1. JHPIEGO in partnership with Save the Children, The Futures Group, The Academy for Educational Development, The American College of Nurse-Midwives and Interchurch Medical Assistance Management of Bleeding in Early Pregnancy Best Practices in Maternal and Newborn Care

2. 2 Vaginal Bleeding in Early Pregnancy Session Objectives To describe best practices for diagnosis of vaginal bleeding in early pregnancy To describe best practices for management of vaginal bleeding during early pregnancy To list post-abortion family planning options

3. 3 Vaginal Bleeding in Early Pregnancy Case Study Let everyone read Case Study 1 and discuss in group.

4. 4 Vaginal Bleeding in Early Pregnancy Definition and Incidence Bleeding in Early Pregnancy is: –Vaginal bleeding that occurs during the first 22 weeks of pregnancy –May occur in up to 25% of all pregnancies

5. 5 Vaginal Bleeding in Early Pregnancy What may cause bleeding...... in early pregnancy?

6. 6 Vaginal Bleeding in Early Pregnancy Bleeding in Early Pregnancy: Diagnosis of Abortion Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Septic abortion Missed abortion Ectopic pregnancy Molar pregnancy

7. 7 Vaginal Bleeding in Early Pregnancy Types of abortions (1) Threatened Abortion –Uterine bleeding –Cervix closed –Risk of Complete Abortion: 50% Inevitable Abortion –Bleeding and/or rupture of gestational sac <20 weeks –Cervix dilated –Menstrual-type cramping –No products of conception expelled yet

8. 8 Vaginal Bleeding in Early Pregnancy Types of abortions (2) Incomplete Abortion –Incomplete evacuation of products of conception Complete Abortion –Complete evacuation of products of conception –Difficult to differentiate from Incomplete Abortion May require dilatation and curettage for diagnosis

9. 9 Vaginal Bleeding in Early Pregnancy Types of abortions (3) Missed Abortion (fetal demise) –Retained non-viable products of conception, up to 4 weeks –May cause coagulopathy Septic abortion –Abortion complicated by infection

10. 10 Vaginal Bleeding in Early Pregnancy Types of abortions (4) Spontaneous Abortion –Gestational age <20 weeks –Weight <500 grams Induced Abortion –Elective Abortion or –Therapeutic Abortion

11. 11 Vaginal Bleeding in Early Pregnancy Ectopic pregnancy The result of an abnormality in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in the death of the fetus. Ectopic pregnancy sites Source: Vicken Sepillan, MD. Dept. of OB/GYN, Univ. of Texas

12. 12 Vaginal Bleeding in Early Pregnancy Bleeding in Early Pregnancy: General Management Rapid evaluation of woman’s general condition including vital signs (pulse, blood pressure, respiration, temperature) If shock suspected, immediately begin treatment. If woman is in shock, consider ruptured ectopic pregnancy. Start an IV infusion and infuse IV fluids.

13. 13 Vaginal Bleeding in Early Pregnancy Management of Threatened Abortion Medical treatment usually not necessary. Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary. If bleeding stops, followup in antenatal clinic. Reassess if bleeding recurs. If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound). Persistent bleeding, esp. in the presence of uterus larger than expected may indicate twins or molar pregnancy. Do not give medications such as hormones (e.g. estrogens or progestins) or tocolytic agents (e.g. salbutamol or indomethacin) as they will not prevent miscarriage.

14. 14 Vaginal Bleeding in Early Pregnancy Inevitable Abortion Management of Inevitable Abortion If pregnancy is less than 16 weeks, plan for evacuation of uterine contents. If evacuation not immediately possible: –Give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary); –Arrange for evacuation as soon as possible. Ensure follow-up after treatment.

15. 15 Vaginal Bleeding in Early Pregnancy Inevitable abortion contd. If pregnancy is greater than 16 weeks: –Await spontaneous expulsion of products of conception and then evacuate uterus to remove any remaining products of conception –If necessary, infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min to help expulsion of products of conception

16. 16 Vaginal Bleeding in Early Pregnancy Incomplete Abortion: Management of Incomplete Abortion: Less than 16 Weeks If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix. If bleeding heavy, evacuate uterus: –Manual vacuum aspiration (MVA) is preferred method. Sharp curettage should only be done if MVA not available –If evacuation not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours if necessary). –Ensure followup of the woman after treatment.

17. 17 Vaginal Bleeding in Early Pregnancy Manual Vacuum Aspiration (MVA) of uterus

18. 18 Vaginal Bleeding in Early Pregnancy Management of Incomplete Abortion: Greater than 16 Weeks Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of POC occurs Evacuate any remaining products of conception from uterus by dilatation and curettage If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg. Ensure followup of the woman after treatment.

19. 19 Vaginal Bleeding in Early Pregnancy Bleeding in Early Pregnancy: Management of Complete Abortion Evacuation of the uterus usually not necessary Observe for heavy bleeding Ensure followup of woman after treatment

20. 20 Vaginal Bleeding in Early Pregnancy Bleeding in Early Pregnancy: Followup after Abortion Tell woman that spontaneous abortion is common. Reassure woman that chances for subsequent successful pregnancy are good unless there has been sepsis or unless cause of abortion is identified that may have an adverse effect on future pregnancies (rare).

21. 21 Vaginal Bleeding in Early Pregnancy Follow-up after spontaneous abortion Encourage her to delay next pregnancy until completely recovered. Provide counseling for women who have had unsafe abortion. If pregnancy not desired, certain FP methods can be started immediately (within 7 days) if: –There are no severe complications requiring further treatment –Woman receives adequate counseling and help in selecting most appropriate FP method.

22. 22 Vaginal Bleeding in Early Pregnancy Family Planning Methods after Post-abortion Care Type of FP Method Advise to Start HormonalImmediately CondomsImmediately IUD Or Voluntary Tubal Ligation Immediately If infection present or suspected, delay insertion/surgery until cleared If Hb < 7 g/dL, delay until anemia improves Provide interim method (e.g. condom)

23. 23 Vaginal Bleeding in Early Pregnancy ECTOPIC PREGNANCY Pregnancy which is outside the uterine cavity –Can be in the tube, ovary, abdomen or other locations –If it ruptures, can lead to hemorrhage and death

24. 24 Vaginal Bleeding in Early Pregnancy Ectopic Pregnancy: Clinical Diagnosis Symptoms: –Pain: 90-100% of patients –Amenorrhea/abnormal menses: 75-95% –Irregular bleeding: 50-80% –Pregnancy symptoms: 10-25% Weckstein 1987.

25. 25 Vaginal Bleeding in Early Pregnancy Ectopic pregnancy: Clinical Diagnosis (cont’d) Signs: –Afebrile –Abdominal tenderness: 80-95% –Rebound tenderness: 45% –Palpable mass: 50% (often opposite side) –Normal sized uterus: 71% Use combination testing to increase sensitivity and specificity

26. 26 Vaginal Bleeding in Early Pregnancy Signs and Symptoms of Unruptured Ectopic Pregnancy Symptoms of early pregnancy –Irregular spotting or bleeding –Nausea –Swelling of breasts –Bluish discoloration of vagina and cervix –Softening of cervix –Slight uterine enlargement –Increased urinary frequency Abdominal and pelvic pain

27. 27 Vaginal Bleeding in Early Pregnancy Signs and Symptoms of Ruptured Ectopic Pregnancy Collapse and weakness Fast, weak pulse (≥110/minute) Hypotension Hypovolemia Acute abdominal and pelvic pain Abdominal distension Rebound tenderness Pallor Ruptured ectopic pregnancy seen through a laparoscope Source: Vicken Sepillan, MD Dept. of OB/GYN, Univ. of Texas

28. 28 Vaginal Bleeding in Early Pregnancy Threatened abortion Acute or chronic PID Ovarian cysts (torsion or rupture) Acute appendicitis Remember: A ruptured ectopic pregnancy could be life-threatening! Differential Diagnosis for Ectopic Pregnancy

29. 29 Vaginal Bleeding in Early Pregnancy Treatment of Ectopic Pregnancy Surgical-Salpingectomy (removal of the pregnancy or tube) Also treated medically, although not available in developing countries

30. 30 Vaginal Bleeding in Early Pregnancy Molar pregnancy Symptoms and signs: –Heavy bleeding –Dilated cervix –Uterus larger than dates –Uterus softer than normal –Partial expulsion of products of conception which resemble grapes

31. 31 Vaginal Bleeding in Early Pregnancy Molar pregnancy contd. Gross and histology

32. 32 Vaginal Bleeding in Early Pregnancy Molar Pregnancy contd. If diagnosis of molar pregnancy is certain, evacuate the uterus: –Use vacuum aspiration Risk of perforation using a metal curette is high Have three syringes cocked and ready for use as uterine contents are copious and must be evacuated rapidly –Infuse oxytocin 20 units in 1 L IV (NS or RL) at 60 drops/minute to prevent hemorrhage once evacuation is under way

33. 33 Vaginal Bleeding in Early Pregnancy Molar pregnancy contd. Subsequent management –Use contraception for at least one year –Follow up every 8 weeks for at least one year to monitor for trophoblastic disease or choriocarcinoma

34. 34 Vaginal Bleeding in Early Pregnancy SummarySummary Vaginal bleeding in early pregnancy could be caused by: –Threatened abortion –Incomplete abortion –Complete abortion –Ectopic pregnancy –Molar pregnancy Diagnosis can often be made clinically, saving time and expense Treatment should be directed at the aetiology

35. 35 Vaginal Bleeding in Early Pregnancy ReferencesReferences Ganges F. Bleeding in Early Pregnancy, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. April, 2006. Jongen V. 1996. Ectopic pregnancy and culdo-abdominocentesis. Int J Gynecol Obstet 55: 75-76. Musnick RA. 1982. Clinical test for placenta in 300 consecutive menstrual aspirations. Obstet Gynecol 60:738-741. Weckstein LN. 1987. Clinical diagnosis of ectopic pregnancy. Clin Obstet and Gynecol 30(1):236-244. WHO. Managing Complications in Pregnancy and Childbirth. WHO. Geneva. 2000