Bleeding in Early Pregnancy - PowerPoint Presentation

Slide1

Bleeding in Early Pregnancy

Dr.Suresh

Babu

Chaduvula

Professor

Dept. of

OBGyn

, College of Medicine,

KKU,

Abha

, KSA

Slide2

What are the causes?

1] Abortion

2] Ectopic Pregnancy

3]

Hydatidiform

mole

4] Implantation bleeding

5] Local causes – Erosion, Polyp, Varicose veins rupture, Cervical malignancy

Slide3

ABORTION or Miscarriage

Definition

: Termination of pregnancy before the period of viability or fetus weighing less than 500 grams.

Expulsion or Extraction of an embryo or fetus before viability

Period of viability

: Developing countries – 28 weeks.

UK, USA – Less than 22 to 24 weeks

Slide4

Incidence

10 – 20%

75 % occur before 16

th

week

75 % occur at 8

th

week

Slide5

Classification

1] Spontaneous

2] Threatened

3] Inevitable

4] Incomplete

5] Complete

6] Missed

7] Septic

8] Recurrent

9] Induced – Legal or Illegal [ Criminal ]

Slide6

Etiology

1]

Genetic factors

–

Chromosomal abnormalities –

Autosomal

trisomy

– 50 % -

Trisomy

16 is common

Polyploidy – 20 % - Presence of extra haploid number of chromosomes – 69 or 92 chromosomes –

Triploidy

is common

Chromosomal rearrangements – Inversion, deletion, translocation

Others - Mosaic

Slide7

2]

Endocrine factors

:

Luteal

Phase defect

Deficient Progesterone

Hyper & Hypothyroidism

Uncontrolled Diabetes Mellitus

Slide8

3]

Uterine Anomalies

:

Cervical incompetence

Bocornuate

uterus

Septate

uterus

4]

Sub-mucus Fibroid

:

5]

Intra-uterine

synechiae

:

[

Asherman’s

syndrome ]

Slide9

6]

Infections:

Viral –

Rubella,

Cytomegalo

,

varicella

,

variola

Parasitic:

Toxoplasmosis, Malaria

Bacterial:

Chlamydia,

Ureaplasma

,

Brucella

Spirochetes:

Treponema

pallidum

Slide10

7]Immunological disorders

:

Antinuclear Antibodies

Anti

phospholipid

antibodies like Lupus anticoagulant and Anti

cardiolipin

antibodies

Slide11

8] Medical Disorders

:

Cyanotic heart diseases

Hemoglobonopathies

9] Paternal Factors

:

Sperm chromosomal anomaly

10]

Inherited

Thrombophilia

11] Environmental -

Smoking, Radiation,

Teratogenic

drugs, chemicals, Alcohol

12] Unexplained – 40- 60%

Slide12

Ist

Trimester Abortions causes

1] Genetic

2] Endocrine disorders

3] Immunological disorders

4] Infections

5] Unexplained

Slide13

2nd Trimester Abortions causes

1] Cervical Incompetence

2]

Bicornuate

uterus

3]

Septate

uterus

4] Uterine

synechiae

5]

Submucus

fibroid

6] Maternal Diseases

7] Unexplained

Slide14

Threatened Abortion

Clinical features

:

Vaginal bleeding

Mild lower abdominal pain

Vitals stable

Vaginal examination – Cervix is closed and uterus size will correspond to pregnancy

Diagnosis – CBC, Ultrasound, Serum Progesterone and Serum HCG levels

Treatment – Rest, sedation and synthetic progesterone and HCG injections?

Slide15

Incomplete Abortion

Clinical features

:

Vaginal Bleeding with passage of products of gestation

Pain lower abdomen

Vitals - disturbed according to the blood loss

Vaginal examination: Cervix is dilated with hanging of fetal products and uterus size will be lesser than amenorrhea

Diagnosis - Ultrasound

Treatment – Stabilize vitals and Suction evacuation / curettage

After 12 weeks – Under GA and IV

oxytocin

drip products are removed by ovum forceps / Curettage

Slide16

Complete Abortion

Clinical features

:

Vaginal Bleeding with passage of products of gestation

Pain may be less or absent

Vitals - disturbed according to the blood loss

Vaginal examination: Cervix is closed and uterus size is lesser than amenorrhea

Diagnosis - Ultrasound

Treatment – No active intervention

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Inevitable Abortion

Clinical features

:

Vaginal Bleeding

Pain lower abdomen

Vitals - disturbed according to the blood loss

Vaginal examination: Cervix is dilated with hanging of fetal products and uterus size will correspond to amenorrhea

Diagnosis - Ultrasound

Treatment – Stabilize vitals and Suction evacuation / curettage

After 12 weeks – IV

oxytocin

drip

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Missed Abortion

Fetus is dead and retained for variable period [ 4 – 6 weeks ]

Clinical Features:

Brownish vaginal

dischage

Subsidence of pregnancy symptoms

Retrogression of breast changes

Vaginal examination: Uterus will be less than amenorrhea and cervix is closed

Diagnosis – Ultrasound

Slide19

Missed Abortion

Complications

:

Disseminated intravascular Coagulation

Coagulation Profile is essential

Treatment:

Dialatation

and Curettage – less than 12 weeks

After 12 weeks – IV

Oxytocin

drip / Prostaglandin vaginal

pessaries

or Gel / IM injections of PG F2

alfa

.

Slide20

Septic Abortion

Any abortion associated with evidence of infection in the uterus and its contents

Clinical features

:

Temperature – 100.4 degree F for 24 hrs or more

Offensive or purulent vaginal discharge

Lower abdominal pain and tenderness

This is mostly due to incomplete and illegal abortions or also following

spontaneus

abortion

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Septic Abortion

Peritonitis features may be present

Vaginal examination – cervix may be closed or dilated , pus like offensive discharge

Tender uterus and size of uterus will be lesser than amenorrhea

Organisms responsible for sepsis:

E.coli

,

Klebsiella

,

Staph.aureus

, Clostridium

welchi

and

perfringens

etc.,

Complications -

Endotoxemic

shock, acute renal failure, DIC, Peritonitis and Gas gangrene

Slide22

Septic Abortion

Investigations:

Endo cervical swab for culture & sensitivity

High vaginal swab for culture & Sensitivity

CBC

DIC profile if required

Blood culture

Urine Culture

Ultrasound

Slide23

Septic Abortion

Treatment

:

IV Antibiotics – for aerobic, anaerobic organisms – IV

Ampicillin

,

Gentamycina

and

Metronidazole

Anti Gas Gangrene serum

Treatment of complications

Surgery – Evacuation of uterus and

Laparotomy

if necessary depending on peritonitis features

Slide24

Blighted Ovum or

Anembryonic

Pregnancy

Development of gestational sac without any evidence of fetus or fetal parts

Diagnosis – Ultrasound

Treatment – Dilatation and Curettage

Tissue should be sent for Fetal

karyotyping

Slide25

Recurrent Abortion

A sequence of three or more consecutive abortions before 20 weeks

Incidence – 1 %

Causes

:

First Trimester

– Genetic, Endocrine and Metabolic, Infection, Inherited

thrombophilia

, Immunological and unexplained

Second Trimester

–

Bicornuate

uterus,

Unicornuate

uterus,

septate

uterus, Cervical incompetence.

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Bicornuate Uterus

Slide27

Septate uterus

Slide28

Uterine anomalies

Slide29

Sub mucus fibroid

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Cervical Incompetence

Cervix is unable to with hold the fetus faulty defect in the

sphincteric

mechanism.

Retentive power of cervix is impaired

Causes:

Congenital

Iatrogenic – Dilatation and Curettage, Amputation of the cervix, cone biopsy

Clinical features

: History of recurrent mid trimester abortions where leaking followed by painless expulsion of fetus

Slide31

Cervical measurements

Slide32

Cervical Incompetence

Diagnosis

:

Ultrasound

– Cervical length less than 2.5 cm and cervical dilatation more than 1.5 cm with funneling of cervix and bulging of membranes

Periodic per speculum examination

Treatment

:

Cervical

Circlage

with

Merseline

tape at 16 – 18 weeks – Mc Donald operation

Shiridkar’s

operation

Slide33

Mc donald

operartion

Slide34

Induced Abortion

Medical Termination of Pregnancy

Indications:

Failure of contraception

Rape

Medical diseases that may deteriorate mother’s health

Congenital anomalies

Slide35

Induced Abortion

First Trimester

Surgical

:

Manual Vacuum Aspiration

Dilatation and Curettage

Suction and Evacuation

Medical:

Prostaglandin preparations

Mifepristone

Misoprostol

Slide36

Induced Abortion

Second Trimester

:

Intraamnitic

instillation of PGF2

alfa

or Hypertonic saline

Extraamniotic

ethacrydine

lactate or PGf2

alfa

Oxytocin

Infusion

Hysterotomy