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First Trimester Bleeding

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... applied to a spectrum of inter-related diseases originating from the placental trophoblast Trophoblastic Disease Gestational trophoblastic disease , ... – PowerPoint PPT presentation

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Title: First Trimester Bleeding


1
First Trimester Bleeding
  • Prepared By
  • Ass,Professor Dr Fahmi El-Uri
  • MB,ChB(Hons), MRCOG,FRCOG

2
First Trimester Bleeding Causes
  • 1- Spontaneous abortion / miscarriage
    2- Ectopic pregnancy
  • 3-Trophoblastic disease
  • 4- Cervical polyps
  • 5- Friable cervix
  • 6- Trauma
  • 7- Cervical cancer

3
First Trimester Laboratory Tests
  • 1- Quantitative ßhCG
  • a- Correlate with gestational age U/S
  • b- 2 measurements,2days apart-doubling
  • c- Falling or plateauing ,signal problem
  • 2- Progesterone
  • a- lt 5ng/ml likely predicts poor outcome
  • b- gt 25 ng/ml associated with living IUP

4
Lab Ultrasound correlates
Serum ßhCG mIU/ml TVS Vaginal scan TAS Abdominal scan Gestational age by LMP
1500 Possible gestational sac None lt 5 weeks
4000-6000 Gestational sac,yolk sac Gestational sac 5-6 weeks
gt 20,000 Same as TAS with FH 5-10mm embryo 7 weeks
5
Indications for First Trimester Ultrasound
  • 1- Suspect miscarriage or fetal death
  • 2- Vaginal bleeding
  • 3- Gestational age (uncertain dates )
  • 4- Adjunct to procedures ( e.g. CVS )
  • 5- Suspected multiple gestation
  • 6- suspected hydatidiform mole
  • 7- suspected ectopic pregnancy
  • 8- IUD localization
  • 9- Evaluation of maternal pelvic masses

6
First Trimester Ultrasound
  • - Best when performed in combination with
    history,physical examination relevant
    laboratory tests
  • - Often used as primary tool in evaluating first
    trimester complications
  • - Transvaginal and transabdominal should be
    obtained

7
Miscarriage
  • 1. A variety of terms have been used to describe
    and define early pregnancy loss
  • 2. We have to differentiate between abortion
    miscarriage
  • 3. Abortion means terminate of unwanted
    pregnancies by a variety of methods , and illegal
    abortion has been the source of considerable
    maternal morbidity and mortality

8
Miscarriage
  • Definition
  • The loss of an early pregnancy is the commonest
    medical complications of the first trimester of
    pregnancy
  • Many conceptions are lost during the first month
    after the last menstrual period and are often
    ignored, particularly if they occur around the
    time of an expected menstrual period

9
Definitions
  • 1- Spontaneous miscarriage
  • Involuntary loss during the first 20 weeks
  • 2- Threatened miscarriage
  • Uterine bleeding, closed cervix, no products
  • of conception passed
  • 3- Incomplete miscarriage
  • Some , but not all , products have passed
  • 4- Inevitable miscarriage
  • Cervix dilated , products not passed

10
Definitions ( continue )
  • 5- Missed miscarriage
  • Fetus dead, but no tissue passed, cervix closed.
  • 6- Septic miscarriage
  • Incomplete miscarriage with ascending infection .
  • 7- Blighted ovum
  • Identifiable sac placental tissue, but no
    embryo.

11
Definitions ( continue )
  • 8- Subchorionic hemorrhage
  • Blood between chorion and uterine wall.
  • 9- Decidua
  • Endometrium of pregnancy that is frequently
    passed as part of a miscarriage.
  • When the decidua is passed intact it is called a
    decidual cast, which often signifies an ectopic
    pregnancy .

12
Pathophysiology of miscarriage
  • 1- Major genetic anomaly
  • At least one half of all spontaneous miscarriages
    are the result of a major genetic anomaly ,
    trisomy,triploidy or monosomy
  • 2- Internal environmental factors
  • Uterine anomalies, leiomyomata, incompetent
    cervix
  • Maternal diethylstillbestrol ( DES ) exposure
  • Luteal phase defect
  • Immunologic factors
  • 3- External environmental factors
  • Tobacco, alcohol, cocaine
  • Irradiation
  • Infection
  • Occupational chemical exposure
  • 4- Advanced maternal age

13
Clinical course of miscarriage
  • 1- Missed menses, pregnancy symptoms
  • 2- Positive ßhCG
  • 3- Vaginal bleeding
  • 4- ßhCG falls or plateaus
  • 5- Lower abdominal cramping, backache
  • 6- Products of conception passed

14
Physical Examination
  • 1- Abdominal exam
  • Pain location , rebound, distension
  • 2- Speculum exam
  • To assess cx dilatation
  • To rule out non-uterine causes of bleeding
  • 3- Bimanual exam
  • To assess uterine size, adnexal masses

15
Fetal Heart tones
  • Listen after 9-10 weeks with Doppler
  • Sensitivity enhanced by elevating uterus during
    bimanual exam

16
Management of Miscarriage
  • 1- 50 loss when bleeding present
  • 2- Presence of FHTs reassuring
  • 3- Majority do not require medical or surgical
    intervention
  • 4- Identify patients at risk for bleeding,
    infection
  • 5- Address contraceptive needs

17
Ectopic Pregnancy
  • Pregnancy outside the uterus , usually in the
  • Fallopian tube .
  • Occurs in gt1100 pregnancies .
  • Second most common cause of M. Mortality.
  • Early diagnosis critical !

18
Definition
  • It is a gestation that implants outside the
    endometrial cavity.
  • gt95 of ectopic pregnancies implant in various
    anatomic segment of fallopian tube including
  • 1 in the interstitial
  • 5 in the isthmic
  • 85 in the ampullary portion
  • 9 in the infundibular fimbrial portion.

19
Other sites of ectopic
  • Other less sites of ectopic pregnancies are
  • The ovary , cervix , the peritoneal cavity .

20
Introduction
  • The Diagnosis management of ectopic pregnancy
    has undergone a revolution a century after Lawson
    Tait successfully performed a laparotomy to
    ligate broad ligament remove a ruptured tube in
    1883(Tait 1884).
  • Improved technology allows to diagnose ectopic
    pregnancy before it ruptures thus making less
    invasive treatment possible,
  • Resulting in reduced Maternal Mortality and
  • Morbidity .

21
Incidence
  • 1- In USA deaths due to ectopic pregnancy was 9
    of all maternal deaths in 1992and its incidence
    has apparently increased fourfold (from 4.5 to
    20/1000pregnancies between 1970 1992(Centers of
    Disease Control 1995 )
  • 2- In UK it represent 4.2 of Maternal death in
    1991-1993, its incidence apparently doubling
    between 1973-75 and1991-93 (from 4.9 to 9.6 per
    1000pregnancies) Department of Health1994.

22
Risk factors for Ectopic
  • 1- History of previous ectopic pregnancy
  • 2-Prior tubal surgery
  • 3-Prior tubal infection
  • 4-Progestin-only contraception
  • 5-Contraceptive IUD
  • 6- In utero Diethylstilbestrol(DES) exposure
  • Many occur in women with no risk factors!

23
Clinical Presentation
  • It can vary from vaginal spotting of old blood to
    vasomotor shock with hematoperitoneum.
  • The classic triad of
  • a- Delayed menses ,
  • B- Irregular vaginal bleeding ,
  • C- Abdominal pain ,
  • The above is not commonly encountered ( speroff
    el al 1994 )

24
General Examination
  • A- Pulse rate blood pressure , because in
    vascular instability BP is low ,fainting,
    dizziness and rapid Heart rate .
  • B- Shoulder pain , occurs due to blood irritating
    the diaphragm as a result of rupture ectopic
    causing intra-abdominal bleeding .

25
Gynaecological Examination
  • Speculum or Bimanual examination must be
    performed in Hospital because it may lead to
    rupture of the tube .

26
Diagnosis of Ectopic
  • 1- Failure of ßhCG to double in 48 hours
  • 2- Low serum progesterone
  • 3- Ultrasound ( transvaginal )
  • a- IUP rules out ectopic
  • b- No gestational sacßhCGgt1500, highly
  • suggestive
  • c- Gestational sac/embryo outside of uterus
    confirms ectopic
  • d- Pitfalls pseudogestational sac,ruptured
    corpus luteum
  • 4- Laparoscopy gold standard

27
Extrauterine signs of Ectopic
  • Finding Risk of
    Ectopic
  • No mass or free fluid
    20
  • Any free fluid
    71
  • Echogenic mass
    85
  • Moderate to large amount of fluid 95
  • Echogenic mass with fluid 100

28
Culdocentesis
  • The test is used to exclude hemoperitoneum which
    is associated with ruptured ectopic pregnancy,
    therefore it is not useful in detecting an early
    ectopic pregnancy .
  • 18 or 20 gauge needle passed through the
    posterior fornix to aspirate for fluid .
  • Bloody fluid with hematocrit gt15represents
  • active intraperitoneal bleeding .
  • TVS has replaced nowadays culdocentesis.

29
hCG Vaginal ultrasound
  • hCG can be detected in the urine as early as
    14days(Post conception), by sensitive
    enzyme-linked immunosorbent assays (detection
    limits 25-40IU/L, and sensitivity 98-100) .
  • It can be detected in the serum 5-9 days
    post-conception by immuno-radioactive assays.

30
hCG ( Continue )
  • Between 2-4 weeks after ovulation serum hCG
    levels double approximately every 2days(48hours)
    in normal pregnancy ,and a lesser increase ( lt66
    over 48 hours) is associated with ectopic
    pregnancy and spontaneous abortion .
  • However,15of normal pregnancy will have an
    abnormal doubling time and 13 of ectopic
    pregnancy will have a normal doubling time .

31
CONTINUE
  • Therefore in order to increase the sensitivity of
    Quantitative hCG ,a discriminatory zone DZ has
    been described whereby a titre of 1000-1500IU/L
    will be associated with the presence of an
    INTRA-UTERINE sac on transvaginal Scan and
    4500-6500 IU/L for trans-abdominal Scan.
  • In multiple pregnancy the Discriminatory zone
    would be a little higher, requiring an extra 2-3
    days for a sac to become visible .

32
CONTINUE
  • 1- The demonstration of a viable IUP does not
    exclude possibility of Heterotopic Pregnancy
    frequency 1 in 30,000 event .
  • 2-TVS( Transvaginal scan), has resulted in the
    diagnosis of normal abnormal pregnancy
    approximately 1 week earlier than using Trans
    abdominal scan TAS.
  • In Ectopic there are an empty uterus,pseudo-sac,
    a tubal ring ( doughnut or bagel sign) with fluid
    in the pouch of douglas .

33
Management Of Ectopic Pregnancy
  • 1- Expectant Management
  • 2- Medical Management
  • 3- Surgical Management

34
Expectant Management
  • Criteria include
  • a- Minimal pain or bleeding
  • b- Reliable follow-up
  • c- No evidence of tubal rupture
  • d- ßhCG lt 1000 and falling
  • e- Adnexal mass lt 3cm, or not detected
  • f- No embryonic heart beat

35
Medical Management Methotrexate
  • 1- Safe, effective ,less costly than surgery
  • 2- Equal or better fertility preservation
  • 3- Criteria for use
  • Stable vital signs , few symptoms
  • No contraindication to drug
  • Unruptured ectopic
  • Absence of embryonic heart activity
  • Ectopic mass 4cm
  • ßhCG levels lt 5000 mIU/ml

36
Methotrexate Dosing
  • 1-Single dose IM regimen with 1mg/kg or 50mg/m²
  • Obtain serum ßhCG on 4th 7th day post-treatment
    ( fall 15 should be expected ) continue follow
    up until level reaches 5mIU/ml in 3-4 weeks
  • 2-Serum progesterone, a drop to 1.5mg/ml means
    successful treatment usually occurs by about
    2-3 weeks
  • 3-Surgical consultation if we need more than one
    dose

37
Surgical Management
  • Mainstay of treatment
  • Conservative conservation of tube
  • Extirpation removal of tube
  • Criteria for selecting surgery
  • Unstable vital signs or hemoperitoneum
  • Uncertain diagnosis
  • Advanced ectopic pregnancy
  • Unreliable follow-up
  • Contraindication to expectant or methotrexate
    management

38
Gestational Trophoblastic Disease GTD
  • Definition
  • It is a term commonly applied to a spectrum of
    inter-related diseases originating from the
    placental trophoblast

39
Trophoblastic Disease
  • Gestational trophoblastic disease , has three
    basic configurations
  • A- Complete hydatidiform mole
  • B- Partial mole
  • C- Mole recurrence ? metastatic choriocarcinoma.
  • GTD is an occasional cause of first trimester
    bleeding should be considered in the
    differential diagnosis until proven otherwise .

40
GTD ( Continue )
  • Complete hydatidiform mole
  • It consists of placental proliferation in the
  • absence of a fetus. The placental villi are
  • swollen often resemble bunches of grapes.
  • Most complete moles have a 46XX chromosomal
    composition , all derived from paternal sources

41
Contnue
  • Partial Mole
  • This refers to molar placenta occuring together
    with a fetus , which is usually non-viable
  • Genetic testing usually reveals triploidy
  • ( 69 XXY )
  • Partial mole is less common than a complete mole
    carries a lower risk of recurrence

42
Recurrence 0f trophoblastic disease
  • About 20 0f women with a complete mole will
    experience recurrence in the form of mole that
    invades the myometrium or becomes aggressively
    metastatic (metastatic choriocarcinoma)

43
Epidemiology
  • GTD occurs in the USA at a rate of in one in 1000
    to 1500 pregnancies, in Asian women in the USA (
    1 in 800 )
  • Higher incidence in Asia ( Taiwan 1in every 125
    to 200 pregnancies )
  • Two factors predispose to trophoblastic disease
  • A- Pregnancy at the extremes of reproductive
    life( specially women over 45) B- Previous molar
    disease

44
Clinical Manifestations
  • 1-Vaginal bleeding 1st/early 2nd trimester
  • Which is often dark in color
  • Grape-like vesicles are passed in cases that
    progress in the 2nd trimester
  • 2-Higher than expected ßhCG levels
  • 3-Uterine sizegtdates without heart tone
  • 4-Hyperemesis
  • 5-Early pregnancy-induced hypertension
  • 6-Thyrotoxicosis
  • 7-Ovarian enlargement( theca-lutein cysts ) due
    to high hCG levels

45
Diagnosis
  • A high index of suspicion is required for early
    diagnosis
  • Ultrasound is the gold standard for diagnosis and
    will show multiple vesicular spaces within the
    uterus ,with an absence of a fetus
  • Enlarged cystic ovaries are common

46
Treatment of GTD
  • 1- Prompt evacuation of the uterus is the primary
    treatment
  • 2- Serial ßhCG monitoring for 6-12 months with
    contraception
  • 3-Recurrence occurs in 20 with complete mole
    invades myometrium or become metastases, so treat
    with chemotherapy ( methotrexate )
  • Most can conceive , carry normal pregnancy

47
Treatment of GTD
  • Treatment has 3 components
  • 1- Evacuation of the uterus
  • The standard therapy for hydatidiform mole is
    suction evacuation followed by sharp curettage of
    uterine cavity ,regardless of duration of
    pregnancy.
  • IV oxytocin is given simultaneously to help
    stimulate uterine contraction ? blood loss.
    This technique is associated with low incidence
    of uterine perforation trophoblastic
    embolization

48
Treatment ( Continue )
  • 2- Monitoring levels of the ßhCG
  • Following evacuation of a hydatidiform mole,
    patient must be monitored with weekly serum
    assays of ßhCG , the level should decline to 1-5
    mIU/ml usually within 12-16 weeks.

49
Treatment ( Continue )
  • 3- Chemotherapy
  • Prophylactic chemotherapy is not indicated in
    patients with molar pregnancy because 90 of
    these individuals have spontaneous remissions .
  • If the ßhCG levels plateau or rise at any time
    Chemotherapy should be initiated
  • Methotrexate 1mg/Kg/day on days 1,3,5,7 followed
    24hr later by 0.1mg/kg/day of folinic acid on
    days 2,4,6,8

50
Prognosis for Future Pregnancies
  • There is 1-2 recurrence rate, most patients can
    conceive carry a normal pregnancy after
    trophoblastic disease
  • Chemotherapeutic agents used to treat recurrences
    have not been shown to affect future pregnancies
  • Clinician should help their patients to overcome
    the psychological impact of this bizarre
    condition

51
Summary of first trimester bleeding
  • Miscarriage can cause significant physical
    psychological morbidity
  • Ectopic pregnancy is a potential cause of
    maternal mortality
  • Serum hormone testing ultrasonography important
    in diagnosis
  • Many patients can be managed nonsurgically
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