Transcript Bleeding in Early Pregnancy, Abortion

Bleeding in Early
Pregnancy
Dr/ Sahar Elkheshen
Lecturer of maternity and neonatal nursing
Faculty of Applied medical sciences
MUST
Objectives:
at the end of this
lecture the student will be able to:
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Type causes of bleeding in early pregnancy.
Define abortion.
List different types of abortion.
Mention clinical picture, prognosis and management
of each type.
Differentiate between all types.
Define ectopic pregnancy.
List possible sites for ectopy.
Mention fate of ectopic pregnancy.
Define Hydatidiform mole of pregnancy.
Mention possible causes and prognosis the mole preg.
Causes:
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Abortion.
Ectopic pregnancy.
Vesicular mole.
Local gynaecological lesions e.g.
cervical ectopy, polyp, dysplasia,
carcinoma and rupture of varicose
vein.
I - ABORTION
Definition
Termination of pregnancy before viability of
the foetus i.e. before 28 weeks (in
Britain) and before 20 weeks or if the
foetal weight is less than 500 gm (in USA
and Australia).
When the abortion occurs spontaneously,
the term " miscarriage" is often used.
Aetiology
 Chromosomal abnormalities: cause at least 50% of
early abortions e.g. trisomy.
 Blighted ovum (anembryonic gestational sac).
 Maternal infections: Acute fever for whatever the
cause can induce abortion.
 Trauma: external to the abdomen or during abdominal
or pelvic operations.
 Endocrine causes: Progesterone deficiency ,Diabetes
mellitus, Hyperthyroidism.
 Drugs and environmental causes:
 Maternal anoxia and malnutrition.
 Over distension of the uterus: e.g. acute hydramnios.
Continued,
 Immunological causes:
 Systemic lupus erythematosus.
 Antiphospholipid antibodies that are directed
against platelets and vascular endothelium leading
to thrombosis, placental destruction and abortion.
 Ageing sperm or ovum.
 Uterine defects Septum, Asherman's
syndrome (intrauterine adhesions).
 Nervous, psychological conditions and over
fatigue.
 Idiopathic.
Threatened Abortion
Clinical picture:
 Symptoms and signs of pregnancy coincide
with its duration.
 Vaginal bleeding slight or mild, bright red in
colour.
 Pain is absent or slight.
 Cervix is closed.
 Pregnancy test is positive.
 Ultra-sonography shows a living foetus.
Prognosis:
 If the blood loss is less than a normal
menstrual flow and is not
accompanied by pain of uterine
contraction there is a reasonable
chance for continuing pregnancy. This
occurs in 50% of cases while other
half will proceed to inevitable or
missed abortion.
Treatment:
 Rest in bed until one week after stoppage
of bleeding.
 No intercourse as it may disturb pregnancy
by the mechanical effect and the effect of
semen prostaglandins on the uterus.
 Sedatives: if the patient is anxious.
 Treatment of controversy:
 Progestogens.
 Gonadotrophins may be of benefit in cases of
luteal phase deficiency and those get pregnant
with ovulatory drugs.
Inevitable Abortion
Clinical picture:
 Symptoms and signs of pregnancy coincide
(match) with its duration.
 Vaginal bleeding is excessive and may
accompanied with clots.
 Pain is colicky felt in the suprapubic region
radiating to the back.
 The internal os of the cervix is dilated and
products of conception may be felt through
it.
 Rupture of membranes between 12-28
weeks is a sign of the inevitability of
abortion.
Treatment
 Any attempt to maintain pregnancy is
useless.
Incomplete Abortion
 Retention of a part of the products of
conception inside the uterus. It may
be the whole or part of the placenta
which is retained.
Clinical picture
 The patient usually noticed the
passage of a part of the conception
products.
 Bleeding is continuous.
 The uterus is less than the period of
amenorrhoea but still large in size.
The cervix is opened and retained
contents may be felt through it.
 Ultrasonography: shows the retained
contents.
Complete Abortion
 All products of conception have been
expelled from the uterus.
Clinical picture:
 The bleeding is slight and gradually
diminishes.
 The pain ceases.
 The cervix is closed.
 The uterus is slightly larger than normal.
 Ultrasound: shows empty cavity.
Missed Abortion
 Retention of dead products of conception for 4 weeks
or more.
Symptoms:
 Symptoms of threatened abortion may or may not be
developed.
 Regression of pregnancy symptoms as nausea,
vomiting and breast symptoms.
 The abdomen does not increase and may even
decrease in size.
 The foetal movements are not felt or ceases if
previously present.
 A dark brown vaginal discharge may occur (prune
juice discharge).
Signs:
 The uterus fails to grow and becomes firmer
and The cervix is closed.
 The foetal heart sounds cannot be heard.
Investigations:
 Pregnancy test becomes negative within two
weeks from the ovum death.
 Ultrasound shows either a collapsed
gestational sac, absent foetal heart
movement or foetal movement.
Complications:
 Disseminated intravascular
coagulation (DIC) may occur if the
dead conceptus is retained for more
than 4 weeks.
 Superadded infection.
Treatment:
 The dead conceptus is expelled
spontaneously in the majority of cases.
Evacuation of the uterus is indicated in
the following conditions:
 spontaneous expulsion does not occur
within four weeks,
 there is bleeding,
 infection or DIC developed or,
 patient is anxious. Although some
gynaecologists advise evacuation of the
uterus once sure diagnosis of missed
abortion is made.
Evacuation is carried out as
following:
 If the uterine size is less than 12 weeks’
gestation: vaginal or suction evacuation is
done
 If the uterine size is more than 12 weeks'
gestation: evacuation can be done by
 Prostaglandins: given intravaginally (PGE2),
intravenously, intra-or extra- amniotic (PGF2α).
 Oxytocin infusion.
 Combination.
 Hysterotomy: is rarely indicated in 2nd trimester
missed abortion if the medical induction fails
initially and after repetition few days later.
Septic Abortion
 It is any type of abortion, usually
criminal abortion, complicated by
infection.
 Microbiology:
 E.Coli, bacteroids, anaerobic
streptococci, clostridia, streptococci
and staphylococci are among the
most causative organisms.
Clinical picture:
 General examination:
 Pyrexia and tachycardia.
 Rigors suggest bacteraemia.
 A subnormal temperature with tachycardia is
ominous and mostly seen with gas forming
organisms.
 Malaise, sweating, headache, and joint pain.
 Jaundice and /or haematuria is an ominous sign,
indicating haemolysis due to chemicals used in
criminal abortion or haemolytic infection as
clostridium welchii.
 Abdominal examination:
 Suprapubic pain and tenderness.
 Abdominal rigidity and distension indicates
peritonitis.
 Local examination:
 Offensive vaginal discharge. Minimal inoffensive
vaginal discharge is often associated with severe
cases.
 Uterus is tender.
 Products of conception may be felt.
 Local trauma may be detected.
 Fullness and tenderness of Douglas pouch indicates
pelvic abscess which will be associated with
diarrhoea.
Treatment
 Isolate the patient . Bed rest in semisitting position??????????????????.
 An intravenous line is established for
therapy.
 Observation for vital signs:
 A cervico-vaginal swab is taken for
culture and sensitivity,
 Antibiotic therapy:.
 Fluid therapy:
 Blood transfusion: is given if CVP is low
(normal: 8-12 cm water).
Continued,
 Oxytocin infusion: to control bleeding
and enhances expulsion of the retained
products.
 Surgical evacuation of the uterus can
be done after 6 hours of commencing
IV therapy but may be earlier in case of
severe bleeding or deteriorating
condition in spite of the previous
therapy.
 Hysterectomy may be the last choice
to safe life
Other types of abortion
Therapeutic Abortion
 Abortion induced for a medical
indication.
Criminal Abortion
 Illegal abortion induced for a nonmedical indication.
Recurrent (Habitual) Abortion
 Three (two by some authors) or more
consecutive abortions.
Ectopic pregnancy
Definition
 Ectopic means "out of place." In an
ectopic pregnancy, a fertilized egg
has implanted outside the uterus. The
egg settles in the fallopian tubes in
more than 95% of ectopic
pregnancies. This is why ectopic
pregnancies are commonly called
"tubal pregnancies.
Signs and Symptoms
 Ectopic pregnancy can be difficult to
diagnose because symptoms often
mirror those of a normal early
pregnancy. These can include missed
periods, breast tenderness, nausea,
vomiting, or frequent urination.
 The first warning signs of an ectopic
pregnancy are often pain or vaginal
bleeding.
Most common site
Other sites
Fate of ectopic pregnancy
 Tubal abortion
 Tubal rupture
Morbidity and Mortality Rates
 Abdominal pain occurs in 97% of women
with an ectopic pregnancy,
 Vaginal bleeding in 79%,
 abdominal tenderness in 91%, and
infertility in 15%.
 Persistent ectopic pregnancy after surgical
treatment occurs in 5–10% of cases.
 Ectopic pregnancy accounts for 10–15% of
all maternal death; the mortality rate for
ectopic pregnancy is approximately one in
2,500 cases.
Hydatidiform pregnancy
Hydatidiform Mole
 A hydatidiform mole is a relatively rare
condition in which tissue around a fertilized
egg that normally would have developed
into the placenta instead develops as an
abnormal cluster of cells. (This is also called
a molar pregnancy.) This grapelike mass
forms inside of the uterus after fertilization
instead of a normal embryo.
Causes
 The cause of hydatidiform mole is
unclear;
 some experts believe it is caused by
problems with the chromosomes
 A mole sometimes can develop from
placental tissue that is left behind in
the uterus after a miscarriage or
childbirth.
Symptoms
 Women with a hydatidiform mole will have a positive
pregnancy test and often believe they have a normal
pregnancy for the first three or four months.
 However, in these cases the uterus will grow
abnormally fast.
 By the end of the third month, if not earlier, the
woman will experience vaginal bleeding ranging from
scant spotting to excessive bleeding.
 Sometimes, the grapelike cluster of cells itself will be
shed with the blood during this time.
 Other symptoms may include severe nausea and
vomiting and high blood pressure. As the pregnancy
progresses, the fetus will not move and there will be
no fetal heartbeat.
Prognosis
 A woman with a molar pregnancy often
goes through the same emotions and sense
of loss.
 In addition, there is the added worry that
the tissue left behind could become
cancerous.
 In the unlikely case that the mole is
cancerous the cure rate is almost 100%. As
long as the uterus was not removed, it
would still be possible to have a child at a
later time.
Summary