EARLY PREGNANCY BLEEDING

Abortion
Ectopic pregnancy
Gestational Trophoblastic Disease
(GTD)
 Abortion
 Abortion is the expulsion of the fetus from the uterus or
termination of pregnancy before fetal viability. This is
usually taken to be so if it happens before 28 completed
weeks of gestation or less than 1000g weight in Ethiopia.
According to WHO definition, it is termination of

pregnancy or fetus before it reaches viability. This is

usually taken to be so if it happens before 20wks or fetal
weight less than 500gm.

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Etiology
1. Abnormalities of pelvic organ
 Congenital anomalies of uterus (Unicornuate,
Bicornuate, or Septate uterus)
 Tumor of the uterus (submucous or intramural myoma,
have been associated with spontaneous abortions)
 Cervical incompetence
2. General disease of mother
 Acute febrile illness (malaria, Typhoid fever)
 Chronic illness (DM, Hyper/hypo thyroidism &HTN

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3. Drugs and Poison (Anticoagulant Drugs, cytotoxic
drugs)
4. Immunologic Disorders
 ABO or Rh incompatibility , reaction b/n sperm and
cervix enhance the possibility of abortion
5.Advanced age(>35): b/c of chromosomal defect due to
age
6.Habit : smoking
7. Multiple gestation
8. Local mechanical interference
9. Endocrine disorders
10. Chromosomal abnormalities

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 Classification of abortion is based on
 Etiology
 Spontaneous (miscarriage)
 Induced
 Legally (Legal and illegal )
Clinical features
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Recurrent abortion
Trimester (first and second TM abortion)
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 Spontaneous abortion; Is a type of abortion in which
termination is not deliberately provoked.
 Induced abortion; when termination of pregnancy is
provoked that is either
Therapeutic abortion or
Criminal abortion
 Legal abortion
 Is a procedure for terminating pregnancy by skilled
professionals, taken place in the appropriate place with
all necessary equipments and with all the guide lines of
safe abortion
 llegal abortion
 Abortion taken place by unskilled person, in an
environment lacking the minimal medical standards,
6 with inadequate instruments
 Legal aspects of abortion
In principle abortion illegal based on article 545(1) , but It
is legal only in the following conditions according to
article 551(1)
 if pregnancy is from relatives - incest
 If the woman is raped
 if the continuation of pregnancy is danger for the life
of mother
 If the fetus has sever congenital mal formation
 if mother is not ready to cope up with
pregnancy(social, mental or economical problem)

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 Threatened abortion
 Vaginal bleeding prior to 28wks of gestation
 Pregnancy at risk of abortion
 Pregnancy may continue in 80% of the cases
 Is due to hormonal insufficiency (decreased luteal
development )
 C/F
 Minimal bleeding
 Cervix Closed and uneffaced
 Slight abdominal pain, cramp, back pain
 DDx
 Cervical polyp
 Vaginitis
 Cervical carcinoma
 Ectopic pregnancy
 Trauma, foreign body
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  Investigation (HCG, U/S)
 Management
 No effective therapy
 Advice bed rest
 Avoid sex, douching and stannous exercise
 Sedation
 Reassurance

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 Inevitable abortion
 The abortion is most likely to occur- impending abortion
 Greater amount of bleeding for >7days when compared
with threatened abortion
 Cervical dilation greater or equal to 3cm and 50-80
%effacement
 membrane rapture
 Persistent abdominal pain
 Visible conceptus tissue at cervical os, but not passed
 Cervical motion tenderness

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 .

 Lab investigation
 Hct, BG/RH, CBC,
 Mgt
 Administer anti pain,
 If GA is before 12wks=MVA
 If GA is after 12wks=D&C
 Anti-D for Rh negative women
 Incomplete abortion
 Is a partial expulsion of conceptus tissue
 There will be profuse vaginal bleeding
 Cervix is opened and effaced
 Visible and palpable conceptus tissue
 Vaginal discharge if infected
 Lab investigation
 CBC, Hct, BG/Rh

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 .
 Mgt
 Evacuation as quickly as possible according to
gestational age(before 12wks=MVA& after
12wks=D&C or E&C)
 Blood and fluid replacement if needed
 Antibiotics
 Anti-D for Rh negative women
 Counseling
 Complete abortion
 All parts of the conceptus tissue is expelled
 Difficult to diagnosed unless conceptus tissue
witnessed, endometrial biopsy taken or proven by
ultrasound
 All symptoms will disappear
 Even cervical os is closed
 Mgt
 Counseling and reassurance
 Advice if bleeding recurs or fever develops
 Anti-D for Rh negative women

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 Missed abortion
 When the fetus is dead and retained inside the uterus for a variable
period (silent miscarriage or early fetal demise )
 C/F
 Subsidence of positive sign of pregnancy
 Persistent brownish vaginal discharge
 Decreased uterine size
 Retrogression of breast changes
 Firm cervix
 Declining HCG
 No bleeding
 Negative FHB, no fetal movement

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 Mgt
 Termination
 If >4wks
 Dilation and curettage (D&C)
 Induction with oxytocin, prostaglandin (mesopristol
20microgramvx suppository every four hour ) if GA >12wks
 Expectant management
 If <4wks,
 By doing clotting profile
 Complication
 hypofibrinogenemia leads to DIC
 Infection
 DDx
 Wrong date
16  Pelvic tumor (myoma)
 Recurrent abortion
 Recurrent abortion more than 3 times (consecutive spontaneous
abortion termination of pregnancy)
 Affect 1% of all women
 Mgt – cervical circlage
 Associated factors are
 Genetic cause –abnormal karyotyping
 Immunologic factor- lack of IgG blocking agent
 Hypersecration of LH hormone w/c can cause error in
endometrial implantation or ocyte age
 Infection ;TORCH
 Structural anomalies
 both uterine anomalies and cervical incompetence

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 Septic abortion
 Any of the stage of abortion complicated by pelvic
infection, caused by many infectious agents
(pollymicrobial)
 C/F
 Fever, shivering, offensive &purulent vaginal discharge
 Low BP, tachycardia & tachypnea
 Suprapubic tenderness or rebound tenderness.
 Lab investigation
 Hgb and BG/Rh
 Culture and sensitivity of urine, urine pus (discharge )
 Abdominal x-ray
 Urinary HCG, WBC, ESR, U/S
 hysteroscopy, laparoscopy
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 DDx
 Ectopic pregnancy
 GTD
 Appendicitis
 Myoma
 Ovarian cancer
 UTI
Mgt
 Admission, resuscitation
 IV antibiotics
 V/S monitoring
 Anti- D for Rh -ve women
 Laparatomy if pelvic abscess or generalized peritonitis
 Salpingo-opharectomy
 Hysterectomy for gangrenous uterus, unsatisfactory response, sever
trauma to the uterus , pelvic abscess and long standing infection.

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 First TM abortion (<12wks)
 Possible causes
 Chromosomal abortion
 Immunological abnormalities
 TORCH infection
 Systemic illness
 Anatomic defect
 Endocrine factor

Second TM abortion(12-28ws)
 Possible causes
 Anatomic defect
 Fetal death
 Rh-isoimmunization
 Syphilis
 trauma

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 General management of abortion

 First TM abortion can be managed by

 MVA suction &curette
 Medical abortion
 Surgical curettage of D&C
 Hysterectomy
 Second TM abortion can be managed
 Using oxytocin &PGE2
 Hysterectomy
 Foley catheter

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  Medical abortion
 High dose oxytocin
 Mesopristol
 Mifepristone
 Methotrexate
 Saline abortion
 Surgical abortion
 Vacuum aspiration(MVA &EVA)
 D&C (1st TM abortion procedure, uses sharp curette to clean
out the uterus).
 D&E (second TM abortion procedure, 12-24 weeks)
 Destructive abortion ;takes place in 20-26 weeks of
pregnancy, by using forceps ,hooker and scissors

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 Protocol for Misoprostol Administration
 Day 1 is defined as the day mifepristone is taken
Vaginal use:
≤ 56 days/8 wks on day 2, 3, or 4, insert four 200 mcg
tablets (800 mcg total) misoprostol

56-63 days/8-9 wks  on day 2 or 3, insert four 200

mcg tablets (800 mcg total) of misoprostol

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 Protocol for Misoprostol……

 Day 1 is defined as the day mifepristone is taken

Oral use:
≤ 49 days/7 wks  on day 2 or 3 take two 200 mcg
(400 mcg total) tablets of misoprostol
49-63 days/7-9 wks  not recommended due to lower
efficacy—use vaginal misoprostol

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 Protocol
 GA<18WKS
mefipristol 200mg oral after 36-48 hrs, misoprostol 800mcg
vaginal(loading dose), 400mcg every 3-4hrs maximum 5 dose
 GA 18-24 WKS
mefipristol 200mg oral after 36-48 hrs, misoprostol 400mcg
vaginal, sublingual, oral or bucal every 3-4hrs maximum 5 dose.
 GA >24 WKS
mefipristol 200mg oral after 36-48 hrs, misoprostol 100mcg
vaginal every 6-8hrs maximum 5 dose. Or misoprostol 50 mcg
vaginal, bucal, sublingual.
 Medical mgt of abortion using;
 Mesopristol -mifepristone combination has been studied
for gestation at 9-13wks
 Induction of abortion using
High-dose Oxytocin infusion in second TM
Helps to avoid hemorrhage and perforation of uterus by
curettage
20-300Iu oxytocin with starting dose of 20 Iu for
primigravida and 50Iu for multigravida started with
20drop/min for 20 min and the protocol will be same
with induction
 Saline abortion; A needle is inserted through the mother’s
abdomen and 50-250 ml of amniotic fluid is replaced
with a solution of concentrated salt. Used after 16 weeks
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 Manual vacuum aspiration(MVA)
 Vacuum aspiration is an outpatient procedure w/c
takes less than 15 minutes.
 vacuum aspiration is 98% effective in removing all
uterine contents when the procedure is performed very
early in pregnancy, before 6 weeks gestational age.
 Suction can be created either by
 Electric pump (EVA) or
 Manual pump (MVA).

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 MVA…
 The clinician may first use
1. A local anesthesia to numb the cervix.
2. Use dilators to open the cervix, or sometimes
medically induce dilation with drugs
(mesopristol).
3. Finally, a sterile canula is inserted into the uterus
and attached via tubing to the pump. The pump
creates a vacuum which empties uterine contents.

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 Advantage of MVA
 Has lower rates of complications when compared to D&C
 Is significantly cheaper than D&C
 MVA can be performed as an outpatient procedure
 Performed by mid-level health care providers
 Does not require electricity, MVA also has the advantage
of being quiet, without the noise of an electric vacuum
pump
 Important to have endometrial biopsy

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 Sign of completeness of MVA are;
 Greatening sound
 Decreased bleeding
 Foamy blood will come out
 Resistant cervix
 Uterus will start to contract
 Complication
 Perforation
 Hemorrhage
 Adhesion
 Infection

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 Dilation and curettage (D&C)
 Refers to the dilation (widening/opening) of the cervix
and surgical removal of part of the lining of the uterus
and/or contents of the uterus by scraping and scooping
(curettage ).
 It is a therapeutic gynecological procedure as well as a
rarely used method of first trimester abortion scoop
 D&C normally is referred to a procedure involving a
curette, also called sharp curettage.
 WHO recommends D&C only if vacuum aspiration
unavailable

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  Indication of D&C
 abnormal uterine bleeding
 Remove excess uterine lining
 Retained placenta
 Missed or incomplete abortion

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Complication

Uterine perforation
Hemorrhage
Infection
Ectopic pregnancy
Miscarriage
Pathological adherent placenta
Placenta previa , cervical incompetence
 Complication of abortion
Immediate cxns
 Perforation, bleeding, drug complication
Early cxns
 Pain, bleeding, infection(endometritis, Salpingitis embolism)
Late cxtns
 Menstrual disorders, tubal occlusion, asherman's syndrome
Future pregnancy
 Recurrent abortion
 Ectopic pregnancy
 Premature labor
 APH, PPH
 Rh sensitization
 Psychosexual disturbance
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 Comprehensive abortion care (CAC)
 It is a serious of medical and related interventions designed to
manage the complications of abortion either safe or unsafe
 Have the aim of reducing maternal morbidity and mortality and
improve woman’s sexual reproductive health and lives
 Can be provided for all mothers with abortion
 Has the following components;
1. Emergency treatment of incomplete abortion and abortion
related complications that are life threatening
 Secure IV line
 Give antibiotics accordingly
 Evacuation or curettage

2. Counseling to identify and respond to woman’s emotional

and physical health needs
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 3. Post-abortion family planning counseling and services to
help women‘s to prevent unwanted pregnancy or practice
birth spacing
4. Links between post-abortion emergency services and the
reproductive health care system.
5. Community service provider partnership-provider partnership
to prevent unwanted pregnancies and unsafe abortion,
mobilize resources to help women receive appropriate and
timely care and ensure health services reflect and meet
community expectations and needs

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 Ectopic pregnancy

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 Ectopic pregnancy
 Implantation of fertilized ovum outside of the uterine
endometrium
 99% of ectopic pregnancy occur any where in the
fallopian tube, ampulla is being the commonest site.
 Rare form of ectopic px
 Cervical epx
 Ovarian epx
 Abdominal epx
 Very rare form of epx
 Bilateral epx

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Incidence;
 0.25%-1.4% of all pregnancies
 High in women of age 35-44yrs
 After an ectopic px, there is 7-13 folds increase in the risk of
subsequent ectopic pregnancy
Natural course of ectopic px
 Majority ectopic px ends as gynecologic/obstetric emergency in
the first or early second TM.
 As the fertilized ovum grows, it results progressive distention of
the tube w/c leads to unilateral lower abdominal pain. Further
distention eventually leads either
 Tubal abortion(rupture into the lumen) or
 Tubal rupture(rupture into peritoneal cavity)

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  Ectopic pregnancy will end up within

 6-8wks for isthemic epx

 8-12 wks for ampulla epx

 12-16wks for interstitial epx (why?)

 very rarely abdominal epx reaches term, even born alive

 Unless surgical intervention is undertaken majority of pts die of

massive intra peritoneal bleeding

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 Site of ectopic pregnancy
 Ampulla-55%

 Isthmus -25%
>95%
 Infundibulum and fimbrie-17%

 Interstitial -2%

 Ovary-0.5%

 Cervix-0.1%

 Abdominal -0.3%

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  Risk factors
 Previous tubal pregnancy

 Current IUCD

 Progestin only pills

 Previous tubal surgery

 Ovulation induction

 Tubal damage

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 Risk factors …
 Infection (PID)

 Age >35yrs

 Myoma

 Endometriosis

 Smoking

 Delayed ovulation

 Abortion , tubaligation

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 The risk factors can be summarized into;
1. Tubal factor
 Adhesion (due to infection /surgery)
 Anatomical abnormalities
2. Zygote abnormality
 chromosomal abnormalities
Interferes on
 gross malformations
implantation
 neural tube defects
3. Ovarian factor
 Transmigration of the ovum to the contralateral tube
 Post mid cycle ovulation and fertilization
4. Exogenous hormone
 POP

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 Clinical features
 Pain (99%) ( crampy, dull, sharp upper/lower,
unilateral/bilateral abdominal pain), shoulder pain is
suggestive of accumulation of blood
 Vaginal bleeding
 Variable period of missed menstrual period
 Adnexial pain
 Vital sign ranges from normal to profound Shock
 Syncopal attack in case ruptured epx
 Abdominal tenderness
NB; negative culdocentesis doesn’t rule out ectopic
pregnancy
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 Dx
 Hx
 Menstrual hx
 Previous px
 Hx of infertility
 Current contraceptive status
 Current symptoms
 P/E
 v/s may be normal or changed (why?)
 Pelvic and abdominal exam
 Investigation
 HCG, doubling in 66% of cases
 U/S
 Serum Progesterone level less than normal px
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  Lab HCG test and U/S important to confirm the dx
 Culdocentesis ; most valuable bedside diagnostic procedure for
rupture epx. dark red, non clotting blood is invariably confirms
rupture of epx
 Laparoscopy
 Hct, ABO &Rh
DDx
 Abortion
 GTD
 Rapture ovarian cyst PID
 Appendicitis
 UTI

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Complication
 Recurrence
 Hemorrhage
 Infertility
 Abortion
 Molar pregnancy
 Extra tubal pregnancy
 Cervical px
 Ovarian px
 Abdominal px (primary &secondary )
 Interstitial px

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Mgt
 The treatment can be medical or surgical based on
clinical circumstance ,the site of ectopic px, and
available resource.
 For ruptured epx emergency laparatomy to ligate the
bleeding vessels coupled with aggressive resuscitation
to counter act the effect of hypovolumia
 Timely referral to hospital setting with continued
resuscitation along the way is life saving
 Un rupture epx is managed by conservative tubal
surgery or medically using drug like Methotrexate

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  Medical mgt if
 Size is <4cm
 Un rupture
 HCG <1500Iu/L

 Surgical mgt (most widely used )

Conservative
 Linear salpingostomy
 Segmental resection
 Milking into the fimbre
Radical
 Salpingo-opharectomy
 Salpingoectomy guided by laparoscopy
 laparatomy

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 Gestational Trophoblastic Disease

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 Gestational Trophoblastic Disease
 Is the general term for a spectrum of proliferative abnormalities
originating from the trophoblast of the placenta.
Clinical Classification
 Hydatidiform mole (molar pregnancy)
 Complete, or classic
 Incomplete, or partial
 Gestational trophoblastic neoplasia
 Nonmetastatic
 Metastatic
 Low risk (good prognosis)
 High risk (poor prognosis)

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 GTD…
Hydatidiform mole

 Characterized by abnormal proliferation of the placental

trophoblastic cells.

 Abnormal cells distend the uterus and secrete the

polypeptide hormone hCG.

 complete (classic) or partial (incomplete).

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 Gestational trophoblastic tumor (GTT)

Malignant form of GTD, which arises from the

trophoblastic elements of the developing blastocyst,
retains the invasive tendencies of the normal placenta
and remains able to secrete hCG.
 Can be either metastatic or nonmetastatic

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 Incidence
Benign GTD
 Occurs in 1 of 1500 pregnancies in the United States
and in as many as 1 of 125 pregnancies in parts of
eastern Asia.
 Risk factors:
 age < 20 or > 40
 Genetic factors
 Low socioeconomic status
 Protein,folic acid & carotene deficiency
 Previous molar pregnancy

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 Incidence
Malignant GTD
 Develops in 20 % of complete moles
 Identified in 1 of 20,000 pregnancies in the United
States and can occur after any type of pregnancy.
 May follow
 Molar pregnancy (50%)
 Normal pregnancy (25%)
 Spontaneous abortion or ectopic pregnancy (25%)

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 Hydatidiform Mole

 Complete mole
 Partial mole

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 Complete mole
 The whole conceptus is transformed into a mass of
vesicles.
 No embryo is present.
 It is the result of fertilization of anucleated ovum (has
no chromosomes) with a sperm which will duplicate
giving rise to 46 chromosomes of paternal origin only.

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62
 Partial mole

 A part of trophoblastic tissue only shows molar

changes.
 There is a fetus or at least an amniotic sac.
 It is the result of fertilization of an ovum by 2 sperms
so the chromosomal number is 69 chromosomes.

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64
 DIFFERNTIATION BETWEEN COMPLETE & PARTIAL MOLE

Feature Complete Partial

Embryonic or Absent Present
Fetal tissue
Swelling of villi Diffuse Focal

Trophoblastic Diffuse Focal

hyperplasia
Karyotype 46 XX(96%) or 69XXY or
46 XY(4%) 69 XYY
Risk of 20% 4%
persistence
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 Hydatidiform Mole
Characteristics (microscopic features )
Complete mole
a. Marked edema & enlargement of villi.
b. Disappearance of the villous blood vessels
c. Proliferation of the trophoblastic lining of the villi
d. Absence of fetus, cord & amniotic membrane.
e. Normal karyotype (usually XX, rarely XY)

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 Hydatidiform Mole
Characteristics (microscopic features )
Incomplete mole
a. Marked swelling of the villi with atrophic
trophpblastic cells.
b. Presence of normal villi.
c. Presence of fetus, cord and amniotic membrane.
d. Abnormal karyotype, usually triploidy or trisomy.

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 Hydatidiform Mole
Clinical features
 Vaginal bleeding
 Passage of grape like vesicles
 The uterus is often larger than expected in terms of
LMP
 Nausea & vomiting ( 1/3 of pts)
 Preeclampsia (27% of cases)
 Clinical hyperthyroidism (7%)

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 Hydatidiform Mole
Clinical features
 Abdominal pain : may be
 Dull-aching due to rapid distension of the uterus
 Colicky due to starting expulsion
 Sudden & severe due to perforating mole.
 20 to theca luthein cysts (15%)

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 Hydatidiform Mole
Diagnosis
 Passage of vesicular tissue
 A quantitative hCG titer of > 100,000 mlU/ml with
enlarged uterus & bleeding is suggestive of a mole.
 Amniography (honey comb appearance).
 A flat plate of the abdomen after 15 wks fails to show a
fetal skeleton.
 U/S : multiple echoes without normal GS or fetus
(typical snow storm appearance).

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 Hydatidiform Mole
1) Diagnostic studies
 Laboratory tests: CBC, quantitative hCG, coagulation
studies, type and screen and thyroid function tests.
 Imaging studies include chest radiograph to evaluate for
lung metastases and ultrasound

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 Complications
 Hemorrhage
 Infection due to absence of amniotic sac
 Perforation of the uterus
 PIH
 Hyperthyroidism
 Subsequent development of
choriocarcinoma.

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 Management
2) Suction curettage in conjunction with iv
Oxytocin.
3) Hysterectomy is a treatment option for patients
who do not desire future fertility.

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  The risk of developing GTT after
evacuation is
 20% for a complete mole and
 4% for a partial mole.
 High-risk factors associated with persistent
disease include :
 pretreatment hCG > 100,000 mIU/mL
 theca lutein cysts > 6 cm
 age older than 40 years
 previous molar pregnancy.

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 Follow-up
 After evacuation, the expected average time to
complete elimination of hCG is 9 to 11 weeks.
 This period depends on :
 The initial level of hCG,
 The amount of viable trophoblastic tissue
remaining after evacuation
 The half-life of hCG.

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 Follow-up
Determinations of hCG
 at 48 hours post evacuation, then
 weekly until the results are negative for 3
consecutive weeks, then
 every month for 6 months, and then
 yearly.
An increase or plateau in hCG indicates the
development of GTT and necessitates the
initiation of chemotherapy.

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 It is expected that urine pregnancy test is negative
4 weeks after evacuation & serum ß-hCG is
undetectable 4 months after evacuation.
 Early features suggesting molar tissue include:
 Recurrent or persitant vaginal bleeding
 Amenorrhea
 Failure of uterine involution
 Persistence of ovarian enlargement.

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 Follow-up
Physical examination, including a pelvic examination, at
regular intervals until remission to ensure adequate
involution of pelvic organs.
Birth control (recommended for 1 year).
Oral contraceptives or medroxyprogesterone (Depo-
Provera) injections are recommended.
Pregnancy can be attempted after 1 year from the
diagnosis.
Prophylactic Chemotherapy is rarely recommended

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 Future fertility
 Normal pregnancy is the most likely result of
future gestations.
 Risk of :
 a second molar pregnancy is 1% ; risk of
 a third molar pregnancy is 15-28% .
 The risk following three molar pregnancies is nearly
100%.

 Subsequent molar pregnancies may be complete or

partial, regardless of the type of initial molar
pregnancy.

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