04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 1

VAGINAL BLEEDING IN EARLY PREGNANCY

PLAN Introduction Objectives Aetiology Management Conclusion

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 2

INTRODUCTION

Vaginal bleeding occurring during the first 22 weeks of pregnancy

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 3

OBJECTIVES

To understand and manage the causes of bleeding in early pregnancy

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 4

AETIOLOGY

1. Implantation bleeding

2. Abortion(incomplete, complete,inevitable)

3. Ectopic pregnancy

4. Molar pregnancy

5. Cervicitis or vaginitis

6. Cervical or vaginal neoplasia

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 5

Implantation bleeding

This bleeding which occurs during implantation

Trophoblasts penetrate the wall of the uterus

Bleeding is usually mild

Requires no treatment

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 6

Spontaneous abortion

Definition: Loss of pregnancy before foetal viability (22 weeks of gestation)

chromosomal abnormalities

Risk increases with parity, maternal and paternal age

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 7

Types of spontaneous abortion

Threatened abortion (pregnancy may continue)

Inevitable abortion Pregnancy will not continue

Incomplete /complete abortion

Septic abortion

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 8

Threatened Abortion

Vaginal bleeding- may be slight

20 – 25% of pregnancies

Half of them finally abort

Pain may be present, anterior and rhythmic simulating labour or mensis

The cervix is closed

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 9

Inevitable abortion

Vaginal bleeding

Rupture of membranes

Cervix is open

Parts of conceptus in the cervical os

Painful uterine contractions

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 10

Incomplete ABORTION

Products of conception are partially expelled

Heavy bleeding

Pregnancy is usually more than ten weeks

Patient may be severely anaemic

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 11

Complete abortion

Products of conception have been completely expelled.Cervix is closedLittle or no bleedingMild or no uterine cramping or painOccurs mostly in pregnancies before ten weeks

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 12

INDUCED ABORTION

Process by which pregnancy is terminated before foetal viability

Criminal

Therapeutic

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 13

Septic abortion

Abortion complicated by infection

Organisms arise from the lower genital tract

Likely to occur where there are retained products

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 14

MANAGEMENT OF ABORTION

1. Threatened abortion

Bed rest

Avoid strenuous activity

Avoid intercourse

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 15

MANAGEMENT OF ABORTION

2. Inevitable abortion

Pregnancy less than 16 weeksUterine evacuation

Give ergometrine 0.2 mg repeat after 15 minutes if necessary

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 16

MANAGEMENT OF ABORTION

Pregnancy greater than 16 weeksAwait spontaneous expulsion

Evacuate the uterus

If necessary, infuse 40 units of oxytocin at 40 dpm to facilitate expulsion

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 17

Incomplete abortion

If bleeding is light or moderate and pregnancy less than 16 weeks

Use sponge forceps to remove products of conception

If bleeding is heavy and pregnancy is less than 16 weeks

Manual Vacuum Aspiration

If pregnancy is greater than 16 weeks

Infuse oxytocin 40 units at 40 dpm

Evacuate the remaining products

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 18

SEPTIC INCOMPLETE ABORTION

Antibiotics for at least 24 hours

Uterine evacuation-Aspiration or curettage

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 19

ECTOPIC PREGNANCY

Products of conception developing outside the uterus

Combined heterotopic – Simultaneous intrauterine and extrauterine pregnancy

Cornual or rudimentary horn pregnancy.

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 20

ECTOPIC PREGNANCY

The fallopian tube is the most common site of ectopic pregnancy (> 90%)Incidence parallels Chlamydia infections1991 incidence of 1/63 deliveries in maternite ppleCould be ruptured or not

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 21

Symptoms/signs of unruptured ectopic pregnancy

Symptoms of early pregnancy

Abdominal and pelvic pain

Palpation of a mass in the adnexa

May have spotting

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 22

Differential diagnosis of unruptured ectopic pregnancy

Threatened abortion

Acute PID

Chronic PID

Complicated ovarian cyst

Acute appendicitis

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 23

Symptoms / signs of ruptured ectopic pregnancy

Collapse and weakness

Fast, weak pulse (110/min or more)

Hypotension

Hypovolaemia

Acute abdominal and pelvic pain

Abdominal tenderness

Rebound tenderness

Pallor

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 24

ECTOPIC PREGNANCY.cont.

Immediate management of ectopic pregnancy

Cross match blood

Arrange for immediate laparotomy

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 25

Molar pregnancy

Hydatiform mole

Vaginal bleeding spotting to heavy

Passage of grapelike vesicles

Increased uterine size

Pregnancy induced hypertension

Thyroid dysfunction

spontaneous expulsion common

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 26

Molar pregnancy Management

Immediate uterine evacuation

Follow up by serial dosage of serum chorionic gonadotrophins levels for one year

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 27

References

William’s Obstetrics

Jeffcoats gynecology

Current obstetrics and gynecology diagnosis and treatment

04/15/23 Dr. F. Tumasang, MD, MPH, CHES, OB/GYN 28

Thank you for your kind attention