Bleeding in first trimester -

miscarriage,
non-obstetrical reasons
I trimester
Since conception

To the end of 14th week of gestation (calculated
from the first day of LMP)
I ntensity of bleeding
Spotting (minimal amount of blood, spots on the
underwear)
Bleeding (average amount of blood)
Hemorrhage (life-threatening condition above 1500
ml or 25-35% of total blood volume; more than 150
ml/min)
Non-obstetrical reasons
Trauma (vulva, vagina)
Neoplasms (uterine cervix, vagina, vulva)
Cervical ectopia
Polyps (decidual)
Infections
Coagulation disorders
Diagnosis
Trauma (vulva, vagina)
Neoplasms (uterine cervix, vagina, vulva)
Cervical ectopia
Polyps (decidual)
Infections
Coagulation disorders
History
Speculum (blood, place of bleeding, local status)
Pap-smear, pathology (tissue sampling)
Laboratory tests of coagulation, thrombophilia
Treatment
Trauma - sutures
Antiinflammatory treatment
We do not remove polyps except extremal situations risk of
miscarriage
We do not treat surgically cervical ectopias (antiinflammatory
treatment)
Genital herpes acyclovir per os, local antiviral treatment
Genital warts kryotherapy, curetage
Obstetrical reasons
Miscarriage
Ectopic pregnancy
Hydatiform Mole


Miscarriage (spontaneous aborion)
Definition spontaneous loss of the fetus before 22 weeks of
gestation and before the fetus is able to exist by itself
(independently of weght).
Reasons chromosomal abnormalities, hormonal insufficiency
(progesteron, thyroxin), uterine malformations, homeostatic
disturbancies, maternal diseases (hypertension, autoimmunologic
diseases, diabetes)...
Spontaneous, induced (indications)
Complete, incomplete
In tractu
Threatening
Missed (fetal demise)
Ovum caecum
Recurrent
Types of miscarriages
Implantation of the pregnancy out of the uterine cavity (95% in Fallopian
tube, uterine cervix, ovary, visceral peritoneum)
None of the listed surfaces is covered with decidua, which limits lytic
abilities of the trophoblast. In the consequence the tissues are
destroyed, hemorrhage starts and may cause life-treatening situation.
1-2% of all gestations are ectopic


Ectopic pregnancy
Abnormal development of trophoblastic cells being a result of
abnormal conception (triploid) and having an occurence 1 per
1000 pregnancies.
Hydatiform mole
History
- LMP
- Time of bleeding
- Intensity and character of bleeding
- Abdomen and back pain
- Other symptoms (nausea and vomiting, headache, heart palpitation,
muscular tremor, weakness, fainting)
Bleeding diagnosis
Physical examination
- Overall condition (blood pressure, heart rate)
- Skin colour (pale, yellow)
- Examination with speculum (bleeding assessment, tissue pieces)
- Gynecological examination (size of the uterus, uterine tension, ovaries)
Bleeding diagnosis
Additional tests
- Progesteron level
- Choriogonadotropin level
- Thyroid hormones
- Ultrasound
Bleeding diagnosis
Threatening
abortion
Abortion in
tractu/completed
Hydatiform mole Ectopic
pregnancy
Overall condition Good Good / average Good / average Diversely
Abdominal pain Contractions Contractions Persistent/contractions Persistent, strong
Bleeding Scarce/average Average/heavy,
tissue pieces
Diversely Scarce
Other symptoms No No Vomiting, palpitations Vomiting, fainting
Progesteron Normal/decreased Decreased Normal/increased Decreased
HCG Normal/decreased Decreased Increased Decreased
Differential diagnosis
Bleeding or spotting, abdominal pain.
Gynecological examination:
Uterus of the size corresponding to the LMP, increased tonus of the
uterus (threatening abortion, abortion in tractu);
Uterus smaller than expected (complete or incomplete abortion)
External os closed (threatening abortion, complete abortion, incomplete
abortion when bleeding finished);
Cervix open for 1-2 fingers (abortion in tractu, complete or incomplete)
Miscarriage diagnosis
US:
Gestational sac with live fetus in uterine cavity (threatening abortion)
Gestational sac with dead fetus in uterine cavity (missed abortion)
Gestational sac without fetus in uterine cavity (ovum caecum)
Gestational sac in the uterine cervix (abortion in tractu, ectopic pregnancy)
No gesational sac at all (comlete or incomplete abortion)
Gestational sac out of uterus (ectopic pregnancy)


Miscrriage diagnosis
In threatening abortion hormone supplementation and minimal physical
activity.
In missed abortion, abortion in tractu and incomplete abortion:
Conservative treatment observation (60-85% abortion without medical
intervention)
Farmacological treatment (prostaglandins Mizoprostol)
Instrumental uterine cavity content evacuation (curretage) if requires
cervical dilatation may cause cervical insufficiency in consecutive
pregnancies
Miscarriage treatment
Symptoms:
hyperemesis,
spotting,
quickly growing uterus,
high HCG level,
hypertension,
hyperthyroidism (thyreotoxicosis)
pathognomonic US image (snowstorm)
multiple ovarian cysts like in hyperstimulation syndrome
Hydatiform
mole
Types of hydatiform mole:
- Hydatiform mole (complete and incomplete),
- Invasive mole (limited to hte uterus or with metastases)
- Chorioncarcinoma (limited to the uterus or with metastases)
- Persistent trophoblastic disease
Hydatiform mole
FIGO classification:
I limited to the uterine cavity
II- limited to the genital organs
III metastases to the lungs
IV metastases to other organs
Hydatiform mole
Evacuation of the uterine cavity content (curettage)
Beta-hCG control

In cases of suspition of chorioncarcinoma:
X-ray of the chest
Bones scintigraphy
MRI of the head
Methotrexat therapy
Mole treatment
Thank You