1. bleeding in early pregnancy Dr. Abdalla H. Alsadig MD

2. Causes of early bleeding in pregnancy Abortion Ectopic pregnancy Hydatidiform mole

3. Abortion/Miscarriage Definition : any fetal loss from conception until the time of fetal viability at 24 weeks gestation. Definition : any fetal loss from conception until the time of fetal viability at 24 weeks gestation. OR: OR: Expulsion of a fetus or an embryo weighing 500 gm or less Expulsion of a fetus or an embryo weighing 500 gm or less Incidence: 15 - 20% of pregnancies total reproductive losses are much higher if one considers losses that occur prior to clinical recognition. Incidence: 15 - 20% of pregnancies total reproductive losses are much higher if one considers losses that occur prior to clinical recognition. Classification: Classification: 1. spontaneous: 1. spontaneous: occurs without medical or mechanical means. occurs without medical or mechanical means. 2. induced abortion 2. induced abortion

4. Pathology Haemorrhage into the decidua basalis. Haemorrhage into the decidua basalis. Necrotic changes in the tissue adjacent to the bleeding. Necrotic changes in the tissue adjacent to the bleeding. Detachment of the conceptus. Detachment of the conceptus. The above will stimulate uterine contractions resulting in expulsion. The above will stimulate uterine contractions resulting in expulsion.

5. Causes of miscarriage : Fetal causes :  Chromosome Abnormality: - - 50% of spontaneous losses are associated with fetal chromosome abnormalities. - autosomal trisomy (nondisjunction/balanced translocation): is the single largest category of abnormality and → recurrence. occurs in - monosomy (45, X; turner): occurs in 7% of spontaneous abortions and it is caused by loss of the paternal sex chromosome. -, - triploids: found in 8 to 9% of spontaneous abortions. it is the consequence of either dispermy or failure of extrusion of the second polar body,

6. Causes of miscarriage Maternal causes : Maternal causes : 1. 1. Immunological: - alloimmune response: failure of a normal immune response in the mother to accept the fetus for a duration of a normal pregnancy. - autoimmune disease: antiphospholipid antibodies especially lupus anticoagulant (LA) and the anticardiolipin antibodies (ACL) 2. uterine abnormality: - congenital: septate uterus → recurrent abortion. - fibroids (submucus): → (1) disruption of implantation and development of the fetal blood supply, (2) rapid growth and degeneration with release of cytokines, and (3) occupation of space for the fetus to grow. Also polyp > 2 cm diameter. - cervical incompetence: → second trimester abortions.

7. Causes of miscarriage Maternal causes: Maternal causes: 3. Endocrine : - poorly controlled diabetes (type 1/type 2). - hypothyroidism and hyperthyroidism.. (questionable). - Luteal Phase Defect (LPD): a situation in which the endometrium is poorly or improperly hormonally prepared for implantation and is therefore inhospitable for implantation. (questionable). Infections (maternal/fetal): as TORCH infections, Ureaplasma urealyticum, listeria 4. Infections (maternal/fetal): as TORCH infections, Ureaplasma urealyticum, listeria Environmental toxins: alcohol, smoking, drug abuse, ionizing radiation…… Environmental toxins: alcohol, smoking, drug abuse, ionizing radiation……

8. Types of abortion Threatened abortion. Threatened abortion. Inevitable abortion. Inevitable abortion. Incomplete abortion. Incomplete abortion. Complete abortion. Complete abortion. Missed abortion Missed abortion  Septic abortion: Any type of abortion, which is complicated by infection  Recurrent abortion: 3 or more successive spontaneous abortions

9. Clinical features/management Threatened abortion: Threatened abortion: - Short period of amenorrhea. - Short period of amenorrhea. - Corresponding to the duration. - Corresponding to the duration. - Mild bleeding (spotting). - Mild bleeding (spotting). - Mild pain. - Mild pain. - P.V.: closed cervical os. - P.V.: closed cervical os. - Pregnancy test (hCG): + ve. - Pregnancy test (hCG): + ve. - US: viable intra uterine fetus. - US: viable intra uterine fetus.  Management - reassurance. - Rest. - Repeated U/S

10. Inevitable abortion  Clinical feature: - Short period of amenorrhea. - Short period of amenorrhea. - heavy bleeding accompanied with clots (may lead to shock). - heavy bleeding accompanied with clots (may lead to shock). - Severe lower abdominal pain. - Severe lower abdominal pain. - P.V.: opened cervical os. - P.V.: opened cervical os. - Pregnancy test (hCG): + ve. - Pregnancy test (hCG): + ve. - US: non-viable fetus and blood inside the uterus. - US: non-viable fetus and blood inside the uterus. Management: - fluids…..blood. - ergometrinn & sentocinon. - evacuation of the uterus (medical/surgical).

11. Incomplete abortion  Clinical feature : - Partial expulsion of products - Partial expulsion of products - Bleeding and colicky pain continue. - Bleeding and colicky pain continue. - P.V.: opened cervix… retained products may be felt through it. - P.V.: opened cervix… retained products may be felt through it. - US: retained products of conception. - US: retained products of conception.  Treatment as inevitable abortion

12. Complete abortion - expulsion of all products of conception. - expulsion of all products of conception. - Cessation of bleeding and abdominal pain. - Cessation of bleeding and abdominal pain. - P.V.: closed cervix. - P.V.: closed cervix. - US: empty uterus. - US: empty uterus.

13. Missed abortion  Feature: - gradual disappearance of pregnancy Symptoms Signs. - Brownish vaginal discharge. - Brownish vaginal discharge. - Milk secretion. - Milk secretion. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. - US: absent fetal heart pulsations. - US: absent fetal heart pulsations.  Complications - Infection (Septic abortion) - Infection (Septic abortion) - DIC - DIC Treatment - Wait 4 weeks for spontaneous expulsion - evacuate if:  Spontaneous expulsion does not occur after 4 weeks.  Infection.  DIC. - Manage according to size of uterus - Uterus < 12 weeks : dilatation and evacuation. - Uterus > 12 weeks : try Oxytocin or PGs.