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Understanding Bleeding in Early Pregnancy: Causes & Management

This comprehensive guide covers the differential diagnosis, classification, risk factors, aetiology, clinical presentation, and management of bleeding in early pregnancy, including miscarriage, ectopic pregnancy, and other related conditions. Learn about the diagnostic criteria, risk factors, symptoms, and initial management approaches for these critical obstetric scenarios.

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Understanding Bleeding in Early Pregnancy: Causes & Management

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  1. PV BLEEDING IN early pregnancy

  2. DDx of bleeding in early pregnanCy • Physiologic – implantation • Ectopic • Subchorionic haematoma • Gestational trophoblastic disease • Cervical, vaginal or uterine pathology (Ectropion, Cervical neoplasia, vaginal trauma)

  3. Ectropian

  4. Subchorionichaemorrhage

  5. Early pregnancy lossDefinition pregnancy loss prior to 20 weeks gestation or expulsion of foetus/embryo </= 500g

  6. Epidemiology 8-20%

  7. Classification • Threatened Miscarriage • Cardiac activity present. PVB. Cervical os closed. • Mx: repeat USS in 7-10days • Inevitable miscarriage • Bleed and abdominal cramping, os open, may see POC through os • Missed Miscarriage • - Nil FHR, dropping Bhcg • - Failed pregnancy. RPOC have not been expelled . Cervical os is closed. may have small pv loss and cramping • - mx: conservative, medical, surgical

  8. Incomplete Miscarriage • PVB and pain. Cervical os open with POC in os • History of passage of some POC • Mx: remove POC from Cxos, IV syntocinon, D&C Complete Miscarriage • PVB and pain mild or resolving. Closed cervix. Empty uterus. • Mx: nil intervention required Anembryonic / blighted ovum • Empty GS >25mm with no YS/FP Septic Miscarriage - RPOC become infected

  9. Diagnostic USS criteria (TV USS) for miscarriage • MSD >/equal to 25mm with NO embryo or yolk sac = diagnostic of failed pregnancy • Absence of FH with CRL>7mm = diagnostic of failed pregnancy

  10. Risk factors • Previous M/C – 20% risk after 1 M/C. 30% after 2 consecutive M/C. 40% after 3/more M/C • Multip • STIs • Abnormal uterine receptivity e.g. PCOS, endometriosis • Advanced maternal age • Medications/Substance abuse

  11. Aetiology Chromosomal abnormalities (aneuploidy, triploidy etc.) 50% of all miscarriage Congenital Anomalies: teratogens e.g. DM Trauma: amniocentesis, CVS Multiple pregnancy Uterine structural abnormalities - Uterine septum, fibroids - Cervical incompetence (2nd trimester loss) Maternal Disease - Infections – TORCH, Listeria, parvo, rubella, herpes simplex, CMV, BV - Endocrine: Thyroid dysfunction, Cushings, PCOS, endometriosis - Thrombophilia, SLE, antiphospholipid syndrome Drugs, smoking, alcohol

  12. Clinical presentation • - PVB – with or without passage of foetal tissue • - Even heavy/prolonged bleed can have normal outcome • 90% of first trimester bleeds where FHR present (between 7-11 weeks) continue the pregnancy. Success rate increases with gestation • Signs • - Pallor, Tachycardia, hypotension (shock/collapse). Abdominal distension, tenderness, cervical motion tenderness. • - Cervical shock

  13. investigations - Serial bhcg monitoring, 48 hours apart - Blood Group/ Rhesus status - USS

  14. What we will ask • Pain? • PV bleeding? How much? • How many weeks • Is it intrauterine (prior scans) • Vital signs • Bhcg, Hb, USS

  15. MANAGEMENT – UNCERTAIN VIABILITY OR LOW BHCG Monitoring with bhcg and USS • If bhcg doubles in 48hrs -> repeat USS in 7 -10 days once bhcg in discriminatory zone for viability • If bhcg dropping or plateaus -> failed IUP or ectopic pregnancy

  16. Confirmed non viable intrauterine pregnancy

  17. Conservative management • majority of expulsions occur in first two weeks after diagnosis • May require medical/surgical management if does not spontaneously miscarry. • Not suitable if • significant haemorrhage • Evidence of infection • Risk from effects of haemorrhage e.g. coagulopathies / unable to have blood transfusion

  18. Medical management • - Misoprostil (Prostaglandin E1 analog) • Protocol based, PV or oral • can do progesterone antagonist mifepristone + misoprostol combination • - Expect bleeding within 24 hrs • - Medical help/EPAS contact if pain/bleeding • - S/E: GI – nausea, vomiting, diarrhoea. Pyrexia -> Analgesia, antiemetics • - risk of D&C

  19. Surgical management – D&C • - Risks: general, Uterine perforation, cervical trauma, retained products & need for repeat procedure, ashermans • - lowers risk of unplanned hospital admissions and need for subsequent treatment. • Chance of Complete evacuation surgery > medical > expectant

  20. Ectopic pregnancy

  21. incidence • 1-2%

  22. classification • Tubal 90% • 70% ampullary

  23. Risk factors • PID • IVF • Previous ectopic • Tubal pathology / surgery • congenital anomalies • tumour • endometriosis • IUD • Smoking • Age – extremities of age 18 AMA>35

  24. Symptoms & Signs • PV bleeding • abdominal pain • Amenorrheoa • if ruptured -> haemoperitoneum -> peritonism / shoulder tip pain / syncope • Cervical excitation, adnexal mass • Hypotension, tachycardia, pallor

  25. investigation • FBC • beta HCG • 70% ectopic pregnancy < 6000iu • < 53-66% increase in 48 hr • Pelvic ultrasound (TV)

  26. Ultrasound FINDINGS • adnexal mass separate to ovary • echogenic FF • pseudosac • ring of fire

  27. Initial Management DR ABC IVC FBC + G+H NBM Analgesia Resuscitate with IVT/blood products

  28. Inpatient management Depends on • Vital signs • Size of ectopic • Level and trend of bhcg • Clinical signs of ectopic rupture? Blood in pelvis? • Patient compliance • Presence of a FHR • Conservative • Medical : methotrexate • Surgical: salpingectomy, salpingotomy

  29. Pregnancy of unknown location • Normal IUP • Miscarriage • Ectopic • Hcg secreting tumors (GTD, germ cell of ovary)

  30. The Gynaecology consult

  31. History • Age • Pain: SOCRATES (assoc. sx incl. N+V, bladder, bowel, temp, rigors, vaginal discharge) • PVB • Gynae Hx: LMMPPSC • LMP • Menarche • Menses : dysmenorrheoa, AUB, regularity/length • PID/STI • Pap smear (CST) • Sexual activity • Contraception • Obstetric Hx: pregnancies, outcomes, complication

  32. PMHx/surg/psyche/meds, allergies – complications of surgery in the past? • FHx: malignancy • SHx • Cancer: weight loss, LOA, fevers, bloating

  33. Examination • UA, bhcg • Abdomen • Spec: Swabs • Bimanual: cervix, adnexal masses, cervical excitation

  34. Investigation • Bhcg • FBC, G+H • UECs/LFTs/coags? • UA, MSU • STIs screen • Chase outpatient images and bhcg results • Radiology: USS, CT

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