve
and anaerobic organism
change antibiotics according to culture and sensitivity
result
Remove the septic focus
ERPOC
Laparotomy and drainage for pelvic abscess
TAH for septic uterus and uterine perforation

67. What are the advantages of arranging
histological examination of tissue passed
at the time of miscarriage?

68. Tissue obtained at the time of miscarriage
should be examined histologically to
confirm pregnancy and
to exclude ectopic pregnancy or
unsuspected gestational trophoblastic
disease.

69. CASE 1.2
A 32-year-old patient, Mrs. A, immigrated to the United
States several years ago. Following the birth of their first
daughter, Mrs. A has had three miscarriages between
eight and 12 weeks' gestation, the most recent one being
one month ago.

70. What are the recommended investigations of
couples with recurrent first-trimester
miscarriage and second-trimester miscarriage?

71. Investigations would include the following:
•chromosomal analysis of the products of conception;
•chromosomal analysis of both parents – a chromosomal
abnormality (e.g.balanced translocation) will be
diagnosed in one of the partners in 5–7per cent of cases
of recurrent abortion;
•maternal blood for anticardiolipin antibodies and lupus
anticoagulant

72. Should I be given some kinda drug to avoid
getting another miscarriage?

73. “Aspirin alone or in combination with heparin is
being prescribed for women with unexplained
Recurrent miscarriage,with the aim of improving
pregnancy outcome.”
KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu
lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent
miscarriage.NEngl J
Med2010;362:1586–96.

74. Recent Data suggest that the use of empirical
treatment in women with unexplained
recurrent miscarriage is unnecessary and
should be resisted.
KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu
lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent
miscarriage.NEngl J Med2010;362:1586–96.

75. In the absence of any identifiable cause,what
are my chances of achieving an ongoing
pregnancy on the next occasion?

76. There is a 60–70% likelihood of
successful pregnancy if no cause is
found for recurrent miscarriage

77. Is there potential benefit from support
and follow-up after pregnancy loss?

78. “All professionals should be aware of the
psychological sequelae associated with
pregnancy loss and should provide support,
follow-up and access to formal counselling when
necessary. “