An overview of First trimester bleeding in pregnancy

1. First Trimester Bleeding
A Case Series

2. Case 1
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27 yr old G5A4 at 6w 5d POG
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Post IUI pregnancy
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c/o spotting P/V for 1 day
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No c/o pain abdomen
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O/E – Afebrile, PR 84/min, BP 130/80 mm Hg, No pallor
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P/A – soft, non-tender, no organomegaly
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P/S/V – Altered blood at os +, uterus 6-8 wk size, mild Rt fornyceal
tenderness
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TVS – SLIUF, FCA+, Rt cornual pregnancy
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CORNUAL (INTERSTITIAL) PREGNANCY
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Medical management with Inj Methotrexate, both locally (intra sac
instillation) and systemic

4. Case 2
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30 yr old G2A1 at 7w 5d POG, Post IVF-ET pregnancy
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c/o pain abdomen, bleeding P/V since 3 hrs
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P/A – soft, non-tender, uterus not palpable
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P/S/V – altered blood at os +, uterus 8w size, No adnexal mass,
no fornyceal tenderness
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TVS – SLIUF, FCA+, CRL 7w4d, 2.1 x 1.6 cm clot present
anterior to internal os ?subchorionic haemorrhage
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THREATENED ABORTION
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Admitted and managed with rest, progesterone support.
Discharged after 1 week, with resolution in size of clot

5. Case 3
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24 yr old G2P1L1 at 8 wk POG
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c/o worsening nausea/vomiting since 2 weeks
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Bleeding P/V, irregularly since last 7 days
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P/A – uterus just palpable, non tender
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P/S/V – altered blood at os, uterus 12wk size, no adnexal mass,
no fornyceal tenderness
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TVS – Heterogenous intrauterine mass with multiple follicles
seen in “snow storm” appearance
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HYDATIDIFORM MOLE
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Admitted, D&E done. Discharged subsequently and on regular
follow up with β-HCG monitoring and advise on contraception

6. EARLY PREGNANCY BLEEDING

7. Introduction
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Pregnancy complications
– More during first trimester (upto 12 weeks gestation)
– 20-40% of women
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Most commonly
– Bleeding per vaginum
– Pain abdomen
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Accurate diagnosis is needed
– Reassurance to patient if pregnancy is well
– Appropriate intervention if not
– Worse prognosis if heavy bleeding or extends into second
trimester

8. Differential Diagnosis
●
Pregnancy related
– Implantation Bleeding
– Abortion
– Ectopic Pregnancy
– Hydatidiform mole
– Single fetal demise
●
Gynae conditions asso with
pregnancy
– Ruptured corpus luteum
– Ovarian cyst accident
– Torsion or degeneration of
pedunculated fibroid
●
Non-gynaecological
– Appendicitis
– Renal Colic
– Cholecystitis
●
Gynaecologic conditions
– Pelvic Inflammatory
Disease
– DUB
– Endometriosis

9. Evaluation
●
History
– Last menstrual periods, regularity of cycles
– Amount and character of bleeding (fresh, altered)
– Severity of early pregnancy symptoms, esp
nausea/vomiting
– Character and severity of pain
– Past history (ectopic, abortion, GTD, medical disorders,
risk factors)

10. Evaluation
●
Physical Examination
– Vitals
– Abdominal exam (distention, guarding, rebound
tenderness)
– Speculum exam
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Local causes – warts, vaginitis, cervicitis, ectropion, cervical
polyps
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Character of blood – fresh, altered, clots
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Open cervical os – tissue available for examination
– Bimanual exam:
●
Uterine enlargement, cervical/adnexal tenderness, adnexal
masses

11. Evaluation
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Ultrasound
– Forms the cornerstone of evaluation
●
Transvaginal preferred over transabdominal
– Gives immediate information regarding
●
Location of pregnancy
●
Fetal viability and dating
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Rare findings (GTD, single fetal demise)
– Correlation of USG findings with β-HCG values

12. ●
Gestational Sac
– Anechoic area within the uterus surrounded by two
echogenic rings
●
Decidua vera (outer ring)
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Decidua capsularis (inner ring)
– Known as double decidual sac sign
– Sac alone is not a definitive diagnosis of intrauterine
pregnancy
– Corresponding β HCG values >1500 IU (Threshold
value)

14. Pseudosac vs Gestational Sac

15. ●
Yolk sac
– Earliest definitive sign of pregnancy
– Seen on TVS at
●
4-5 wks POG
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Β-HCG >2000
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Thin echogenic ring within the gestational sac
– Readily seen when Gest sac >10 mm

16. Yolk Sac

17. ●
Embryo (Fetal Pole)
– Thickened area adjacent to yolk sac
– Seen on TVS when ~2 mm size
– CRL (Crown Rump Length) measured at this stage
accurately determines gestational age
– Should be seen when Gest Sac >18mm size

19. ●
Fetal Cardiac Activity (FCA)
– Earliest seen on TVS at 6 wks or fetal pole >5mm
– Important prognostic indicator
– Rate of spontaneous abortion reduces to 2-4% once
FCA visualised

20. Embryonic Fetal Demise
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Gest Sac > 10mm without yolk sac
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Gest Sac > 18 mm without fetal pole
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Embryo without cardiac activity
– Beyond 7 wks GA
– Fetal pole >5mm

21. Evaluation
●
Laboratory:
– β-HCG concentration complement information available
from TVS
– Absolute values of help only in confirmation of
pregnancy
●
Value > 1500 and if no intra-uterine gest sac seen, highly
suggestive of ectopic pregnancy
●
Exercise caution if IVF pregnancy – heterotropic pregnancy
– Serial titres of clinical significance
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Rise of minimum 66% in 48 hrs suggestive of a viable
pregnancy

23. Implantation Bleeding
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Disruption of lacunar spaces in syncytiotrophoblast
due to incresed blood flow
– Extravasation of blood into endometrial cavity
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Occurs 8-10 days post-fertilization
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Corresponds to date of expected menses
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Diagnosis of exclusion
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Physiological bleeding

26. Abortion
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Derived from Latin aboriri – to miscarry
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Literally means – premature birth before a live birth
is possible (Oxford Dictionary)
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WHO defines – pregnancy termination prior to 20
weeks or fetus born with weight less than 500 gms
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Bleeding
– in 1/5th of pregnancies before 20 weeks
– 50% end in spontaneous abortions
●
Pregnancy Loss Iceberg

28. Causes
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Major genetic abnormality
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Internal environment
– Uterine: anomalies, leiomyomata, incompetent cervix
– Luteal phase defect
– Immunologic factors
– Endocrine abmormalities: Hypothyroidism, Diabetes
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External environment
– Substance abuse (tobacco, alcohol, cocaine, caffeine)
– Radiation
– Infection
– Occupational chemical exposure
●
Advanced maternal age

29. Types
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Missed abortion
– In utero demise of the fetus before 20 wks with retention of
pregnancy for prolonged period of time
– Managed:
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Surgically – D&E
●
Medical – Misoprostol
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Expectant
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Threatened abortion
– Closed uneffaced cervix, uterine size appropriate for gestation
– FCA + if gestation sufficiently advanced
– Management
●
Expectant, Progesterone support

30. Types
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Inevitable abortion
– External os closed, cervical canan ballooned
– Increased bleeding with cramps, passage of clots
– Management
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Surgical
●
Medical
●
Expectant

31. Types
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Complete/Incomplete abortion
– Complete:
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small contracted uterus, cervix closed, scant bleeding/pain
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No intervention required, observation
– Incomplete:
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Some products retained in utero
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Uterus smaller than gestation, not well contracted
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Cervix open, POC present at os
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Variable bleeding/cramps
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Management:
– Surgical
– Medical

32. Types of abortion

33. Missed Abortion/Blighted Ovum

35. Complete abortion

36. Types
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Septic Abortion
– Fallout of illegal abortions: relook at MTP Act?
– Rare with spontaneous abortions
– Signs/Symptoms:
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Fever with chills/rigors, tachycardia
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Pain abdomen, bleeding P/V, foul-smelling discharge
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Cervix dilated, uterus boggy and tender
– Management:
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Stabilize pt, obtain blood and endometrial cultures
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Broad spectrum antibiotics
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D&E

37. Prognostic Factors
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Abnormal Yolk sac (Irregular, large for gestation)
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Fetal bradycardia (HR <85 bpm at 6-8 wk have 0%
chance of survival)
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Small Sac (<5 mm)
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Subchorionic hematoma (if > 25% of gestational
sac volume, abortion rates double)

38. Psychological Aspects of Abortions

39. Long walks, Papaya & Missed Sleep
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Universal seeking of explanation
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Self blame
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Belief/concern that doctors can do something to
prevent miscarriage

40. ●
Dispel guilt
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Comfort, support from physician and family
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Counsel, reassure about future
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Include partner in psychological care
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Assess level of grief and adjust counselling
accordingly
– Half of pregnancies are unintended!!

41. Ectopic Pregnancy
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Pregnancy outside the endometrial cavity
– Most common in the fallopian tube
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15% of first trimester bleeding
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Occurs in 1:100 pregnancies
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Leading cause of maternal mortality in first trimester
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Early diagnosis is critical!!!
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Classic triad of symptoms:
– Amenorrhoea, bleeding P/V, pain abdomen

43. Risk Factors
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Previous ectopic pregnancy
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Prior tubal surgery
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Pelvic inflammatory disease
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Progestin-only contraceptives
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IUCD
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Iatrogenic – ART procedures
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No Risk Factor!!!!

44. Initial Evaluation
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Pregnancy test on all women in reproductive age
group with irregular bleeding
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Ectopic suggestive when:
– Complex adnexal mass on USG with UPT + and empty
uterine cavity
– Fluid filled adnexal mass surrounded by echogenic ring
– Free fluid in POD

45. Diagnosis of Ectopic
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Laparoscopy – Gold Standard
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Ultrasound (Transvaginal)
– No intra-uterine sac and β-HCG >1800 is highly
suggestive
– Gestational sac/embryo outside uterus confirms ectopic
– Pitfalls: pseudogestational sac, ruptured corpus luteum
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Failure of β-HCG to double in 48-72 hrs

46. β-HCG
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Rises in a curvilinear
fashion, peaking at 10
weeks, then plateaus
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Mean doubling time: 1.4 –
2.1 days
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Should rise by atleast 66%
within 48 hrs
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Ectopic pregnancy – only
21% follow this rule

48. Hemoperitoneum from Ectopic
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Always assess RUQ view in suspected ectopic

49. Right Tubal Ectopic

50. Right Interstitial Ectopic

51. Ovarian Ectopic

52. Abdominal Pregnancy

53. Abdominal Pregnancy

54. Ruptured Ectopic

55. Heterotropic Pregnancy
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Presence of both Intra-uterine as well as ectopic
pregnancy
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Rare
– 1:8000 in spontaneous pregnancy
– 1:100 in IVF pregnancies

56. Heterotropic Pregnancy

57. Management
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Expectant
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Surgical
– Laparoscopic
– Laparotomy
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Medical (Methotrexate)

58. Gestational Trophoblastic Disease
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Disorders arising from the trophoblastic cells of the
placenta:
– Hydatidiform Mole (most common)
●
Complete
●
Partial
– Invasive Mole
– Choriocarcinoma
– Placental site trophoblastic tumours

59. Epidemiology
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Incidence 1:1000
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Risk factors:
– Extremes of age (> 40 yrs, < 20 yrs)
– Previous GTD
– Smoking
– Blood type A, B or AB
– H/o infertility
– Use of OCPs

60. Clinical Manifestation
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Bleeding P/V
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Pelvic pressure/pain
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Hyperemesis gravidarum
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Passage of hydropic vesicles P/V
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Anaemia
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Hyperthyroidism
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Enlarged uterus
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Theca lutein cysts
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Pre-eclampsia prior to 20 wks

61. Complete Mole
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No fetus present
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Results from aberrant fertilisation followed by
trophoblastic proliferation
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46XX (both X paternal)
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Uterine height more than period of gestation
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Excessively elevated β-HCG (>100,000)
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USG shows central heterogenous mass with
swelling of hydropic chorionic villi – snow storm
appearance

62. Complete mole

63. Snow Storm Appearance

64. Incomplete/Partial Mole
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Associated with fetus and amniotic fluid
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Polyploidy, usually triploidy
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Less associated with signs/symptoms of excessive
β-HCG
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USG shows possible fetus, often growth restricted,
reduced amniotic fluid, swiss cheese pattern of
chorionic villi

65. Incomplete Mole

66. Management
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Prompt evacuation of the uterus (D&E)
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Serial β-HCG monitoring
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Contraception for 1 year
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Recurrence:
– 20% with complete mole
– May invade myometrium or become metastatic
– Treated with methotrexate
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Most can conceive, carry normal pregnancy

67. Conclusion

68. ●
First trimester bleeding is common
– Correct clinical approach
●
Ectopic pregnancy has a high mortality rate, keep
high degree of suspicion
●
Ultrasound (TVS) and β-HCG important pillars of
diagnosis
●
Abortions – significant physical and psychological
morbidity

69. Thank You