King Khalid University Hospital Department of Obstetrics & Gynecology Course 482 BLEEDING IN EARLY PREGNANCY

SPONTANEOUS ABORTION Definition: Abortion termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks) Incidence: 15% It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups: 1. Threatened 4. Missed 2. Inevitable 5. Recurrent abortion 3. Incomplete 6. Septic Abortion

Threatened Abortion: 25% of pregnancies This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy. In practice any case of bleeding before the 24th wks may be classed as threatened abortion in the absence of any other explanation.

Management: Slight bleeding which may persist for weeks, mild pain, internal os closed. It is then essential to decide whether there is any possibility of continuation of the pregnancy by vaginal ultrasound gestation sac can be seen by scan 33-35 days after LMP

Serial qualitative HCG level: BHCG level – 1000 miu/ml if gest. Sac seen  BHCG less than 1000  unlikely to survive. Qualitative BHG level should ↑ 65% every 48 hours. S. Progesterone level The 5 ng/ml associated dead fetus > 25ng/ml associated with alive fetus Expectant observation No benefit from use of progesterone or bed rest although it is often advised.

Inevitable Abortion Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental  fetus is dead. Pain usually more. Dilated internal os. USS – Non viable fetus. P.T. +ve Emergency suction: D & C

Complete Abortion Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding Examination confiremd dilated os of Cx. Minimal current bleeding TVU – empty uterus R/O ectopic pregnancy by serial BHCG level until P.T. -ve Anti D injection if patients RH – ve to prevent sensitization

Incomplete Abortion If the internal cervical os is open and patient has passed some tissue. Management: Emergency suction and curettage

Missed Abortion It is defined as retention of dead products of conception in utero for several weeks. Symptoms of early pregnancy disappear Uterus not only has ceased to enlarge but also has become smaller. Occasionally serious coagulation defect may develop. Abnormal sonographic finding: Irregular gest. Sac Trophoblastic reaction Irregular and thin Yolk sac not seen Absent embryo or amorrphous

Septic Abortion Uterine infection at any stage of abortion causes: Delay in evacuation of uterus Delay seeking advice Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours: Anaerobic streptococcus Clostridium welchin Bacterial fragilis Coliform bacilus

Trauma: Treatment: Perforation or cervical tear Criminal abortion Should be active to minimize risk of septic shock Cervical & HVS, blood culture Blood spectrum antibiotic Evacuation – perforation is common Hystrectomy

Induced Abortion Therapeutic abortion – termination of pregnancy before time of fetal viability for the purpose of safe guarding the health of the mother. Heat disease, invasive Ca of Cx. A certificate of opinion is given by 2 heart consultant obstetrician. Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of inpaired maternal health or fetal disease.

Cont: Illegal abortion usually performed in unsterile condition by operators with little or nor medical training. It is often incomplete and complicated by:  Hemorrhage  Infection Infertility tubal occlusions Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

Recurrent Miscarriage When a woman has had 3 consecutive miscarriage. Risk of abortion for next pregnancy: 1 abortion  15% 1 Normal pregnancy  15% 1 Abortion 1 Normal  25% 2 Abortion 2 abortion  40%

Etiology and Investigation: 1. Genetic factors Karyotyping of both partners will reveal chromosome anomalies 2. Anatomical factors Uterine anomalies Cervical incompetence Hysteroscopy & HSG – Septum / Fibroid 3. Endocrine problem ↑ LH in PCO 4. Immunological factors Recurrent miscarriage is common in couples with similar HLA types Common in women with antiphopholipid antibodies syndrome Anticardiolipid ant. & Lupus anticoagulant Maternal disease SLE, Renal disease Encironmenta factor: Smoking / Alcohol

Abortion Technique: Surgical / Medical Medical : Oxytocin Prostaglandins Anti progesterone Ru 486 (Mifepristone) Surgical : Suction, D & C Prostaglandin vaginal suppressions applied to Cx. To ripen or soften and dilated cervix before termination by curettage or as adjunct for mifepristone termination

1. Confirm diagnosis – history examination MANAGEMENT OF ABORTION 1. Confirm diagnosis – history examination If unsure of date of LMP And /or irregular cycle Take serum hCG If sure of date of LMP and / Or regular cycle, i.e.> 6 weeks’gestation, arrange TV ultrasound and classify Miscarriage according to RCOG guidelines If hCG > 1000, Use protocol for Suspected ectopic pregnancy If hCG (?miscarriage/ ? Early intrauterine/ ? Ectopic pregnancy If viable pregnancy (threatened miscarriage)  Reaasure  Check whether pregnancy is wanted or not and give appropriate written info and arrange follow-up.  Offer repeat scan in 2 weeks if further significant bleeding, otherwise offer nuchal thickness scan between 11 and 14 weeks followed by detailed anomaly scan at 20 weeks.  Give anti-D if >12 weeks and Rhesus negative

2. If complete miscarriage (bleeding settled and endometrium <15mm)  Reassure and give appropriate written information  Give anti-D if> weeks and Rhesus negative  Home pregnancy test in 2 weeks Spontaneous incomplete or delayed (missed) or inevitable (cervical os open) miscarriage Exclude  Haemodynamically unstable (BP 90/50 mmHg pulse > 100 bpm  Septic (temp >37.50C)  Anaemic (Hb <10g/Dl)  Significant medical disorder Inform consultant and admit to gynecology ward for surgical management Discuss surgical and conservative treatment and give written information

Conservative management Review weekly clinically and serum hCG Surgical management Organize ERPC Emergency admission to Ward or to DSU Rescan if still bleeding in 2 weeks to confirm complete miscarriage (endometrium <15mm) Complete miscarriage Home pregnancy test 2 weeks later Incomplete miscarriage Consider surgery

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