Vaginal Bleeding in Early Pregnancy

Dr Dalya AlhamdanConsultant Ob/ Gyn

Salmaniya Medical Complex

Detailed Hx: Present pregnancy: LMP, Gx, previous USS

Obstetric HxMedical, surgical, Systemic review

Physical examUltrasoundβ-hCG

MiscarriagePregnancy loss occurring before 24 completed

weeks of gestation or of a fetus less than 500gm weight if gestation is unknown

Threatend MiscarriageAny vaginal bleeding: spotting, brownish, bleedingProducts of conception are intact and Cx os is

closed

Inevitable miscarriageMiscarriage is imminent or is in the process

of happening Threatened miscarriage with an open

cervical os and/or rupture of the membranes

Incomplete miscarriageA miscarriage where some of the fetus or

placenta are unable to be spontaneously expelled by the mother

complete miscarriageA miscarriage needing no medical or surgical

interventionsProducts of conception have been passed; USS

shows no apparent products; bleeding generally settles

Miscarriage

Threatened Miscarriage

Missed MiscarriageTVS showing no FH with fetal pole >7mm or GS >25mm

without fetal pole or lack of sac/fetal growth over 7 days period

Incomplete MiscarriageHx: Woman c/o PVB and lower abdominal pain, passed

clots or tissue P/E: Cervical os open, products in cervix

Causes of miscarriage

1. Embryonic abnormalities/chromosomal2. Immunological diseases3. Uterine abnormalities

4. Cervical incompetence

5. Maternal diseaseo Hypertensiono Renal diseaseo Infection: CMV, rubella, toxo, listeriosiso Diabetes Mellituso Severe malnutrition

Septic MiscarriageAscent of organisms from vagina to uterus, seen

commonly in illegal abortions done under non-sterile conditions

Woman presents with abdominal pain, abnormal PVB with fever and endotoxic shock

Commonest organisms: E. Coli; Streptococcus faecalis

Ectopic pregnancy• Clinical:

– History of amenorrhea– Pelvic pain and/or abnormal bleeding in the first trimester– Shoulder tip pain– Dizziness or spells of fainting– Other evidence of blood in the peritoneum.

• Bio-chemical:– Positive pregnancy test (urine or serum)

On TVS ultrasound:An adnexal mass will not be found in 15-35% of women

with an ectopic pregnancy at presentation, pregnancy of unknown location

Management of Ectopic pregnancyOffer expectant or medical Tx if:- Clinical stabe, stable hemoglobin level on two

measurements (0 and 12-24 h apart) -Absence of acute abdomen-Serum hCG < 3,500 IU/L, adnexal mass measure < 30 mm-Absence of fetal cardiac activity on TVS-Absence of significant hemoperitoneum, defined as blood

above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space).

-Subsequent management: based upon hCG ratio at 0 h/48 h. -ComplianceOtherwise: SURGERY

Molar pregnancy

Benign lesion of cervixEctropion/erosionCentral ( endocervical) columnar epithelium protrudes out through the external os

Cervical polyp

Cervical cancer

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