Bleeding in Early Pregnancy

Chuah Wei Hong

Lee Chun Sian
PV Bleeding in Early Pregnancy
MAIN differential diagnosis are:

Miscarriage
Ectopic pregnancy
Molar pregnancy
Local causes (Benign/Malignant lesions)
Trauma
Miscarriage
Pregnancy that ends spontaneously before the fetus has reached a
viable gestational age (<22weeks, Malaysia). (=<24weeks Ten
teachers)

Also known as Spontaneous abortion

Types of miscarriage
Threatened miscarriage
Inevitable miscarriage
Missed miscarriage
Complete miscarriage
Incomplete miscarriage
Septic miscarriage
General Management of Miscarriage

General
Assessment

Expectant Medical Surgical

Threatened miscarriage

Definition:
Not severe enough to terminate the pregnancy.
Viable pregnancy
BUT up to 50% may proceed to inevitable
miscarriage.
Per vagina bleeding. (Pain)
Closed cervical os.
Management
Ix
Blood- Hb, HCT, ABO, Rh grouping (KIV blood transfusion)
Serial serum hCG (monitor viability of fetus)
Transvaginal Ultrasound
Healthy fetus- well-formed gestation ring with central echoes
Blighted ovum
Loss of definition of the gestation sac
Smaller diameter
Absent of fetal echoes
Absent fetal cardiac movement
Management
Rx
Observation
Bed rest
Pelvic rest (Restrained from any sexual intercourse)
Folic acid supplement (promote fetal development)
Progesterone supplement, Oral Duphaston 10mg (Luteal support)
Cerclage (treat incompetence cervix)
Inevitable miscarriage

Definition:
Continuation of pregnancy is IMPOSSIBLE.
Per vagina bleeding + pain
Opened cervical os.
Management
Ix
FBC
Transvaginal Ultrasound (Gestational sac seen with/without fetus
(with/without cardiac movement)

Principle of Management
To maintain the general condition of the patient
To accelerate expulsion
To maintain strict asepsis
Management
Rx
IV fluid or blood transfusion (in shock)
Ergometrine/syntometrine 0.2mg (if the cervix is dilated and uterine size<12
weeks; to control excessive bleeding)
Management
Active treatment
Before 12 weeks:
Dilatation and curettage (D&C) under general anaesthesia (effective and safe).
Alternatively suction evacuation followed by curettage may be employed.
After 12 weeks:
The uterine contraction is accelerated by oxytocin drip (10 units in 500 ml of 5%
dextrose) 40-60 drops per minute. If the fetus is expelled and the placenta is
retained, it is removed by ovum forceps, if lying separated. If the placenta is not
separated, digital separation followed by its evacuation is to be done under general
anaesthesia.
If the bleeding is profuse with the cervix closed (suggestive of low implantation of
placenta) evacuation of the uterus may have to be done by abdominal hysterotomy
Missed Miscarriage

Definition:
Retention of dead fetus inside the uterus for a
period of time.
No fetal heartbeat
No expulsion of POC.
C.F. : Intermittent vaginal bleeding
Management
Ix
Transvaginal ultrasound
Empty gestational sac/ crumpled
If fetal pole present- no sign of activity
Blighted ovum
Management
Uterus less than 12 weeks:
Expectant management- many women expel the conceptus spontaneously.
Medical management- misoprostol vaginally.
Suction evacuation or dilation and evacuation - high risk of uterine damage
and haemorrhage.

Uterus more than 12 weeks:

Induction by:
Misoprostol 200 g tablet inserted into the posterior vaginal fornix.
Oxytocin.
Otherwise ERPC should be done.
Incomplete Miscarriage

Definition:
Incomplete: Some parts of POC retained inside
the uterus.
Os remains opened.
May or may not see the POC located at the os.
Management
Ix
FBC- Baseline, Blood GXM
Transvaginal ultrasound
Retained products of conception
Rx
IV fluid, blood transfusion (stabilize the haemodynamic status)
Ergometrine 0.5mg IM (control bleeding)
Evacuation of the retained product of conception (ERCP) under GA.
Complete miscarriage

Definition:
POC is expelled out completely.
Os is closed.
Management
Ix
FBC- Baseline, Blood GXM
Transvaginal ultrasound (empty uterus)

Rx
IM Anti-D gamma globulin 50 g or 100 g (For Rh-negative mother)
Curettage (do not miss incomplete miscarriage)
Send product of conception to verify intrauterine pregnancy
Observe for any further bleeding or sign of infection
Septic miscarriage

Definition:
Any miscarriage associated with clinical evidence of
infection of the uterus and its contents.
Management
Ix
cervical/ high vaginal swab - culture in aerobic and anaerobic media,
sensitivity of the microorganisms to antibiotics, and smear for gram stain.
blood- hemoglobin, white cells, ABO and Rh grouping.
Urine analysis and culture
Pelvic and abdominal ultrasonography
Detect retained product of conception
Free fluid in the pouch of Douglas
Management
Rx
IV fluid, blood transfusion
Broad spectrum IV antibiotics (anaerobic coverage: IV clindamycin,
carbapenem, piperacillin, tazobactam)
D & C when patient is stable
Ectopic Pregnancy
Definition
implantation of a conceptus outside the normal uterine cavity.

Common sites of implantation

Fallopian tubes (95 per cent)
-> ampulla (74 per cent)
-> isthmus (12 per cent)
-> fimbrial end of the tube (12 per cent)
-> interstitium (2 per cent)
ovaries (3 per cent)
peritoneal cavity (1 per cent).
Investigation
1. Haemoglobin level
2. bHCG level
3. Transvaginal ultrasound scan (TVS) -> Identification of an intrauterine
pregnancy (gestation sac, yolk sac along with fetal pole) excludes the
possibility of an ectopic pregnancy, presence of free fluid during TVS is
suggestive of a ruptured ectopic pregnancy.
4. Laparoscopy -> diagnose and treat ectopic pregnancy
Management
Expectant
1. assumption that some tubal pregnancies will resolve through regression or a tubal abortion
without any treatment.
2. for patients who are haemodynamically stable and asymptomatic

Medical
Systemic methotrexate (folic acid antagonist)
-> inhibits DNA synthesis in trophoblastic cells
-> single intramuscular injection or in a multiple fixed dose regimen.
-> Dose -> 50 mg/m2.
-> indications -> (1) cornual pregnancy; (2) persistent trophoblastic disease; (3) patient with
one Fallopian tube and fertility desired; (4) refuses surgery / high risks of surgery; (5)
trophoblast is adherent to bowel or blood vessel
-> contraindications -> (1) chronic liver, renal or haematological disorder; (2) active infection;
(3) immunodeficiency; and (4) breastfeeding.
-> side effects -> nausea, vomiting, stomatitis, conjunctivitis, gastrointestinal upset,
photosensitive skin reaction, nonspecific abdominal pain.
-> avoid sexual intercourse during treatment
-> contraception for three months after methotrexate treatment.

Surgical management
1. laparoscopy -> mainstay of management
-> less blood loss, shorter operating time, less analgesia requirement, shorter hospital stay,
shorter convalescence

2. Laparotomy -> for severely compromised patients

-> salpingectomy / salpingotomy
-> Salpingotomy -> higher rate of subsequent ectopic pregnancy.
Molar Pregnancy
Definition
-> abnormal pregnancies characterized histologically by aberrant changes within the placenta.
-> categorized as either complete hydatidiform moles or partial hydatidiform moles

Complete Hydatidiform Mole

1. Diploid karyotype -> 85 to 90 percent o cases are 46,XX. The ovum fails to contribute
chromosomes.
2. Microscopically -> enlarged, edematous villi and abnormal trophoblastic proliferation.
3. Macroscopically -> clusters of vesicles -> bunch of grapes appearance, no fetal tissue or
amnion is produced
4. Clinically -> vaginal bleeding, anemia, uterine sizes in excess of that predicted or their
gestational age, hyperemesis gravidarum, preeclampsia, and theca-lutein cysts
5. infrequently present today as a result o -hCG testing and sonography
Partial Hydatidiform Mole
1. differ from complete hydatidiform moles clinically, genetically, and histologically.
2. most partial moles contain fetal tissue and amnion, in addition to placental tissues.
3. present with signs and symptoms of an incomplete or missed abortion -> vaginal bleeding
4. Preevacuation -hCG levels -> lower than complete moles
Diagnosis
Clinical Assessment
1. In reproductive-aged women with vaginal bleeding, diagnoses may include gynecologic
causes of bleeding and complications of first-trimester pregnancy.

Laboratory Investigation
1. urine or serum -hCG level
2. serum free thyroxine level -> elevated in complete moles (thyrotropin-like effect of -hCG
3. transvaginal sonography
-> complete moles -> complex, echogenic, intrauterine mass containing many small
cystic spaces, which reflect swollen chorionic villi. Fetal tissues and amnionic sac are
absent
-> partial moles -> thickened, hydropic placenta with a concomitant fetus
Histopathology
1. complete moles -> two prominent features:
(1) trophoblastic proliferation
(2) hydropic villi.

2. Partial moles -> three or four major diagnostic criteria:

(1) two populations of villi
(2) enlarged, irregular, dysmorphic villi (with trophoblast inclusions)
(3) enlarged, cavitated villi ( 3 to 4 mm)
(4) Syncytiotrophoblast hyperplasia/atypia

Ancillary Techniques
Histopathologic evaluation can be enhanced by immunohistochemical staining or p57
expression and by molecular genotyping.
Treatment
1. Suction curettage -> wish to remain fertile
2. Hysterectomy -> wishes surgical sterilization, approaching menopause
3. Symptomatic theca-lutein ovarian cysts -> wait for regression or
aspirated
4. blood products and adequate infusion lines -> prior to the evacuation
of larger moles -> tremendous vascularity of these placentas
5. Rh immune globulin is given to nonsensitized Rh D-negative women.
Management of Late
Pregnancy Bleeding
Causes of Late Pregnancy Bleeding
1. Uterine rupture
2. Vasa praevia
3. Placenta praevia
4. Abruptio placenta
Uterine rupture
 Impending rupture
Contraction pain Impending rupture sign and symptom

No tenderness *Scar tenderness / vaginal bleeding

intermittent Continous pain

Abdominal examination : high presenting

part and obvious fetal part on palpation
Vital signs stable Maternal Hypotension

Normal CTG *CTG : Fetal tachycardia

Continous cervical dilatation together *Failure of cervical dilatation despite

with regular uterine contraction regular uterine activity

*- warning sign of pending rupture

Avoid : hyperstimulate scarred uterus
Management
PROPHYLAXIS
1. Identification mother with the risk factor
a) Contracted pelvis
b) Previous history of cesarean section, hysterotomy or myomectomy
c) Uncorrected transverse lie
d) Grand multiparity
2. Multipara with delay labour should raise concerned
3. Judicious selection of cases with previous history of cesarean sections for
vaginal delivery
4. Judicious selection of cases and careful watch are mandatory during oxytocin
infusion either for induction or augmentation of labor.
5. Attempted forceps delivery or breech extraction through incompletely dilated
cervix should be avoided.
Vasa praevia
Definition : exposed fetal vessels traverse the amniotic membranes between the
babys presenting part and the internal cervical os, unprotected by placental
tissue or umbilical cord
Investigation
Diagnostic test
1) Color flow Doppler helpful for antenatal diagnosis
2) Apt test (alkaline denaturation test)
1) Positive : Hb appear pinkish in colour under microscope suggestive of
fetal blood
Management
Depends on : fetal gestational age , severity of bleeding , persistence
or recurrence of bleeding
Confirmed vasa praevia antenatal admission 28-32 weeks of
gestation , administration of steroid and elective caesarean section
Confirmed vasa praevia at term elective caesarean section
If rupture
1. Iv fluid and blood transfusion ( ix for FBC , coagulation profile , CXM)
2. Fetal and maternal monitoring
3. emergency caesarean delivery is a definite management.
MANAGEMENTS OF
PLACENTA PREVIA
NG ELSON
1001439090
Prevention
Adequate antenatal care.

Antenatal diagnosis (ultrasound).

Significance of warning hemorrhage should not be ignored.

Colour flow Doppler USG

Indicated to detect any placenta accreta
Admission to Hospital
ALL cases of APH, even if the bleeding is slight or absent by
the time the patient reaches the hospital, should be
admitted.

Reasons:
All the cases of APH should be regarded as due to placenta previa
unless proved otherwise.
The bleeding may recur sooner or later and none can predict when
it recurs and how much she will bleed.
Treatments

Immediate attention

Formulation of the line of treatment

Expectant management
Active (definite) management
Immediate Attention
Overall assessment
Amount of blood loss (general condition, pallor, pulse rate, b/p)
Blood samples (cross matching, hemoglobin)
A large-bore IV cannula is sited and an infusion of normal saline
Gentle abdominal palpation (uterine tenderness, auscultate fetal heart rate)
Inspection of vulva (active bleeding)

Confirmation: history, PE and sonographic examination.

Expectant Management
Policy by Macafee and Johnson (1945), in an attempt to
improve the fetal salvage without increasing undue maternal
hazards.

Aim: to continue pregnancy for fetal maturity without

compromising maternal health.
 Vital prerequisites:
Availability of blood for transfusion whenever required.
Facilities for cesarean section should be available throughout 24
hours, should it prove necessary.

Selection of cases:
Mother is in good health status (Hb 10 g%; hematocrit > 30%)
Duration of pregnancy < 37 weeks
Active vaginal bleeding is absent
Fetal well-being is assured (CTG, USG)
 Conduct of expectant management:
1. Bed rest with bathroom and toilet privileges.
2. Investigations Hb, blood grouping, urine for protein.
3. Periodic inspection of vulval pads and fetal surveillance with USG at interval
of 2-3 weeks.
4. Supplementary hematinics and blood transfusion (if anemic).
5. When the patient is allowed out of bed (2-3 days after bleeding stops), a
gentle speculum (Cuscos) examination is made to exclude local cervical and
vaginal lesions for bleeding. However, the presence does not negate
placenta previa.
6. Use of tocolysis (magnesium sulfate) if vaginal bleeding is associated with
uterine contractions.
7. Use of cervical cerclage to reduce bleeding and to prolong pregnancy is not
helpful (RCOG 2005).
8. Rh immunoglobin should be given to all Rh negative (unsensitized) women.
 Can be managed at home if:
Patient lives close to hospital.
24-hour transportation is available.
Best rest is assured.
Patient is well motivated to understand the risks.

Termination of expectant treatment: the expectant

treatment is carried up to 37 weeks of pregnancy.
 However, preterm delivery may have to be done when:
Recurrent of brisk hemorrhage and which is continuing
Fetus is dead
Fetus is found congenitally malformed on investigation

Repeated small bouts of hemorrhage is NOT an indication for

termination of expectant treatment.

Steroid therapy in preterm delivery. (Betamethasone)

Active (Definite) Management - Delivery
Indications:
Bleeding occurs at or after 37 weeks of pregnancy.
Patient is in labour.
Patient is in exsanguinated state on admission.
Bleeding is continuing and of moderate degree.
Baby with nonreassuring cardiac status or dead or known to be
congenitally deformed.
1. Cesarean delivery
When there is sonographic evidence of placenta previa where
placental edge is within 2cm from the internal os.

2. Vaginal delivery
Where placenta edge is clearly 2-3 cm away from the internal
cervical os.
 Vaginal examination should be done with a double set up
arrangement in the operation theater keeping everything
ready for cesarean section.

Contraindications:
Patient in exsanguinated state.
Diagnosed cases of major degree of placenta previa confirmed by
USG.
Associated complicating factors such as malpresentation, elderly
primigravidae, pregnancy with history of previous cesarean
section, contracted pelvis, etc. which themselves are indications
for cesarean section.
 Precautions during vaginal delivery:
All possible steps should be taken to restore the blood volume.
Oxytocin 10 IV/IM/methergine 0.2mg should be given IV with the
delivery of the baby to prevent blood loss in 3rd stage.
Proper examination of the cervix should be done soon following
delivery to detect any evidences of tear.
Babys blood hemoglobin level is to be checked and if necessary
arrangements are to be made for blood transfusion.
MANAGEMENT OF
ABRUPTIO PLACENTAE
NG ELSON
1001439090
Prevention
Aims:
Elimination of the known factors likely to produce placental
separation.
Correction of anemia during antenatal period so that the patient
can withstand blood loss.
Prompt detection and institution of the therapy to minimize the
grave complications namely shock, blood coagulation disorders
and renal failure.
 Prevention of known factors:
Early detection and effective therapy of preeclampsia and other hypertensive
disorders of pregnancy.
Needle puncture during amniocentesis should be under ultrasound guidance.
Avoidance of trauma specially forceful external cephalic version under
anesthesia.
To avoid sudden decompression of the uterus in acute or chronic
hydramnios, amniocentesis is preferable to artificial rupture of the
membranes.
To avoid supine hypotension the patient is advised to lie in the left lateral
position in the later months of pregnancy.
Routine administration of folic acid from the early pregnancy of doubtful
value.
Treatment
Assessment:
Amount of blood loss
Maturity of the fetus
Whether the patient is in labor or not (usually labor start)
Presence of any complication
Type and grade of placental abruption (revealed, concealed, mix)

Emergency measures:
Blood (Hb, hematocrit, coagulation profile, ABO and Rh, urine for protein)
Ringers solution drip and arrange for blood transfusion
Close monitoring
Treatment
Immediate delivery

Management of complications

Expectant management (rare)

Definitive Treatment Immediate Delivery
Patient in labor
Vaginal delivery in cases with:
Limited placenta abruption
FHR tracing is reassuring
Facilities for continuous (electronic) fetal monitoring is available
Prospect of vaginal delivery is soon
Placental abruption with a dead fetus
Advantages of amniotomy:
Initiates myometrial contraction and labor process
Expedites delivery
Better compression of spiral artery to arrest hemorrhage
Reduces entry of thromboplastin into maternal circulation and thereby reduces the risk
of renal cortical necrosis and DIC
 Patient not in labor:
Bleeding continues
> Grade I abruption:
Delivery by induction of labor or cesarean section

Induction of labor is done by low rupture of membranes.

Oxytocin may be added.
Placenta with varying amount of retroplacental clot is expelled most often
simultaneously with the delivery of the baby.
Inj. Oxytocin 10. IU IV (slow) or IM or Inj. Methergine 0.2 mg IV is given to
minimize postpartum blood loss.
 Cesarean section indications:
Severe abruption with live fetus.
Amniotomy could not be done (unfavorable cervix).
Prospect of immediate vaginal delivery despite amniotomy is remote.
Amniotomy failed to control bleeding.
Amniotomy failed to arrest the process of abruption (raising fundal height).
Appearance of adverse features (fetal distress, falling fibrinogen level,
oliguria).

Regional anesthesia is generally avoided when there is significant

hemorrhage to avoid profound and persistent hypotension.
Expectant Management
Is an exception and not the rule.

Cases where bleeding is slight and has stopped (Grade I), fetus reactive (CTG) and remote from
term may be considered.

Goal is to prolong the pregnancy.

Continuous electronic fetal monitoring is maintained.

Patient should be observed in the labor ward for 24-48 hours to ensure no further placental
separation is occurring.

Betamethasone is given to accelerate fetal lung maturity in the event preterm delivery.
Management of Complications

Complications:
Hemorrhagic shock
DIC
Renal failure
Uterine atony and postpartum hemorrhage