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Bleeding in Early Pregnancy

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Ectopic pregnancy accounts for 10 15% of all maternal death; the mortality rate for ectopic pregnancy is approximately one in 2,500 cases. – PowerPoint PPT presentation

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Title: Bleeding in Early Pregnancy


1
Bleeding in Early Pregnancy
  • Dr/ Sahar Elkheshen
  • Lecturer of maternity and neonatal nursing
  • Faculty of Applied medical sciences
  • MUST

2
Objectives at the end of this lecture the
student will be able to
  • 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.

3
Causes
  • Abortion.
  • Ectopic pregnancy.
  • Vesicular mole.
  • Local gynaecological lesions e.g. cervical
    ectopy, polyp, dysplasia, carcinoma and rupture
    of varicose vein.

4
I - ABORTION
5
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.

6
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.

7
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.

8
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.

9
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.

10
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.

11
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.

12
Treatment
  • Any attempt to maintain pregnancy is useless.

13
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.

14
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.

15
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.

16
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).

17
  • 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.

18
Complications
  • Disseminated intravascular coagulation (DIC) may
    occur if the dead conceptus is retained for more
    than 4 weeks.
  • Superadded infection.

19
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.

20
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 (PGF2a).
  • Oxytocin infusion.
  • Combination.
  • Hysterotomy is rarely indicated in 2nd trimester
    missed abortion if the medical induction fails
    initially and after repetition few days later.

21
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.

22
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.

23
  • 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.

24
Treatment
  • Isolate the patient . Bed rest in semi-sitting
    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).

25
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

26
Other types of abortion
  • Therapeutic Abortion
  • Abortion induced for a medical indication.
  • Criminal Abortion
  • Illegal abortion induced for a non-medical
    indication.
  • Recurrent (Habitual) Abortion
  • Three (two by some authors) or more consecutive
    abortions.

27
Ectopic pregnancy
28
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.

29
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.

30
Most common site
31
Other sites
32
Fate of ectopic pregnancy
  • Tubal abortion
  • Tubal rupture

33
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 510 of cases.
  • Ectopic pregnancy accounts for 1015 of all
    maternal death the mortality rate for ectopic
    pregnancy is approximately one in 2,500 cases.

34
Hydatidiform pregnancy
35
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.

36
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.

37
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.

38
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.

39
Summary
40
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