Bleeding in Early Pregnancy

1. DR NURULHUDA
O&G DEPARTMENT
SGH

2.  MISCARRIAGE
 THREATENED
 SILENT
 INEVITABLE
 INCOMPLETE
 TROPHOBLASTIC DISEASES
 ECTOPIC PREGNANCY
 LOCAL CAUSE

3. Clinical presentation

4. Clinical Presentation
 Amount of bleeding
 Pain
 Passage of products

5. MISCARRIAGE
 SPORADIC MISCARRIAGE
Definition
In UK : loss of an intrauterine pregnancy before 24
completed weeks of gestation.
 WHO : expulsion of fetus / embryo wt < 500 g & gestation limit of <
22 completed wks of pregnancy.

6. MISCARRIAGE
 SPORADIC MISCARRIAGE
 A distressing complication of pregnancy
 Occur ~ 20% of pregnancies
 Majority of sporadic miscarriage occur in 1st trimester = early
pregnancy loses
 Only 2-5% of pregnancy miscarry after FH activity has been
detected by USG

7. Spontaneous Miscarriage
Incidence
 10-15% in clinically evident pregnancy
 30% in chemically evident pregnancy
 80% of spontaneous miscarriage occurred in
gestational age less than 14 weeks.

8. Miscarriage
 Threatened - 25% of all pregnancies
~ uterine bleeding prior to 24 w of pregnancy
 Inevitable - complete or incomplete depending on
whether all or not POC expelled from the uterus.
 Early fetal/embryonic demise
(missed/anembryonic/blighted ovum)
~ failure of pregnancy is identified before the
expulsion of fetal and placental tissue.

9. Miscarriage
 Septic
 Recurrent miscarriage
~ primary - no previous live birth
~ secondary - at least one previous successful
pregnancy.

10. AETIOLOGY
 No demonstrable cause – commonest
MORPHOLOGIC AND GENETIC ABNORMALITY
 Abnormal karyotype~
 50% in first trimester
 20 - 30% in 2nd trimester
 5- 10% in 3rd trimester

11. AETIOLOGY
 50% of spontaneous miscarriage is due to aneuploidy
 50% of aneuploidy is autosomal trisomies eg: trisomy 16
during first trimester- commonly trisomy 16 or
monosomy X (45XO Turner Syndrome - 20%)
polyploidy (triploidy) 20%,
producing blighted ovum or partial mole

12. AETIOLOGY
MATERNAL FACTORS
 underlying systemic diseases:
~ endocrine
~ CVS - HPT
~ renal disease
~ CTD - SLE
 maternal infection
 uterine defects
 malnutrition
 emotional disturbance - no valid evidence

13. Infective Causes of Miscarriage
 Mechanisms – unclear but postulated due to maternal
pyrexia/ bacteraemia
 Recent prospective study found :
 Women experience 1st trimester miscarriage – no more
likely to have a clinical infection than those having a
successful pregnancy
 In recurrent miscarriage :
 Infective causes (> genital tract infection) is unclear

14. Infective Causes of Miscarriage
 HIV
 Remains unknown
 Syphillis & Parvovirus B19
 Commonly cause late 2nd trimester miscarriage &
stillbirth
 Group B Streptococcus (GBS)
 In late miscarriages & preterm labour

15. Structural causes of Miscarriage
 Mullerian duct defects - Anatomical uterine abn
 Prevalence : 3% (in lap sterilisation)
 Prevalence in recurrent miscarriers: 3 – 27%
 Most sensitive method of Ix :
 Hysteroscopy > HSG > ? USG
 In early preg loss,
 embryo must be presumed to implant in an avascular area of
endometrial cavity – lead to arrested dev & early preg failure.
 This process is unlikely in recurrent preg loss

16. Structural causes of Miscarriage
 Open surgical / abd resection :
 Risk of pelvic & intrauterine adhesion formation(Asherman’s
Syndrome)
 myomectomy
 Hysteroscopic resection of intrauterine septa
 More promising but lack of randomised studies
 Cervical incompetence
 Def :
 Painless dilatation of the cx lead to miscarriage in the absence
of uterine contractions / haemorrhage
 Aetiology of 2nd trimester loss

17. Other causes of miscarriage
 Fetal sex
 More in males, but sex ratio remain unknown
 Multiple pregnancy
 Assoc with an increased risk of fetal loss (either by resorption, post-
implantation loss / 2nd trimester miscarriage)
 Risk of miscarriage 2x singleton preg
 Monochorionic twin preg – 12% risk
 Parity
 Rises risk with parity
 Results of reproductive compensation & related with maternal age
(assoc with trisomic pregnancies)

18. Maternal health in miscarriage
 Cigarete smoking
 Correlated with miscarriage
 Nicotine has adverse effect on trophoblastic invasion
 Cocaine – increased risk of miscarriage
 Alcohol - higher in women ended up with miscarriage
 Caffeine – high level ass. with miscarriage
 Chemicals : lead,ethylene oxide, solvents, pestisides, vinyl chloride &
anaesthetic gases – ass. with fetal loss
 Radiotherapy & Chemotherapy
 May cause miscarriage & fetal abnormality in a dose of > 25 rads –
0.1% risk

19. CLINICAL FINDINGS
 Threatened
Minimal vaginal bleeding + pain (usually painless)
Closed cervical os,
Without expulsion of POC
Viable pregnancy by USG
 soft, non-tender abdomen, uterus=POA
 Continued vomiting ass. with increased chance of life birth

20. CLINICAL FINDINGS
 Inevitable
 fresh vaginal bleeding with abdominal/back pain with cx
dilatation and effacement
 50% will miscarry
 Diagnosis determined by confirmation of cervical dilatation
at VE
 Occasionally severe shock – may be due to massive
haemorrhage / vasovagal reaction – cervical shock syndrome
due to distension of the cervix by POC (Treatment is by
quick removal of the POC from os by bedside)

21. CLINICAL and USG FINDINGS
 Incomplete
heavy bleeding & abd cramps with open cx os
 POC partially expulsed & USG showed hyperechoic material in the
uterine cavity
 Complete
 A hx of pain + bleeding + POCs seen
 bleeding and pain cease afterwards as POCs completely expelled.
USG ~ empty uterus
 Recent studies of women showed around 20-30% of all miscarriage
is complete(Chung et al 1994; Mansur 1992)
 Expectant mx of early fetal demise has demonstrated that, with
time, up to 25% women go on to have complete miscarriage
(Jurkovic et al 1998)

22. CLINICAL FINDINGS
 Early Embryonic / Fetal Demise* (Missed /
Silent)
 Failure of preg is identified before any
expulsion of POC occur
 Disappearance of sn/sx of pregnancy with ut <
gest age & closed cervical os
 An USG dx of non-viable preg in the absence of
PV bleeding / pain(accidental finding)
 A fetal pole > 5 mm w/out FH activity or when
USG I / 2 wks apart have shown no growth / no
FH activity: Missed / silent miscarriage

23. CLINICAL FINDINGS w/out a fetal pole :
 A sac > 20 mm in diameter
a blighted ovum*
 Goldstein - most of anembryonic pregnancy
are not truly without embryos. They lose
viability before our ability to image them.
 Many initially had early embryonic dev. with
subsequent loss of viability, followed by
embryonic resorption and thus ,appearance of
empty sac.
* An embryonic pregnancy / blighted ovum has been
replaced with early embryo/ fetal demise in UK

24. CLINICAL FINDINGS
 Septic
 A complication of incomplete miscarriage where the
remaining POCs become infected by ascending
organisms + instrumentation of the uterus
 Presented with suprapubic pain, malaise, fever + PV
bleeding
 O/E : Fever, suprapubic pain/abd rigidity, uterine &
adnexal tenderness and closed cervix.
 Around 3-6% following termination of pregnancy
 Common organisms : E.Coli,Bacteroides, streptococci
Clostridium welchii
 Complications : Septicaemia → bactaremic shock →
maternal death

25. INVESTIGATIONS
 USG
~ is essential in the diagnosis - usually TVS.
~ will determine on-going pregnancy/failing
pregnancy/rule out ectopic and trophoblastic
disease.
 Pregnancy test - by urinary or serum hCG to
distinguish an early complete miscarriage or on-
going ectopic pregnancy.
 Blood grouping and Rh typing - Rh neg. should
receive anti-D Ig regardless of gestational age.

26. Management of miscarriage
 Tx aim : to reduce the potential complication of
miscarriage (i.e prolonged pain & bleeding, sepsis & rh-
iso-sensitisation)
 Conservative
 Expectant Mx ~ avoids surgical procedure &
anaesthetic.
 Appropriate for pts with an incomplete miscarriage with
POC < 50mm in diameter on TVS
 In cases without haemodynamic compromise /
maternal anaemia, spontaneous resolution
occurred within 3 days in up to 80% of cases with
minimal retained POC
 No evidence of impairment of future fetility

27. Management of miscarriage
Conservative Management
less useful for blighted ovum
 because bleeding appears to be heavier & more
prolonged than surgical management
 60% which treatment conservatively require
ERPOC at some stage

28. Management of miscarriage
 Surgical
 Evacuation of retained POC (ERPOC) – most common form of tx
for miscarriage
 Cx is dilated & retained POC removed by S+C
 Cpx :
 Perforation of the uterus (by dilator / currete), infection
(commonest) & incomplete emptying of the cavity ~ in up to 6%
of cases, tearing of cervix
 Incidence of serious morbidity : 2.1% (RCOG 1985)
 Potential anaesthetic cpx
 Asherman syndrome (intrauterine adhesions)
 Incidence of mortality : 0.5 / 100 000 (Lawson et al 1994)

29. Threatened Miscarriage Mx
 97-98% chance of a live birth
 Women > 40s, miscarriage rate : 15-30% - even after FH present by
USG
 Tx : reassurance & continued medical & emotional support
 Advise bedrest & avoiding SI
 Bedrest ↓pressure & improve outcome – but no clinical evidence
 Progesterone supplementation
 However, several meta-analysis trial unable to demonstrate
beneficial effect of progesterone tx (Goldstein et al 1989)

30. Incomplete Miscarriage Mx
 Tx : Surgical evacuation of POC
 Without tx : maternal mortality of 1.6%
 Due to haemodynamic compromise of cervical shock.
 Suction evacuation >safer technique than sharp curettage
 Lower rate of perforation, blood loss & subsequent intrauterine
adhesion formation (Edmonds 1992, Verkuyl & Crowther 1993)
 Routine use of syntocinon / ergometrine – no benefits in
↓blood loss during surgical tx of 1st trimester miscarriage (Beeby et al
1984)
 Screening for chlamydia infection is recommended

31. Early Fetal Demise Mx
 Same for incomplete miscarriage
 Tx :
 Surgical tx after cervical ripening (with mifepristone/
prostaglandin)
 To ↓ risk of cx trauma / ut perforation assoc with forced cx
dilatation
 Expectant mx :
 < effective than cases of incomplete miscarriage
 With only 25% proceeding to complete miscarriage
 Efficacy of medical tx also < inc miscarriage
 Complete miscarriage rate can be up to 90% with higher dose of
mifepristone & misoprostol

32. Coronal TVUS of the uterus shows a gestational sac with
hyperechoic margins (arrow) and endometrial cavity (curved
arrow).

33. Double Decidual Sac Sign. Coronal TVUS of the uterus reveals an
intrauterine gestational sac (straight arrow), decidua capsularis
(curved arrow), decidua parietalis (arrowhead), and effaced
endometrial cavity (asterisks)

34. Yolk sac (thin arrow) outside the amniotic membrane
(arrowhead), which has not yet fused with the chorion (curved
arrow). Embryo (thick arrow) is seen within the amniotic sac

35. Anembryonic Pregnancy

36. Abnormal Shape of the GS

37. Abortion in Progress

38. Missed Abortion

39. Subchorionic Haemorrhage

40. Retained Products of Conception

41. Retained Products of Conception

43. Introduction
 Leading cause of death of pregnancy related deaths during
first trimester
 13 maternal deaths resulting from ectopic pregnancy in the
UK in 1997–99.
 Incidence of ectopic pregnancy has remained static in
recent years (11.1/1000 pregnancies)
 32000 ectopic pregnancies are diagnosed in the UK within
a three year period.

44. Clinical presentation
 Clinical suspicion – positive pregnancy test, pain, bleeding
and adnexal mass
 Clinical triad – pain, bleeding, adnexal mass
~ 45% of patients Pain
Clinical Triad
Bleeding Adnexal mass

45. Clinical presentation
 Location of pain
lower abdominal ~ 74%
generalised abdominal
ipsilateral lower quadrant
contralateral lower abdomen
shoulder tip
back pain
vaginal

46. Risk Factors for Ectopic pregnancy
 High Risk
Tubal surgery
Sterilization
Previous ectopic pregnancy
Use of IUCD
Documented tubal disease
In utero exposure to diethylstilbesterol

47. Risk Factors for Ectopic pregnancy
 High Risk
 Moderate Risk
Infertility
Multiple sexual partners
Previous genital infections
 Slight Risk
Cigarrette smoking
Previous pelvic / abdominal
surgery

48. Pregnancy testing
 Urine pregnancy test
- Sensitive radioimmunoassays are widely available
- +ve at approximately 23 menstrual days (9 days
postconception)

49. Pregnancy testing
 Beta hCG quantitation (serum B hCG)
Normal intrauterine pregnancy
- hCG doubling time of 2 days (66%)
- Intrauterine GS (US Scan) with hCG 1000 – 2000
mIU/ml

50. Pregnancy testing
 Beta hCG quantitation (serum B hCG)
Ectopic pregnancy
- hCG doubling time is different
- hCG doubling time increased
- disproportionately high level of hCG in correlation
ultrasound findings

51. Diagnosis of Ectopic Pregnancy
 Clinical
 Biochemical
 Ultrasound
 Diagnostic laparoscopy ~ GOLD
STANDARD

52. SONOGRAPHY
Early intrauterine pregnancy
 Earliest sign ~ small fluid collection in the
endometrium

53. SONOGRAPHY
 Gestational sac
Early intrauterine pregnancy
intradecidual sign with echogenic ring formed by chorionic villi
double decidua sac sign (DSS)
eccentric to the endometrial cavity
Uterus
Bladder

54. SONOGRAPHY
 Gestational sac
Early intrauterine pregnancy
presence of yolk sac & the embryo
Yolk Sac

55. No identifiable intrauterine GS
 One of three possibilities
- Very early intrauterine pregnancy
- recent spontaneous miscarriage
- Ectopic pregnancy
Bladder
Cervix
Uterus

56. Sites of Ectopic Pregnancy

57. Sites of Ectopic Pregnancy

58. SONOGRAPHY
Ectopic Pregnancy
Empty uterus
Normal ovary
**Normal pelvic sonogram does
not exclude Ectopic pregnancy
~ 26%

59. SONOGRAPHY
Ectopic Pregnancy
Pseudogestational sac
20% of ectopic pregnancy

60. SONOGRAPHY
Ectopic Pregnancy
Uterus
Uterus
Adnexal ring
“doughnut sign”

61. SONOGRAPHY
Ectopic Pregnancy
Uterus
Adnexal mass
Mass

62. SONOGRAPHY
Ectopic Pregnancy
LIVER
LIVER
Kidney
Kidney
Free fluid at Morrison’s
Pouch
Normal

63. MANAGEMENT OF ECTOPIC PREGNANCY
 Surgical option
- Laparotomy VS Laparoscopy
- Salpingotomy VS salpingectomy
• Nonsurgical treatment
- Expectant management
- Metrotrexate
• Combined medical-surgical treatment

64. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY
Laparoscopy VS Laparotomy
A laparoscopic should be the surgical management of
tubal pregnancy, in the haemodynamically stable
patient.

65. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY
Laparoscopy VS Laparotomy
shorter operation times,
less intraoperative blood loss,
shorter hospital stay
lower analgesic requirements

66. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY
Laparoscopy VS Laparotomy
 no difference in overall tubal patency rates
 Similar subsequent intrauterine pregnancy rates
 Lower repeat ectopic pregnancy rates in laparoscopic
approach
 laparoscopic salpingotomy was less successful than an
open approach in elimination of the tubal pregnancy
(higher rates of persistent trophoblast)

67. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY
In haemodynamically unstable, management should be
by the most expedient method.
In most cases, this will be laparotomy.

68. MANAGEMENT OF TUBAL ECTOPIC
Medical Management – Methotrexate
Patient selection :
Compliant
Adnexal mass < 3.5 cm
Beta hCG < 3000 mIU/ml
Absent fetal heart activity
Minimal symptom
 15% of women will require more than one dose of
methotrexate
 7% will experience tubal rupture during follow up.
 75% will experience abdominal pain following treatment

69. MANAGEMENT OF TUBAL ECTOPIC
Medical Management – Methotrexate
 im methotrexate as a single dose
calculated from patient body surface area (50 mg/m2)
- 75 mg and 90 mg.
 Serum hCG levels checked on days four and seven
 a further dose is given if hCG levels have failed to fall > than
15% between day four and day seven.
 < 10% of women treated with this regimen will require
surgical intervention

70. MANAGEMENT OF TUBAL ECTOPIC
Medical Management – Methotrexate
 2 X weekly hCG measurements
(ideally < than 50% of its initial level within seven days)
 weekly transvaginal US examinations (reduction in the size
of adnexal mass by seven days)
 Thereafter, weekly hCG and transvaginal US examinations
until serum hCG levels are < than 20 mIU/ml

71. Pregnancy of unknown location
Conservative Management
 clinically stable women with minimal symptoms
 Beta hCG level < 1500 to 2000 mIU/ml
 44–69% of pregnancies of unknown location resolve
spontaneously with expectant management
- small ectopic pregnancies which were :
spontaneously absorbed or resolved by tubal
abortion.
- early intrauterine pregnancies that miscarried.
 14-28% lead to ectopic pregnancy

72. Remember !!!
Rhesus Negative women
 Nonsensitised women who are rhesus negative with a
confirmed or suspected ectopic pregnancy should receive
anti-D immunoglobulin.

73. WORK-UP FOR ECTOPIC PREGNANCY
Qualitative Beta HCG (UPT)
negative positive
TVS
Pregnancy excluded
Intrauterine pregnancy
(normal / abnormal) No IUP & Tubal mass
No IUP &
stable unstable
No adnexal mass /
Free Fluid
Laparoscopy / Laparotomy
Medical
Follow up

74. WORK-UP FOR ECTOPIC PREGNANCY
Empty uterus & no
adnexal mass / Free fluid
Serum Beta HCG
Serum Beta HCG < 1500
Serum Beta HCG > 1500
Repeat 48 hours later
Laparoscopy
66% or more rise
Rise by < 66% or
condition worsen
Repeat scan in 1 week unless
condition worsen