HAEMORRHAGE IN EARLY PREGNANCY

CAUSES OF BLEEDING Those related to the pregnant state Abortion Ectopic pregnancy Hydatidiform mole Implantation bleeding Those associated with the pregnant state Cervical lesions

ABORTION

Normal Implantation

DEFINITION Termination of pregnancy before 20 weeks gestation calculated from date of onset of last menses Early Abortion: before 12 weeks Late Abortion: from 12-20 weeks Delivery of a fetus of weight less than 500 grams

INCIDENCE: About 10-20% of hospital pregnancy 10% Illegal 75% occur before 16wks

CLASSIFICATION OF ABORTION SPONTANEOUS INDUSED ISOLATED RECURRENT Threatened Inevitable Complete Incomplete Missed Septic Legal Illegal/ Criminal

ETIOLOGY: 1.OVULAR OR FETAL FACTORS(GENETIC FACTORS) a) OVO-FETAL FACTORS Chromosomal abnormality Gross congenital malformation Blighted ovum Hydropic degeneration of villi Death or Disease of fetus

OVULAR OR FETAL FACTORS(GENETIC FACTORS)…..Contd b) INTERFERENCE WITH CIRCULATION Knots Twists Entanglements c) LOW ATTACHMENT OF PLACENTA d) TWINS OR HYDRAMNIOS.

ETIOLOGY…..Contd 2. MATERNAL FACTORS Maternal illness Infection Trauma Maternal hypoxia Chronic illness Endocrine factors Trauma Direct Psychic Susceptible individual Amniocentesis Toxic agents

MATERNAL FACTORS……Contd Cervico-uterine factors Cervical incompetence Congenital malformation of uterus Uterine tumour Retroverted uterus Immunological Autoimmune disease Alloimmune disease Antifetal antibodies Blood group incompatibility Premature rupture of membranes Dietetic factors

ETIOLOGY…..Contd 3.PATERNAL FACTORS 4. UNKNOWN

Mechanism of Abortion Before 8 wks Ovum surrounded by the villi with decidual covering is expelled out intact External os fails to dilate Entire mass is accomadated in the dialated cervical canal Also called as cervical miscarriage 8-14 wks Expulsion of fetus leaving placenta & membranes Beyond 14th wks Like mini labour

SPONTANEOUS ABORTION DEFINITION It is defined as the involuntary loss of the products of conception prior to 20 weeks of gestation. INCIDENCE 15% of all confirmed pregnancy 80% occur in first trimester

THREATENED ABORTION

DEFINITION It is a clinical entity where the process of miscarriage has started and not progressed to a state from which recovery is impossible

CLINICAL FEATURES BLEEDING PER VAGINAM Slight bleeding Brownish or bright red in colour Rarely brisk and sharp bleeding specially in the second trimester PAIN Mild backache or dull pain in the lower abdomen

PELVIC EXAMINATION Speculum examination – Bleeding escapes through the closed external os Digital examination – Closed external os Uterine size corresponds to the period of amenorrhoea Uterus and cervix feels soft

INVESTIGATIONS BLOOD URINE USG

TREATMENT BED REST DRUG Sedation and relief of pain – Phenobarbitone 30mg or diazepam 5mg Enema should not be given

GENERAL MEASURES Advice to preserve vulval pads Report pain/bleeding if aggravated Routine note of TPR,Bp and vaginal bleeding

ADVICE ON DISCHARGE Limit her activities for two week Avoid heavy work, strenuous exercise and excitement Coitus is contraindicated

INEVITABLE ABORTION

DEFINITION It is the clinical type of abortion where the changes have progressed to the state where continuation of pregnancy is impossible

CLINICAL FEATURES Increased vaginal bleeding Aggravation of pain in the lower abdomen Pain may be colicky in nature Dilated internal os of cervix through which the products of conception are felt May starts with rupture of membranes or intermittent lower abdominal pain

MANAGEMENT AIM To accelerate the process of expulsion To maintain strict asepsis GENERAL MEASURES Methergin 0.2mg IV fluid Blood transfusion ACTIVE TREATMENT Before 12weeks D/E followed by blunt curette S/E followed by curettage After 12weeks Uterine contraction accelerated by oxytocin Placenta if seperated and retained removed with ovum forceps If placenta is not seperated,digital seperation followed by evacuation

COMPLETE ABORTION

DEFINITION When the products of conception are expelled en masse,it is called complete miscarriage

CLINICAL FEATURES Subsidence of abdominal pain Vaginal bleeding becomes trace or absent INTERNAL EXAMINATION Uterus is smaller than the period of amenorrhoea and little firmer Cervical os is closed Bleeding is trace Expelled mass is found complete

MANAGEMENT S/E or curettage if uterine cavity is not empty Rh negative women – Anti D gamma globulin

INCOMPLETE ABORTION

DEFINITION When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it is called as incomplete miscarriage

CLINICAL FEATURES Continuation of pain lower abdomen Persistence of vaginal bleeding INTERNAL EXAMINATION Uterus smaller than the period of amenorrhoea Patulous cervical os often admitting the tip of the finger Varying amount of bleeding Expelled mass is found incomplete

COMPLICATIONS Profuse bleeding Sepsis Placental polyp

MANAGEMENT IN RECENT CASES Evacuation of the retained products of conception(ERCP) She should be resuscitated before any active treatment EARLY ABORTION D/E under analgesia or GA LATE ABORTION Uterus is evacuated Products are removed by ovum forceps or blunt curette

MEDICAL MANAGEMENT Tablet Misoprostol 200µg vaginally every 4 hours

MISSED MISCARRIAGE

DEFINITION When the fetus is dead and retained inside the uterus for a variable period it is called missed miscarriage or early fetal demise

PATHOLOGY….BEYOND 12 WEEK Baby is dead Become macerated Liquor amnii gets absorbed Placenta becomes pale,thin and adherent

PATHOLOGY….BEFORE 12 WEEK CARNEOUS MOLE Small hemorrhages in the choriodecidual space Disrupt the villi from its attachment Bleeding is slight, it does not rupture the decidua capsularis Clotted blood remain within the ovum BLOOD MOLE Ovum is dead Fluid portion of the blood gets absorbed and walls become fleshy FLESHY OR CARNACEOUS MOLE

CLINICAL FEATURES Persistence of brownish vaginal discharge Subsidence of pregnancy symptoms Retrogression of breast changes Cessation of uterine growth Non audible FHS Cervix feels firm Immunological test of pregnancy becomes negative USG – empty sac,absence of fetal motion or fetal cardiac movement

COMPLICATION Psychological upset Infection Blood coagulation disorders During labour Uterine inertia Retained Placenta PPH

MANAGEMENT EXPECTANT MEDICAL SURGICAL

MANAGEMENT….UTERUS LESS THAN 12 WEEKS EXPECTANT Expel the conceptus spontaneously MEDICAL PG E1(Misoprostol) 800mg vaginally Repeated after 24 hours Expulsion occur within 48 hours SURGICAL S/E D/E

MANAGEMENT….UTERUS MORE THAN 12 WEEKS PROSTAGLANDIN E1 (MISOPROSTOL) 200 µg Vaginally in the posterior fornix Every 4hours for a maximum of 5 OXYTOCIN ERPC D/E

SEPTIC MISCARRIAGE

DEFINITION Any abortion which is associated with clinical evidences of infection of the uterus and its contents is called septic abortion

CLINICAL FEATURE Pyrexia with chills and rigor Pain abdomen A rising pulse rate of 100-200/min Variable systemic and abdominal findings INTERNAL EXAMINATION Purulent vaginal discharge Tender uterus Patulous os or boggy feel of the uterus

CLINICAL GRADING GRADE I Infection is localised in the uterus GRADE II Infection spreads beyond the uterus GRADE III Peritonitis,endotoxic, shock,jaundice,acute renal failure

INVESTIGATION Cervical or high vaginal swab taken prior to internal examination Blood for hemoglobin Urine analysis SPECIAL INVESTIGATION USG X-ray Blood – culture, coagulation profile and S.Electrolyte

COMPLICATIONS IMMEDIATE Haemorrhage Injury Spread of infection Generalised peritonitis Endotoxic shock Acute renal failure Thrombophlebitis REMOTE Chronic debility Chronic pelvic pain Dyspareunia Ectopic pregnancy Secondary infertility

MANAGEMENT GENERAL MANAGEMENT Hospitalisation To take high vaginal or cervical swab Vaginal examination Overall assessment of the case Investigation protocol Formulate line of treatment AIM To control sepsis To remove source of infection To give supportive therapy To remain vigilant

MANAGEMENT…….Contd GRADE I Antibiotic Prophylactic anti gas – gangrene serum of 8000 units - IM Antitetanus serum 3000 units – IM Analgesics and sedatives Blood transfusion Evacuation of the uterus

MANAGEMENT…….Contd GRADE II Antibiotic Clinical monitoring – TPR,urine output, progress of pain, tenderness and mass in the lower abdomen Evacuation of the uterus Posterior colpotomy

MANAGEMENT…….Contd GRADE III Antibiotic Clinical monitoring Supportive therapy Management of Endotoxic shock and renal failure

RECURRENT MISCARRIAGE

DEFINITION Recurrent miscarriage is defined as three or more consecutive spontaneous miscarriage

ETIOLOGY FIRST TRIMESTER ABORTION Genetics Endocrinal Poorly controlled diabetic Presence of thyroid autoantibodies Inadequate leuteal phase PCOD Infection Immunological causes Autoimmunity Alloimmunity Idiopathic

SECOND TRIMESTER ABORTION CAUSES CERVICAL INCOMPETENCE DIAGNOSIS History Internal examination INVESTIGATION Passage of No 6-8 Hegar dilator Pre menstrual hystero- cervicography USG

SECOND TRIMESTER ABORTION CAUSES…Contd UTERINE SYNECHAE UTERINE FIBROID RETROVERTED UTERUS CHRONIC MATERNAL ILLNESS INFECTION IDIOPATHIC

INVESTIGATION Blood glucose TFT ABO and Rh Toxoplasma antibodies Serum LH USG Hysterosalpinography Hysteroscopy or laproscopy Karyotyping Endocervical swab

TREATMENT INTERCONCEPTIONAL PERIOD Alleviate anxiety To correct uterine pathology Genetic counselling Treat PCOS Treat endocrine dysfunction

TREATMENT DURING PREGNANCY Reassurance and tender loving care USG Rest Avoid strenuous activities, intercourse and travelling Progesterone and HCG Aspirin,Prednisolone and heparin injection Circlage operation Alloimmunity husbands leukocyte injectios