Bleeding in Early Pregnancy: P. Bwalya

BLEEDING IN
EARLY
PREGNANCY

P. BWALYA
INTRODUCTION
Vaginal bleeding during pregnancy is
abnormal. 
It is a cause of concern to mothers,
particularly those who have had a previous
experience of fetal loss.
Any reports of bleeding should be viewed
seriously by the midwife.
If the woman presents with a history of
bleeding in the current pregnancy, it is
important to establish when it occurred.
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INTRODUCTION
CONT’D

How much blood was lost, the colour of the
loss and whether it is associated with any
pain should be noted.
If the symptoms have subsided it is
important to advise the mother to report any
recurrence.
Assessment of fetal condition will depend on
gestation.
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If the symptoms have subsided it is
important to advise the mother to report any
recurrence.

Assessment of fetal condition will depend on
gestation.
Ultrasound scanning can confirm viability of
the pregnancy before heart sounds are
audible or movements felt.
 In the second trimester, the use of ultra
sound equipment can elicit the heart sounds,
note of fetal movements may also be made.
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IMPLANTATION
BLEEDING

 As the trophoblast erodes the endometrial
epithelium and the blastocyst implants, a small
vaginal blood loss may be apparent to the woman.
 It occurs around the time of expected menstruation,
and may be mistaken for a period, although lighter.
 It is of significance if the estimated date of delivery
is to be calculated from menstrual history.
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ABORTION (S)

DEFINITION (S)

Abortion is defined as the termination
of pregnancy by the removal or
expulsion from the uterus of a fetus
or embryo prior to viability before 28th
Week gestation in Zambia (MOH,
2001).
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CONT

Abortion is expulsion or extraction
from its mother of an embryo or fetus
weighing 500g or less (WHO, 2004).
Abortion is an expulsion of products of
conception before the 28th week of
gestation and before viability of the
fetus (Hossan 1982)
CLASSIFICATION

An abortion can either be induced or
spontaneous
Induced abortions may be
therapeutically indicated or elective
that is for either social or personal
reasons

CONT.

Spontaneous Abortion also known as
Miscarriage is defined as the
involuntary loss of products of
conception prior to 26 weeks (Cooper &
Frazer 2006).

CAUSES

There are various causes of abortion. The
common causes are as follows:
I. Maternal Causes:
These include the following maternal
influences:

CONT.

Maternal Age – age ≥ 30 years is a high
risk because of degenerative changes.
Maternal infections – Bacteria, viruses
and parasites invade the placenta and
cause degeneration (commonest are,
Toxoplasmosis, cytomegalovirus,
syphilis, Chlamydia and malaria)
CONT.

Structural abnormalities of the genital
tract – Retroversion of the uterus,
bicornuate uterus, unicornuate uterus
and fibroids hinder the growth of the
fetus.

CONT.

Maternal diseases – conditions such as
anaemia, hypertension, renal diseases,
and cardiac diseases lead to placental
insufficiency.

CONT.

Endocrine abnormalities
 Poor development of the corpus
luteum leads low serum progesterone
levels
Incompetent cervix
Failure of cervix to contain the weight
of the growing fetus.
CONT.

 May be caused by previous induced
abortions and congenital cervical
defects.
Stress and anxiety this is due to the
effects of stress hormones which cause
vasoconstriction leading to reduced
blood supply to the fetus.
CONT.

Environmental/ social factors –
Caffeine from coffee, nicotine from
cigarette smoke cause vasoconstriction
leading to poor placental and fetal
perfusion causing abortion.
Alcohol consumption leads to maternal
malnutrition.
CONT.

Exposure to organic solvents such as
lead and radiation.
Foetal Causes
Malformation of the conceptus- due to
chromosomal abnormalities accounts
for 50% of abortion cases.

CLINICAL TYPES

Spontaneous
Threatened
Inevitable
Complete
Incomplete
Septic
Missed
CONT.

Habitual
Induced
Therapeutic
Septic
Complete
Incomplete



INVESTIGATIONS

History
History of being pregnant - ask
woman about her LMP to confirm
pregnancy and its duration.
Ask about the amount of bleeding and
how many times she has changed her
pads to rule out haemorrhagic shock.
CONT.

Severity of the lower abdominal
cramping as it can be a sign of pending
abortion.

CONT.

Blood tests
Gravidex test confirms pregnancy by
presence of HCG which is used as a
basis for pregnancy test.
It is produced by the placenta and is
present in maternal serum from 8 to 10
days after fertilization.
CONT.

It prevents normal involution of the
corpus luteum at the end of the
menstrual cycle, if at 11 weeks, the
levels of HCG are low, spontaneous
abortion can result.
It is highest at 14 weeks and reduces
later in the second trimester.
CONT.

Blood for culture and sensitivity will
confirm the increased leucocytes, the
causative organism and its sensitivity if
there is sepsis.
Full blood count may show reduced
hemoglobin due to haemorrhage and
increased leucocytes count if there is
infection.

CONT.

Ultra sound examination
A confirmatory test that will reveal:
Gestational sac which will show that
the patient was pregnant or has
products of conception.
 If the gestation sac is empty, it signifies
that the patient has an incomplete
abortion.
CONT.

Absence of fetal heart sounds will
signify intrauterine fetal death as in
missed abortion


SPONTANEOUS
ABORTION
THREATENEDABORTION


Threatened abortion is diagnosed
when a pregnant woman presents with
slight bleeding through an undilated
cervix (Sellers, 2008).

CONT.


Any vaginal bleeding in early
pregnancy should be thought of as a
threatened abortion until confirmed by
abdominal scanning which can show
the exact type of abortion.
With good management the chances of
the fetus to remain viable and the
pregnancy to continue are high.
SIGNS & SYMPTOMS

History of amenorrhea
Signs of pregnancy present
Height of fundus corresponds with
dates
With or without backache and lower
abdominal pains resembling
dysmenorrhoea
CONT.

Vaginal bleeding may be scanty
Cervical OS closed and the uterus is
soft, with no tenderness when
palpated.
Pregnancy test is positive.

IMMEDIATE MANAGEMENT

History and physical examination is
important to rule out the presence of
pregnancy.
Vital signs such as temperature should
be done half hourly to rule out
infection.

CONT.

Blood pressure is taken hourly to rule
out haemorrhagic shock when there is
hypotension.
 Rapid and feeble pulse will also
signify shock. Increased respiratory
rate will signify pain.

CONT.

Bed rest is the most important form of
treatment.
The patient should remain in bed for 5-
7days or for as long as blood is bright
Bed rest increases blood flow to the
placenta and reduces pain.

CONT.

Give mild sedatives e.g.
phenobarbitone 60mg 8hourly to
enable patient rest in bed.
If uterine contractions become stronger,
analgesics such as pethidine100mg
intramuscularly or morphine 15mg
may be administered.
CONT.

Pads should be saved in order to help
assess the amount of blood loss.
 Report any increase in bleeding or
pain to the doctor for further
management.

INEVITABLE ABORTION

An abortion is inevitable when the
pregnancy can no longer continue
(sellers 2008).
 In inevitable abortion, the cervix is
dilated and products of conception are
yet to be expelled.

SIGNS & SYMPTOMS

History of amenorrhea.
Signs and symptoms of pregnancy
present.
Amniotic membranes may be felt
bulging into the cervical canal or may
be already ruptured.

CONT.

Cramping Lower abdominal pains and
backache.
The Cervical os is dilated (os is open).
 Tissues (products of conception), clots
may be seen in the vagina or
protruding though the os.
Vaginal bleeding may be excessive.
CONT.

In some cases the mother may present
with signs of shock because of severe
bleeding.

MANAGEMENT

If pregnancy is less than 16 weeks:
 Plan for evacuation of uterine
contents. If evacuation not immediately
possible;
Give ergometrine 0.2 mg IM (repeated
after 15 min. if necessary) OR
misoprostol 400 µg by mouth.
CONT.

Arrange for evacuation as soon as
possible.
If pregnancy is greater than 16 weeks:
Await spontaneous expulsion of
products of conception and then
evacuate uterus to remove any
remaining products of conception
CONT.

If necessary, infuse oxytocin 40 units in
1 L IV fluids at 40 drops/min. to help
expulsion of products of conception.
Ensure follow up after treatment.

COMPLETE ABORTION

An abortion is complete when all the
products of conception, which is the
embryo or fetus and the placenta with
intact membranes, are expelled from
the uterus (Sellers 2000).

SIGNS & SYMPTOMS

Signs and Symptoms of pregnancy
regresses
Abdominal pains and backache subside
steadily.
Uterus firm and well contracted

CONT.

History of passage of the products of
conception
An empty cavity is seen on ultrasound
examination
Diminishing or Minimal bleeding per
vagina
Cervical os closed.

Rest in bed, if possible with sedation.
Evacuation of the uterus is usually not
necessary.
Observe for heavy bleeding.
Curettage only needed if bleeding
persists.

CONT.

Check Hb after 24hours in case of
severe anemia due to severe bleeding.


INCOMPLETE ABORTION

Is one in which part of the products of
conception, usually the fetus is passed
while the placenta and membranes are
retained (Sellers 2008).
 The cervix is usually open.

CONT.

There is usually profuse bleeding as the
uterus cannot contract and retract
effectively due to the products of
conception being retained in utero.
Incomplete abortion when unattended
to causes fatal complications.

SIGNS & SYMPTOMS

History of amenorrhea.
Severe and Cramping lower abdominal
pains and backache.
Abdomen soft, height of fundus does
not correspond with dates.
The uterus may feel bogg and not well
contracted.
CONT.

Heavy and profuse vaginal bleeding
Passage of some products of
conception usually the fetus and the
placenta and membranes are retained,
some tissue may be present at the
cervical OS.

CONT.

Signs of shock such as cold clammy
skin, thread pulse, hypothermia,
hypotension may be seen.


Before 16 weeks Gestation;
If bleeding light to moderate, use
sponge holding forceps to remove
products of conception protruding
through cervix.
If bleeding heavy, evacuate uterus:

CONT.

Manual vacuum aspiration (MVA) is
preferred method, evacuation by sharp
curettage should only be done if MVA
not available

CONT.

After 16 weeks Gestation;
Infuse oxytocin 40 units in 1 L IV fluids
at 40 drops/min. until expulsion of
products of conception occurs.
Evacuate any remaining products of
conception from uterus by dilatation
and curettage.
CONT.

If necessary, give misoprostol 200 µg
vaginally every 4 hours until expulsion,
but do not administer more than 800 µg
Replace blood if necessary or if the
hemoglobin level is below 5grams.
Antibiotics to prevent infection.

CONT.

If patient is in shock start a plasma
expander for example dextran 50%,
drip after taking blood for grouping
and cross-matching.
Give ergometrine 0.5mg
intramuscularly.

CONT.

Once these steps have been taken the
condition usually improves and the
patient can safely be transferred to
hospital.
Ensure follow-up of a woman after
treatment.

CONT.

NOTE: Never transfer patient with
haemorrhagic shock to the hospital;
Resuscitate first to prevent
complications.

MISSED ABORTION

This occur when the fetus dies and is
retained in utero, together with the
placenta and membranes (Ladewig
1996).

SIGNS & SYMPTOMS

Signs of pregnancy disappear
Height of fundus less than expected
because the uterus does not grow.
Brownish vaginal discharge.
Cervical OS closed.

CONT.

There is no pain.
Fetal movements if felt before ceases.
Fetal heart cannot be heard by either
fetoscope or doppler
Pregnancy test usually is negative


A uterine evacuation is performed if
the patient is less than 16 weeks
pregnant.
 If the patient is more than 16 weeks
pregnant, an oxytocin or prostaglandin
infusion is erected to expel the fetus.

CONT.

If the condition of missed abortion
persists for over 6-8 weeks,
disseminated intravascular coagulation
(DIC) disorders can occur, therefore,
weekly blood samples are taken so that
estimates of plasma fibrinogen can be
made.
CONT.

DIC comes about when a dead foetus is
retained in utero for more than 3 to 4
weeks.
Thromboplastins are released from the
dead foetal tissues.
These enter the maternal circulation
and deplete clotting factors.
BLOOD MOLE

This condition arises in cases of missed
abortion.
The ovum dies in utero, and the
decidua capsularis remains intact.
The zygote is surrounded by layers of
blood, due to bleeding between the
gestational sac and the uterine wall.
CONT.

It usually occurs before the 12th week of
gestation.
The signs of pregnancy disappear and
there is a brown discharge present.
When fluids drain from the blood
mole, the fleshy, firm, hard mass which
is left, is known as a carneous mole.

An evacuation of the uterus is
performed if it is diagnosed before 12
weeks, and oxytocics or prostaglandins
are used to abort the mole if the
condition is diagnosed after the 12th
week of pregnancy.

HABITUAL ABORTION

 Also called recurrent abortion or recurrent
pregnancy loss (RPL).
 This is when the patient has experienced 3 or more
consecutive spontaneous abortions, usually after
14weeks of gestation (Ladewig 1996).

CONT.

There is usually no obvious cause but
the commonest predisposing factors are
uterine abnormalities and cervical
incompetence.
 Diabetes mellitus also can cause
recurrent abortions if not well
managed.
CONT.

These women should always be
referred to the hospital.
To enable the cervix hold the weight of
the growing foetus and ensure
sustenance and viability of the
pregnancy, the doctor can insert a
shirodkar suture

INDUCED
ABORTION

INDUCED ABORTION

Can either be;
Therapeutic abortion, or
Criminal abortion leading to septic
abortion.


THERAPEUTIC ABORTION

A therapeutic abortion is one in which
the uterus is evacuated by a qualified,
trained medical doctor, for a valid
medical reason (Sellers 2008).
 Therefore this procedure must only be
performed in the interest of the
mother’s life and her total well- being.
04/18/2020THE THIRD P.BWALYA (RUSANGU 2017) 77
CONT.

It can also be done if there is increased
chance of gross fetal abnormalities.
It is only carried out in a hospital
where haemorrhage can be effectively
controlled, resuscitative facilities are at
hand and where strict aseptic measures
are always taken.
CONT.

The consent of the medical
superintendent of the hospital is
required by law, as well as the consent
of the patient and her husband or
guardian if she is less than 18 years.


Evacuation of the uterus if pregnancy
is less than 16 weeks done under strong
analgesia given before the procedure,
 if the pregnancy is more than 16 weeks
oxytocin and cytotec is given to expel
the products of conception.
Psychological care is given throughout
the procedure to gain cooperation.
CONT.

Complete bed rest is essential.
Observe the blood loss through pad
count to assess the amount of blood
loss to prevent shock.
Drugs like benzypenicillin, gentamycin
and metrodidazole are given to combat
and prevent infection.
CRIMINAL ABORTION

This is an abortion which is illegally
procured (Sellers, 2008).
It is usually performed by a qualified
person, possibly under unhygienic
conditions.

CONT.

Methods like use of herbal medicine
taken orally or inserted in the vagina
and use of sharp objects introduced
from the vagina to the uterus with an
intention of disturbing the uterine
environment to induce abortion.

CONT.

This type of abortion can lead to
incomplete or septic abortions.
 If it is incomplete then it should be
treated as incomplete abortion as
described above with an antibiotic
cover to combat infection.
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SEPTIC ABORTION

A Septic abortion can follow any
incomplete abortion, but is more often
associated with a criminal abortion
(Sellers, 2008).
Therefore if infection is disseminated
into the systemic circulation is called
septic abortion.

CONT.

Any abortion where aseptic techniques
are not followed can lead to sepsis.

SIGNS & SYMPTOMS

History of abortion usually unsafe
abortion
General discomfort
Pyrexia usually >38°C,
Headaches
Tachycardia
CONT.

Severe pain around the supra pubic
region.
Uterus bulky and very tender on
palpation
Foul smelling vaginal discharge
usually profuse.
Jaundice is often present.

CONT.

Cervical OS open and products of
conception may be felt in the cervical
canal.
Chills and fever signifies serious
infection.
Cervical motion elicits severe
tenderness.

CONT.

Generalized abdominal tenderness
with rebound tenderness, rigidity or
distension are signs of spreading
peritonitis.
Patient feels weak and seems extremely
ill.


Treatment of these patients with septic
abortion is an emergency as delay may
result in severe complications or death.
Patients should be managed in the
hospital if possible; however treatment
should be instituted as soon the
diagnosis is made.
CONT.

Most serious complication of septic
abortion is septic shock characterized
by hypotension with tachycardia,
normal or subnormal temperature.
Therefore the following should be
instituted.
Resuscitate with intravenous fluids in
order to replace lost fluids.
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CONT.

Give parenteral broad spectrum
antibiotics to combat infection.
Take a cervical swab for culture and
sensitivity before starting antibiotic
treatment
Blood transfusion can be given in cases
of low hemoglobin (5g/dl).

CONT.

Evacuation of the uterus should be
instituted immediately resuscitation is
complete.
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Bleeding in Early Pregnancy: P. Bwalya

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