Early Pregnancy Bleeding

CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.
WHAT IS THE LIKELY DIFFERENTIAL DIAGNOSIS?
Miscarriage
Ectopic Pregnancy
Molar Pregnancy
Six weeks of amenorrhoea and a positive pregnancy
test,after regular menstrual cycles,indicate an early
pregnancy .These small amount of bleeding is a sign
that the patient is threatening to have a miscarriage.
MISCARRIAGE
Is pregnancy loss below 20 weeks
ABORTION
 Aetiology
Chromosomal abnormality
 Trisomies (Down’s syndrome)
 Triploidies and tetraploidies
 Monosomy X (Turner’s syndrome)
 Translocation (hereditary)
 Aetiology
Endocrine Disorder
 Diabetes
 Hypothyroidism
 Luteal phase deficiency
 Polycystic ovarian syndrome
 Aetiology
Abnormalities of the uterus
 Uterine septa (bicornuate uterus)
 Endometrial adhesions (post
curettage or Asherman’s syndrome)
 Aetiology
Others
 Tobacco, anaesthetic gases, arsenic, benzene,
solvents, ethylene oxide, formaldehyde, pesticide,
lead, mercury, cadmium
 Psychological disorders
 Antiphospholipid syndrome
 Thrombophilia (hereditary)
 CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.
What additional features in the history would
you seek to support a particular diagnosis?

How much blood?

How’s the pain?

Do you pass out anything?

What clinical examination would you perform
and why?
Haemodynamic status
General exam, vitals, conjunctival colour

Abdominal Exam
To assess uterine size, to exclude acute abdomen

Per Speculum
To see if os is open , any fetal tissues, cervix.

VE and bimanual exam

Assess os, Elicit cervical excitation and adnexal mass in ectopic pregnancy
 Threatened Miscarriage
Pain : None/ Slight
Bleeding : Slight-moderate
Os : Close

Ultrasound intra:uterine gestational sac,

fetal heart activity+ve
 Inevitable Miscarriage
Pain : Considerable
Bleeding : Heavy
Os : Open

Ultrasound is im:portant in determining the

absence or persistence of
conception products inside
uterine cavity
 Complete Miscarriage
Pain : Slight
Bleeding : Slight-moderate
Os : Open, then close

afterwards
Ultrasound Emp:ty uterus
 Missed Miscarriage
Pain : Absent
Bleeding : Slight, chronic
Os : Close

Ultrasound failur:e to identify fetal heart beat

Gestational sac >20mm in diameter and
no embryonic/fetal part can be seen
6 mm embryo with no heart activity on
TVS
 Molar Pregnancy
Pain : Slight/None
Bleeding : Slight-moderate
Os : Close

Ultrasound Clas:sic “snow-storm”

appearance of vesicles
Honeycomb appearance
 Ectopic Pregnancy
Pain : Present
Bleeding : Slight
Os : Close/tender

Ultrasound Emp:ty uterus

May see adnexal mass
Summary
 CASE 1.1
“My period is 2 weeks late and I am bleeding.”
A 23-year-old nulliparous woman has had 6 weeks of amenorrhoea.
She has not been using any contraception. She normally has a regular
menstrual cycle every 28 days. A pregnancy test is positive. She has
noticed slight vaginal spotting.
What investigations would be most helpful andwhy?

Urine pregnancy test

A quick test but may be unreliable

FBC
To assess Hb, WBC

Blood group
To check rhesus status, and to prepare for tranfusion

Ultrasound
To locate the fetus, to assess viability and to look for POC

Histology
Any tissues expelled should be investigated to exclude molar or ectopic pregnancy
Ultrasound assessment
Look for pregnancy within the uterus
Presence of fetal heart
 Should be present 6 weeks
 If CRL< 6mm or MSD( )<20mm with
Mean sac diameter

no yolk sac/fetus – rescan

 Uncertain viability and unknown location

Presence of yolk sac

Adnexal masses
Free fluid/ endometrial thickness
5.5 weeksGestation sac and contents
 Yolk sac ( left)
6.5 weeks Fetus is 3mm long
A fetal heartbeat
8.5 weeksYolk sac still visible
 CRL

12 weeksNow we can see the baby

“may
Even with expert use of TVS using agreed criteria, it
not be possible to confirm if a pregnancy is
intrauterine or extrauterine in 8–31% of cases at the
first visit.

Condous G, Okaro E, Bourne T. The conservative

management of early pregnancy complications: a
review of the literature. Ultrasound Obstet
Gynecol
–30
What is the role of serial B-hCG assessment in
predicting pregnancy outcome?
 “ RCOG Study Group concluded that access
to serial serum B-hCG estimation is essential,
with results available within 24 hours.

Recommendations from the 33rd RCOG Study Group.

In: Grudzinskas JG, O’Brien PMS, editors. Problems in
Early Pregnancy: Advances in Diagnosis and
Management. London: RCOG Press; 1997. p. 327–31
 B-HCG
Pregnancy hormone
Should approximately double(66%) in the first
trimester every 48 hours

>1500 iu/l Ectopic pregnancy will usually

be visualised with TVS

Plateau below Pregnancy of unknown

1000 iu/l location and miscarriage

are both possible outcomes
Does serum progesterone assay have a role in
predicting pregnancy outcome?
“ unknown
When ultrasound findings suggest pregnancy of
location, serum progesterone levels
below 25nmol/l are associated with pregnancies
subsequently confirmed to be non-viable

Hahlin M, Thorburn J, Bryman I. The expectant

management of early pregnancy of uncertain site.Hum
Reprod 1995;10:1223–7.
20. Banerjee S, Aslam N, Woelfer B, Lawrence A. Elson J,
Jurkovic D. Expectant management of pregnancies of
unknown location:a prospective evaluation of methods
to predict spontaneous resolution of pregnancy. BJOG
2001;108:158–63.
Should all women with early pregnancy loss
receive anti-D immunoglobulin?
 Non-sensitised rhesus (Rh) negative women
Anti-D
should receive anti-D immunoglobulin in the
following:

ectopic pregnancy
All miscarriages over 12 weeks of gestation
(including threatened)
All miscarriages where the uterus is evacuated
(whether medically or surgically)

Royal College of Obstetricians and Gynaecologists. Use

of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.
Which women should be screened for genital
tract infection?
“ trachomatis,
Screening for infection, including Chlamydia
should be considered in women
undergoing surgical uterine evacuation.

Royal College of Obstetricians and Gynaecologists. The

Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.
When should surgical uterine evacuation be
used?
Indications for Surgical uterine evacuation :

Patient’s preference
Persistent excessive bleeding,
Haemodynamic instability,
Evidence of infected retained tissue
Suspected gestational trophoblastic disease

Royal College of Obstetricians and Gynaecologists. The

Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.
How should surgical uterine evacuation be
performed?
“ beSurgical uterine evacuation for miscarriage should
performed using suction & curettage

Royal College of Obstetricians and Gynaecologists. The

Care of Women Requesting Induced Abortion.
Evidence-based Clinical Guideline No.7.London:RCOG
Press; 2004.
 A Cochrane review concluded that vacuum aspiration
is preferable to sharp curettage in cases of incomplete
miscarriage. The advantages include:
Decreased blood loss Less
pain
Shorter duration of procedure

Royal College of Obstetricians and Gynaecologists. Use

of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.
Complications of Surgical uterine evacuation :
Perforation
Haemorrhage
intrauterine adhesions
Intra-abdominal trauma

Royal College of Obstetricians and Gynaecologists. Use

of Anti-D Immunoglobulin for Rh Prophylaxis.
Guideline No. 22. London: RCOG; 2002.
What is the advantages of prostaglandin
administration prior to surgical abortion?
“ significant reductions in
dilatation force,
haemorrhage and
uterine/cervical trauma.
Should prophylactic antibiotics be given prior
to surgical evacuation?
“ There is insufficient evidence to
recommend routine antibiotic
prophylaxis prior to surgical uterine
evacuation.

Antibiotic prophylaxis should be given based on

individual clinical indications
A randomised trial of prophylactic doxycycline in curettage for incomplete
miscarriage did not demonstrate an obvious benefit
What are the alternatives to surgical uterine
evacuation for miscarriage?
Medical methods
are an effective alternative
in the management of
confirmed first-trimester
miscarriage.
 Efficacy rates vary widely
from 13% to 96%,influenced
by many factors
Higher success rates were associated with
Incomplete miscarriage (70–96% success rate)
High-dose misoprostol (1200–1400 micrograms),
Prostaglandins administered vaginally
and clinical follow-up without routine ultrasound.

Hinshaw HKS. Medical management of miscarriage. In:

Grudzinskas JG, O’Brien PMS, editors. Problems in
Early Pregnancy: Advances in Diagnosis and
Management. London: RCOG Press; 1997. p. 284–95.
 Misoprostol
prostaglandin analogue
cheap, highly effective
active orally and vaginally
S/E: Diarhhoea, abd pain, nause, headache
 Cervagem
Gameprost
Inserted into the vagina
S/E: vaginal bleeding or uterine pain
nausea, vomiting, lower abdominal pain, backache
headache, slight fever, flushing, chills
“Vaginal misoprostol for the termination of
second and third trimester of pregnancy
appears as effective as cervagem, but
information about maternal safety is limited.
 Incomplete miscarriage
Can be managed with prostaglandin alone
No statistical difference in efficacy between
surgical and medical evacuation for
incomplete miscarriage and for early fetal
demise at gestations less than 71 days or sac
diameter less than 24mm.
Threatened miscarriage
No specific management
Reassurance
Rest
Sedation
weekly ultrasound examination
 Concerns have been raised about the
infective risks of non-surgical management
But published data suggest a reduction in
clinical pelvic infection and no adverse
affects on future fertility.
 Septic miscarriage
Complicated by infection
- delayed evacuation
 Septic miscarriage
Immediate complication
1.localized endometritis 9.septicaemia
2.spreading endometritis 10. septic shock
11. renal failure
3.salpingitis
12. DIC
4.salpingo-oophritis
5.pelvic peritonitis
6. pelvic abscess
7.tuboovarian abscess
8.generalized peritonitis
Septic miscarriage
Late complication
• Chronic pelvic inflammatory disease
• Pelvic adhesion
• Ectopic pregnancy
• infertility
 Septic miscarriage
Genital swab
I/V broad spectrum antibiotics to cover g(+)ve, g(-)ve
and anaerobic organism
change antibiotics according to culture and sensitivity
result

Remove the septic focus

ERPOC
Laparotomy and drainage for pelvic abscess
TAH for septic uterus and uterine perforation
 What are the advantages of arranging
histological examination of tissue passed
at the time of miscarriage?
Tissue obtained at the time of miscarriage
should be examined histologically to
confirm pregnancy and
to exclude ectopic pregnancy or
unsuspected gestational trophoblastic
disease.
CASE 1.2
A 32-year-old patient, Mrs. A, immigrated to the United

States several years ago. Following the birth of their first

daughter, Mrs. A has had three miscarriages between

eight and 12 weeks' gestation, the most recent one being

one month ago.

Recurrent miscarriage
• 3 or more consecutive miscarriages.
Other term used to describe repetitive early spontaneous pregnancy losses include:

– recurrent spontaneous abortion,

– recurrent pregnancy loss,
– habitual abortion.
The chances for a successful pregnancy are > 50% even after five losses.
• What about 2 consecutive miscarriage?

– American Society of reproductive medicine (ASRM )

• Define as 2 consecutive miscarriage
– Royal college of O&G, UK (RCOG)

• Define as 3 consecutive miscarriage

• Different practices between O&G specialist
– Local practice – usually take 3 consecutive miscarriage
– Earlier investigation should be considered for special cases:

• Advanced maternal age

• Bad obstetric history (e.g. ectopic, IUFD)

• History of infertility

• Patient request
Causes

• Idiopathic in 40-50% of cases

• Easier to divide into 1st or 2nd trimester losses

 • 1st trimester losses

– Chromosomal abnormalities

– Polycystic ovary syndrome (PCOS)

– Antiphospholipid syndrome (APS)

– Endocrine disorders (untreated DM, thyroid disease)

– Uterine abnormalities

• 2nd trimester losses

– Cervical incompetence

– Bacterial vaginosis

– Thrombophilias

– Asherman syndrome (intrauterine synechiae)

– Uterine abnormalities

• Others – SLE, hyperprolactinaemia

• Genetic factors usually result in early embryonic losses

• whereas autoimmune or uterine anatomical abnormalities more likely cause

second-trimester losses.

The chromosomal abnormalities

– Earlier gestations being more likely to be affected

– The loss is often untreatable and unavoidable part, the risk of recurrence is low

Congenital or acquired uterine anomaly

• Asherman syndrome - uterine synechiae

• Uterine leiomyomas – submucous

• Congenital genital tract anomalies:

– Unicornuate

– Bicornuate

– Septate uteri

Immunological Factors

• Miscarriages are more common in women with systemic lupus erythematosus, an

autoimmune disease.
 • Many of these women were found to have antiphospholipid antibodies.

Thrombophilia

• Is a condition where the blood has an increased tendency to form clots.

Types:

• Acquired thrombophilia

– Antiphospholipid Syndrome (APS)

• caused by antibodies against the cell membrane

• Congenital thrombophilia

– Factor V Leiden

– Protein C Deficiency

– Protein S Deficiency

– Antithrombin Deficiency

Presentation:

• Recurrent venous thromboembolism

• Recurrent miscarriage

• Intrauterine growth restriction

• Stillbirth

• Severe pre-eclampsia

• Abruptio placentae.

Screening:

• Lupus anticoagulant

• Anti-cardiolipin antibodies

Treatment:

• Low-dose aspirin

• Heparin
Endocrine Factors

• Progesterone deficiency caused by a luteal-phase defect.

• Polycystic ovarian syndrome.

• Uncontrolled diabetes. Optimal periconceptional glycaemic control will mitigate much of this loss.

• Overt hypothyroidism and severe iodine deficiency are well known. Correction with supplementation reverses these effects.
Investigations would include the
following:
•chromosomal analysis of the products of conception;

•chromosomal analysis of both parents – a chromosomal

abnormality (e.g.balanced translocation) will be

diagnosed in one of the partners in 5–7per cent of cases

of recurrent abortion;
• PCOS screen

• Antiphospholipid antibodies

– Anticardiolipin antibodies

– Lupus anticoagulant

• Karyotyping (both couples)

• Pelvic ultrasound – assess uterine anatomy

• HSG can also be used as an initial screening test

• Suspected uterine anomalies may require further

investigations to confirm diagnosis:

• Hysteroscopy

• Laparoscopy

• 3D ultrasound

• Thrombophilia screen
• Screening for diabetes, thyroid disorders is only indicated if there is clinical suspicion.

• TORCHES – Not useful

Should I be given some drug to avoid
getting another miscarriage?
“Aspirin alone or in combination with heparin is
being prescribed for women with unexplained
Recurrent miscarriage,with the aim of improving
pregnancy outcome.”

KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu
lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent
miscarriage.NEngl J
Med2010;362:1586–96.
Recent Data suggest that the use of empirical
treatment in women with unexplained
recurrent miscarriage is unnecessary and
should be resisted.

KaandorpSP,GoddijnM,vanderPostJA,HuttenBA,VerhoeveHR,Hamu
lyákK,etal.Aspirinplusheparinoraspirinaloneinwomenwithrecurrent
miscarriage.NEngl J Med2010;362:1586–96.
In the absence of any identifiable cause,what
are my chances of achieving an ongoing
pregnancy on the next occasion?
 There is a 60–70% likelihood of
successful pregnancy if no cause is
found for recurrent miscarriage
Is there potential benefit from support
and follow-up after pregnancy loss?
 “All professionals should
be aware of the
psychological sequelae
associated with
pregnancy loss and should
provide support,
follow-up and access to formal
counselling when necessary
 MIDTRIMESTER ABORTION
• From the end of the first trimester until the gestational age reaches 20 weeks.

• Spontaneous loss in the second trimester is estimated at 1.5 - 3 %, and after 16

weeks, it is only 1 %.

Management

• Midtrimester abortions are classified similarly to first-trimester abortions.

Management is also similar in many regards

• An exception is that at these later gestational ages, oxytocin in concentrated doses is

highly effective for labour induction or augmentation.

Cervical incompetence (Insufficiency)

• Diagnosis is clinical, usually based on history

– Miscarriage

• 2nd-trimester miscarriage

• Subsequent miscarriages are usually earlier

• Preceded by spontaneous rupture of membranes

• Bulging membranes through the cervix prior to onset of labour

• Painless and progressive cervical dilatation

• Fetus alive during miscarriage

– History of cervical surgery (cone biopsy, LLETZ)

• Transvaginal sonography findings include:

– cervical length < 25 mm

 – as well as the presence of funnelling, which is ballooning of the membranes
into a dilated internal os, but with a closed external os.

Risk Factors:

• Cause of incompetence due to previous cervical trauma:

– dilatation and curettage

– conization

– cauterization

– amputation

Evaluation and Treatment:

• US is performed to confirm a living fetus with no major anomalies.

• Cervical secretions are tested for gonorrhea and chlamydia infection. These and
other obvious cervical infections are treated. For at least a week before and after
surgery.

• Sexual intercourse is prohibited.

• Incompetence is treated surgically with cerclage, which reinforces a weak cervix by a

purse-string suture.

• elective cerclage is usually done between 12 and 14 weeks’ gestation.

• Contraindications to cerclage usually include:

• bleeding

• uterine contractions

• ruptured membranes.

Cerclage Procedures:

• Cerclage operations,

– McDonald (simpler procedure)

– Shirodkar (complicated operation)

• Transabdominal cerclage:

– severe cervical anatomical defects.

– prior transvaginal cerclage failures.

Complications of cerclage:

– membrane rupture

– preterm labour

– haemorrhage

– infection

– All are uncommon.

Bacterial vaginosis
• Presence of BV in the first trimester is a risk factor for 2nd trimester miscarriage or preterm delivery.

• Treatment of BV early in the 2nd trimester with oral clindamycin reduces the incidence of 2nd
trimester miscarriage and preterm birth.

• No data to assess the role of routine antibiotic in women with a previous 2nd
trimester miscarriage.