Bleeding in Early Pregnancy

(1st/2nd trimester)
Learning Objectives
• Able to conduct interview and perform clinical examination and elicit
important clinical signs in pregnant women with antepartum
• Able to outline the steps involved in making the diagnosis/differential
diagnosis
• Able to discuss the plan of management
 Patient’s Demographic
Madam Siti Aisah, 36 year-old Malay lady
History of 2 previous LSCS and macrosomic baby
Married, working as admin assistant
G3P2, currently POG 17 weeks + 5 days
LMP: 16/04/2019 (sure of date, regular menses, not on OCP)
EDD: 23/01/2020 (confirm by ultrasound dating in week 9)
 Presenting Complaint
Chief Complaint: per vaginal bleeding for 1 day
- Heard a pop sound and felt a sudden gush of fluid leaking out after prayer at 0630H
- Mixture of fresh blood and watery fluid staining her robes
- Fully soaked 1 pad upon presenting to hospital at 0730H
- Fresh blood. No blood clot.
- No foul smelling liquor. No fever. No UTI symptoms.
- 1st episode of PV bleed in this pregnancy.
- No abdominal pain.
- No history of contact trauma.
- No contraction pain. No quickening/ fetal movement felt yet.
- Not on NSAIDS or anti-coagulant. No gum bleeding, easy brusing, previous menorrhagia.
- No symptom of anemia (SOB, dizziness, palpitation, decrease effort tolerance)
- No changes in bowel or urination habits.
 Antenatal History
- Unplanned pregnancy.
- Intrauterine pregnancy confirmed by ultrasound at week 9. Fetal heart was
shown to mother. EDD was given on 23/01/2020.
- Booked in KK - not anaemic (11.9), normotensive (120/70).
- Weight and height at booking: 158cm and 70kg (BMI 28kg/m2).
- Infective screening: VDRL & HIV test negative, GBS not detected.
- Blood group A positive and antibodies were negative.
- MOGTT was done at 16 week of gestation (31/7/2019) -
• Indications: BMI>27kg/ m2 and history of macrosomic baby
• Result was not diabetic (4.5/6.3)
- Not diagnosed with any thyroid or cardiac disease throughout this
pregnancy.
 Past Obstetric History
- 2007 - Term (41+0) EMLSCS at HKL due to poor maternal progress, 4.0
kg male, alive and well
- 2011 - Term (40+1) EMLSCS at Hospital Serdang due to suspected
macrosomic baby and fail IOL, 4.19 kg female, alive and well
- No GDM or PIH diagnosed before
 Past Gynecological History
- Menarche at 12 years old, regular cycle (30 days), good flow (7days)
- No dysmenorrhea and menorrhagia
- She was not on any oral contraceptive pills and hormonal pills
- Pap Smear done in 2018 and result was normal
Past Medical History:
- No known medical illness
- No other surgical history apart from 2 previous Caesarean section
- No known drug or food allergy

Family History:
- No family history of DM, hypertension and bleeding disorders
- No history of miscarriage in first degree relative
- Mother has history of PV bleed in all pregnancy but was unsure of
onset, duration, quantity and cause.
Social History:
- Married twice 16/12/2006 & 20/08/2018
- Works as a admin assistant at Sunway Medical Center
- Married for 1 year
- Husband work as a operation manager
- Madam Siti does not smoke however husband is a smoker
Physical Examination
Vital signs:
• Non-Invasive Blood Pressure: 133/77 mmHg
• Heart Rate: 80 bpm, normal volume, regularly regular rhythm
• Respiratory Rate: 16 bpm
• Temperature: 36.8 degree Celsius.

General inspection:
• No signs of dehydration, anemia and distress.
Abdominal Examination:
Inspection
• Distended abdomen with gravid uterus as evidenced by striatum
gravidarum.
• Umbilicus was inverted and centrally located.
• Transverse Pfannenstiel incision scar at the suprapubic region well-healed.

Palpation
• Abdomen was soft and non-tender, no guarding and no scar tenderness.
• The uterus size was approximately 18 week.
• Symphysiofundal height 15 cm.
Per Speculum Examination:
• Cervix is healthy with no erosion or polyps
• Os is closed
• Pooling of liquor with blood stain
• No active PV bleed

Lower limbs - no bilateral lower limbs edema, no brisk reflex or clonus

 Summary
Madam Siti Aisah, 36 year-old Malay lady
History of 2 previous LSCS and macrosomic baby
Married, working as admin assistant
G3P2, currently POG 17 weeks + 5 days

Presented with per vaginal bleeding contained of fresh blood mixed

with clear fluid, soaking one pad one hour before presenting to
hospital. No symptoms and signs suggestive of infection, ectopic
pregnancy, trauma, bleeding of external genitilia. No signs of anemia or
dehydrated.
Approach to Vaginal Bleeding in
Pregnancy
 Common Causes of Vaginal Bleed in Pregnancy
1st Trimester (week 1-12) Week 13-20 > 20 week
• Ectopic pregnancy • Miscarriage • Placenta praevi
• Miscarriage • Cervical insufficiency • Abruptio placenta
(threatened, inevitable, • Cervical, vaginal or • Cervical insufficiency
incomplete, complete, uterine lesion • Cervical, vaginal or uterine
missed) • Ectopic pregnancy lesion
• Cervical, vaginal or • Uterine rupture
uterine lesion (eg. • Vasa praevi
polyps, trophoblastic
disease, fibroids)
History
• Severity – details of bleeding (duration, colour, amount, mixture)
• Causes –
❑ Confirmation of intrauterine pregnancy
❑ Passing out of any tissue or seemingly “blood clot”
❑ Severe abdominal pain or cramping
❑ Previous ectopic pregnancy/miscarriage
❑ Infection
❑ Bleeding tendency
• Complications –
❑ Anemia
❑ Dehydration
Physical Examination
• Hypotensive?
• Tachycardic?
• Dehydrated?
• Abdominal tenderness? Guarding?
• Palpable mass? Or larger than expected? (Trophoblastic diseases, molar, fibroid)
• Daptone – look for fetal cardiac activity (>6 week)
• Speculum examination – cervical os opening; vaginal laceration,
neoplasms, warts, inflammation; cervical polyps, fibroids, ectropion
Investigation
• Transabdominal ultrasound
• Transvaginal ultrasound
• Beta-hCG (rise >35% over 48 hours)
• Full blood count
• Coagulation profile
• Inflammatory markers
• Infective screening
 Diagnostic Approach in PV Bleeding in Early Pregnancy
History, P/E and Ultrasound

Intrauterine pregnancy No intrauterine pregnancy

Fetal Cardiac Activity Speculum exam.

finding
No Yes
D/Dx: Speculum exam.
- Non-viable Os closed Os open
finding
pregnancy
(incomplete/missed D/Dx: Complete
Os is closed. Bleeding from
miscarriage) Visible - Ectopic pregnancy miscarriage
uterus
source of - Very early viable or
- Very early viable bleeding in non-viable pregnancy
pregnancy lower Os open Os closed - Complete miscarriage
genital
tract. Threatened Impending
miscarriage miscarriage
 Relevant Investigations
1. Full Blood Count
Unit Ref. Range Flag Result
HGB g/L 120.0-150.0 132
HCT L/L 0.36-0.46 0.4
RBC 1012 /L 3.80-4.80 4.52
MCV fl 77-97 88
MCH pg 27.0-32.0 29.2
MCHC g/L 332
1. 345

RDW % 11.6- 14.0 H 16.6

WBC 109/L 4.0-10.0 8.4
Platelet 109/ L 150-400 201
2. Differential Counts
Unit Ref. Range Flag Result
Neutrophil % 72.5
#Neutrophil 109/L 2.00-7.00 6.09
Lymphocyte % 21.7
#Lymphocyte 109/L 1.00-3.00 1.82
Monocyte % 3.8
#Monocyte 109/L 0.20-1`.00 0.3
Eosinophil % 2.1
#Eosinophil 109/L 0.02-0.50 0.18
Basophil % 0.1
#Basophil 109/L 0.02-0.10 L 0.01
Immature % 1
Granulocyte
3. Coagulation Screening

Unit Ref. Range Flag Result

PT
PT Patient sec 9.4-12.6 10.5
PT Ratio Ratio 1.0-1.2 1
INR INR 1
APTT
APTT- Normal sec 28.0-40.3 34
APTT- Patient sec 28.0-40.3 29
4. Inflammatory Markers
Unit Ref. Range Flag Result
CRP (Serum) mg/L < 5.00 H 7.88

5. STD Culture
Result
Specimen Type Swab
Specimen Source High vaginal Swab
Result in progress

6. Infective Screening
Result
Hep B Ag (HBsAg) Not Detected
Specimen Source High vaginal Swab
7. Transabdominal ultrasound - (17/08/2019) at ED
• Fetal Heart Present
• BPD 273.0 mm
• HC 112.6 mm
• AC 101.5 mm
• FL 168.0 mm
• EFW 1.543g
• Placenta anterior not low
• No obvious retroplacental clot
• Blood clot seen at lower part of uterus above os (3x4cm)
• Impression: Threaten miscarriage with subchorionic hematoma
 - Ectopic pregnancy
Further Management - Miscarriage
Management for Threatened Miscarriage
• No specific management guideline for subchorionic hematoma due to
limited studies.
• For threatened miscarriage,
- Continue with routine antenatal care
- Return for further assessment if bleeding worsen or persist beyond
14 days
 Management for Confirmed Miscarriage
• First line: expectant management for 7-14 days
- If pain and bleeding resolves, indicate miscarriage had completed (return if not)
- Advice to do urine pregnancy test after 3 weeks (return if positive – molar or ectopic)
- Explore more if: increased risk of haermorrhage, previous adverse event in
pregnancy, evidence of infection
• Medical management: 800mg misoprostol (600mg for incomplete miscarriage)
Pain relief and anti-emetics PRN
• Surgical management: manual vacuum aspiration (Drainage and curettage)
Cx: uterine perforation, post-op pelvic infection, cervical trauma, cervical
incompetence
• Counselling
Management for Recurrent Miscarriage
• Defined as loss of 3 or more consecutive pregnancy
• RF: advanced maternal and paternal age, obesity, balanced
chromosomal translocation, uterine structure abnormalities, anti-
phospholipid syndrome (APLS)
• Investigation:
- Antiphospholipid antibodies
- Uterus imaging
- POC send for cytogenic analysis
- Blood karyotyping of both parents
• Management: aspirin, low dose heparin, progesterone, corticosteroids,
metformin
Management for Ectopic Pregnancy
• Expectant management – haemodynamically stable, asymptomatic.
✓Take serial hCG until levels undetectable
• Medical management – minimal symptom, adnexal mass <40mm,
serum hCG <3000IU/L.
✓Methotrexate (50mg/m2), serial hCG on day 4, 7 and 11 then
weekly until undetectable.
✓C/I: chronic liver, renal, haemotological disorders; active infection;
immunodeficiency; breastfeeding
✓Advice not to conceive in 3 months (teratogenic)
• Surgical management – laparoscopy salpingectomy
Salphingostomy only recommended if contralateral tube is absent or visible
damage. Associated with higher rate of subsequent ectopic pregnancy.
 Patient’s Progress
• Madam Siti was managed as inpatient
• Given PO erythromycin ethylsuccinate (EES) 400mg BD
• No more active bleeding on day 2 of admission
• Ordered for departmental scan but was not granted – to come as
outpatient
• Discharged 3 days later with EES 400mg BD to complete 10 days
• To come back immediately if pain, bleed or pass out product of
conception (POC)
• Final diagnosis: 2nd trimester threatened miscarriage with
subchorionic hematoma
Thank you