«

»

Feb 18 2014

Bleeding in Early Pregnancy

Download PDF


  • 2.  MISCARRIAGE  THREATENED  SILENT  INEVITABLE  INCOMPLETE TROPHOBLASTIC DISEASES ECTOPIC PREGNANCY LOCAL CAUSE
  • 3. Clinical presentation
  • 4. Clinical Presentation  Amount of bleeding  Pain  Passage of products
  • 5. MISCARRIAGE SPORADIC MISCARRIAGEDefinitionIn UK : loss of an intrauterine pregnancy before 24 completed weeks of gestation.  WHO : expulsion of fetus / embryo wt < 500 g & gestation limit of < 22 completed wks of pregnancy.
  • 6. MISCARRIAGE SPORADIC MISCARRIAGE A distressing complication of pregnancy  Occur ~ 20% of pregnancies  Majority of sporadic miscarriage occur in 1st trimester = early pregnancy loses  Only 2-5% of pregnancy miscarry after FH activity has been detected by USG
  • 7. Spontaneous MiscarriageIncidence 10-15% in clinically evident pregnancy 30% in chemically evident pregnancy 80% of spontaneous miscarriage occurred in gestational age less than 14 weeks.
  • 8. Miscarriage Threatened – 25% of all pregnancies ~ uterine bleeding prior to 24 w of pregnancy Inevitable – complete or incomplete depending on whether all or not POC expelled from the uterus. Early fetal/embryonic demise (missed/anembryonic/blighted ovum) ~ failure of pregnancy is identified before the expulsion of fetal and placental tissue.
  • 9. Miscarriage  Septic  Recurrent miscarriage ~ primary – no previous live birth ~ secondary – at least one previous successful pregnancy.
  • 10. AETIOLOGY  No demonstrable cause – commonest MORPHOLOGIC AND GENETIC ABNORMALITY  Abnormal karyotype~  50% in first trimester  20 – 30% in 2nd trimester  5- 10% in 3rd trimester
  • 11. AETIOLOGY  50% of spontaneous miscarriage is due to aneuploidy  50% of aneuploidy is autosomal trisomies eg: trisomy 16 during first trimester- commonly trisomy 16 or monosomy X (45XO Turner Syndrome – 20%) polyploidy (triploidy) 20%, producing blighted ovum or partial mole
  • 12. AETIOLOGYMATERNAL FACTORS underlying systemic diseases: ~ endocrine ~ CVS – HPT ~ renal disease ~ CTD – SLE maternal infection uterine defects malnutrition emotional disturbance – no valid evidence
  • 13. Infective Causes of Miscarriage Mechanisms – unclear but postulated due to maternal pyrexia/ bacteraemia Recent prospective study found :  Women experience 1st trimester miscarriage – no more likely to have a clinical infection than those having a successful pregnancy In recurrent miscarriage :  Infective causes (> genital tract infection) is unclear
  • 14. Infective Causes of Miscarriage HIV  Remains unknown Syphillis & Parvovirus B19  Commonly cause late 2nd trimester miscarriage & stillbirth Group B Streptococcus (GBS)  In late miscarriages & preterm labour
  • 15. Structural causes of Miscarriage Mullerian duct defects – Anatomical uterine abn  Prevalence : 3% (in lap sterilisation)  Prevalence in recurrent miscarriers: 3 – 27%  Most sensitive method of Ix :  Hysteroscopy > HSG > ? USG  In early preg loss,  embryo must be presumed to implant in an avascular area of endometrial cavity – lead to arrested dev & early preg failure.  This process is unlikely in recurrent preg loss
  • 16. Structural causes of Miscarriage  Open surgical / abd resection :  Risk of pelvic & intrauterine adhesion formation(Asherman’s Syndrome)  myomectomy  Hysteroscopic resection of intrauterine septa  More promising but lack of randomised studies Cervical incompetence  Def :  Painless dilatation of the cx lead to miscarriage in the absence of uterine contractions / haemorrhage  Aetiology of 2nd trimester loss
  • 17. Other causes of miscarriage Fetal sex  More in males, but sex ratio remain unknown Multiple pregnancy  Assoc with an increased risk of fetal loss (either by resorption, post- implantation loss / 2nd trimester miscarriage)  Risk of miscarriage 2x singleton preg  Monochorionic twin preg – 12% risk Parity  Rises risk with parity  Results of reproductive compensation & related with maternal age (assoc with trisomic pregnancies)
  • 18. Maternal health in miscarriage Cigarete smoking  Correlated with miscarriage  Nicotine has adverse effect on trophoblastic invasion Cocaine – increased risk of miscarriage Alcohol – higher in women ended up with miscarriage Caffeine – high level ass. with miscarriage Chemicals : lead,ethylene oxide, solvents, pestisides, vinyl chloride & anaesthetic gases – ass. with fetal loss Radiotherapy & Chemotherapy  May cause miscarriage & fetal abnormality in a dose of > 25 rads – 0.1% risk
  • 19. CLINICAL FINDINGS  Threatened Minimal vaginal bleeding + pain (usually painless) Closed cervical os, Without expulsion of POC Viable pregnancy by USG  soft, non-tender abdomen, uterus=POA  Continued vomiting ass. with increased chance of life birth
  • 20. CLINICAL FINDINGS  Inevitable  fresh vaginal bleeding with abdominal/back pain with cx dilatation and effacement  50% will miscarry  Diagnosis determined by confirmation of cervical dilatation at VE  Occasionally severe shock – may be due to massive haemorrhage / vasovagal reaction – cervical shock syndrome due to distension of the cervix by POC (Treatment is by quick removal of the POC from os by bedside)
  • 21. CLINICAL and USG FINDINGS Incomplete heavy bleeding & abd cramps with open cx os  POC partially expulsed & USG showed hyperechoic material in the uterine cavity Complete  A hx of pain + bleeding + POCs seen  bleeding and pain cease afterwards as POCs completely expelled. USG ~ empty uterus  Recent studies of women showed around 20-30% of all miscarriage is complete(Chung et al 1994; Mansur 1992)  Expectant mx of early fetal demise has demonstrated that, with time, up to 25% women go on to have complete miscarriage (Jurkovic et al 1998)
  • 22. CLINICAL FINDINGS  Early Embryonic / Fetal Demise* (Missed / Silent)  Failure of preg is identified before any expulsion of POC occur  Disappearance of sn/sx of pregnancy with ut < gest age & closed cervical os  An USG dx of non-viable preg in the absence of PV bleeding / pain(accidental finding)  A fetal pole > 5 mm w/out FH activity or when USG I / 2 wks apart have shown no growth / no FH activity: Missed / silent miscarriage
  • 23. CLINICAL FINDINGS w/out a fetal pole :  A sac > 20 mm in diameter a blighted ovum*  Goldstein – most of anembryonic pregnancy are not truly without embryos. They lose viability before our ability to image them.  Many initially had early embryonic dev. with subsequent loss of viability, followed by embryonic resorption and thus ,appearance of empty sac. * An embryonic pregnancy / blighted ovum has been replaced with early embryo/ fetal demise in UK
  • 24. CLINICAL FINDINGS  Septic  A complication of incomplete miscarriage where the remaining POCs become infected by ascending organisms + instrumentation of the uterus  Presented with suprapubic pain, malaise, fever + PV bleeding  O/E : Fever, suprapubic pain/abd rigidity, uterine & adnexal tenderness and closed cervix.  Around 3-6% following termination of pregnancy  Common organisms : E.Coli,Bacteroides, streptococci Clostridium welchii  Complications : Septicaemia → bactaremic shock → maternal death
  • 25. INVESTIGATIONS  USG ~ is essential in the diagnosis – usually TVS. ~ will determine on-going pregnancy/failing pregnancy/rule out ectopic and trophoblastic disease.  Pregnancy test – by urinary or serum hCG to distinguish an early complete miscarriage or on- going ectopic pregnancy.  Blood grouping and Rh typing – Rh neg. should receive anti-D Ig regardless of gestational age.
  • 26. Management of miscarriage Tx aim : to reduce the potential complication of miscarriage (i.e prolonged pain & bleeding, sepsis & rh- iso-sensitisation) Conservative  Expectant Mx ~ avoids surgical procedure & anaesthetic.  Appropriate for pts with an incomplete miscarriage with POC < 50mm in diameter on TVS  In cases without haemodynamic compromise / maternal anaemia, spontaneous resolution occurred within 3 days in up to 80% of cases with minimal retained POC  No evidence of impairment of future fetility
  • 27. Management of miscarriage Conservative Management less useful for blighted ovum  because bleeding appears to be heavier & more prolonged than surgical management  60% which treatment conservatively require ERPOC at some stage
  • 28. Management of miscarriage Surgical  Evacuation of retained POC (ERPOC) – most common form of tx for miscarriage  Cx is dilated & retained POC removed by S+C  Cpx :  Perforation of the uterus (by dilator / currete), infection (commonest) & incomplete emptying of the cavity ~ in up to 6% of cases, tearing of cervix  Incidence of serious morbidity : 2.1% (RCOG 1985)  Potential anaesthetic cpx  Asherman syndrome (intrauterine adhesions)  Incidence of mortality : 0.5 / 100 000 (Lawson et al 1994)
  • 29. Threatened Miscarriage Mx 97-98% chance of a live birth  Women > 40s, miscarriage rate : 15-30% – even after FH present by USG Tx : reassurance & continued medical & emotional support Advise bedrest & avoiding SI  Bedrest ↓pressure & improve outcome – but no clinical evidence Progesterone supplementation  However, several meta-analysis trial unable to demonstrate beneficial effect of progesterone tx (Goldstein et al 1989)
  • 30. Incomplete Miscarriage Mx Tx : Surgical evacuation of POC Without tx : maternal mortality of 1.6%  Due to haemodynamic compromise of cervical shock. Suction evacuation >safer technique than sharp curettage  Lower rate of perforation, blood loss & subsequent intrauterine adhesion formation (Edmonds 1992, Verkuyl & Crowther 1993) Routine use of syntocinon / ergometrine – no benefits in ↓blood loss during surgical tx of 1st trimester miscarriage (Beeby et al 1984) Screening for chlamydia infection is recommended
  • 31. Early Fetal Demise Mx Same for incomplete miscarriage Tx :  Surgical tx after cervical ripening (with mifepristone/ prostaglandin)  To ↓ risk of cx trauma / ut perforation assoc with forced cx dilatation Expectant mx :  < effective than cases of incomplete miscarriage  With only 25% proceeding to complete miscarriage Efficacy of medical tx also < inc miscarriage  Complete miscarriage rate can be up to 90% with higher dose of mifepristone & misoprostol
  • 32. Coronal TVUS of the uterus shows a gestational sac withhyperechoic margins (arrow) and endometrial cavity (curvedarrow).
  • 33. Double Decidual Sac Sign. Coronal TVUS of the uterus reveals anintrauterine gestational sac (straight arrow), decidua capsularis(curved arrow), decidua parietalis (arrowhead), and effacedendometrial cavity (asterisks)
  • 34. Yolk sac (thin arrow) outside the amniotic membrane(arrowhead), which has not yet fused with the chorion (curvedarrow). Embryo (thick arrow) is seen within the amniotic sac
  • 35. Anembryonic Pregnancy
  • 36. Abnormal Shape of the GS
  • 37. Abortion in Progress
  • 38. Missed Abortion
  • 39. Subchorionic Haemorrhage
  • 40. Retained Products of Conception
  • 41. Retained Products of Conception
  • 42. Introduction Leading cause of death of pregnancy related deaths during first trimester 13 maternal deaths resulting from ectopic pregnancy in the UK in 1997–99. Incidence of ectopic pregnancy has remained static in recent years (11.1/1000 pregnancies) 32000 ectopic pregnancies are diagnosed in the UK within a three year period.
  • 43. Clinical presentation Clinical suspicion – positive pregnancy test, pain, bleeding and adnexal mass Clinical triad – pain, bleeding, adnexal mass ~ 45% of patients Pain Clinical Triad Bleeding Adnexal mass
  • 44. Clinical presentation Location of pain lower abdominal ~ 74% generalised abdominal ipsilateral lower quadrant contralateral lower abdomen shoulder tip back pain vaginal
  • 45. Risk Factors for Ectopic pregnancy High Risk Tubal surgery Sterilization Previous ectopic pregnancy Use of IUCD Documented tubal disease In utero exposure to diethylstilbesterol
  • 46. Risk Factors for Ectopic pregnancy High Risk Moderate Risk Infertility Multiple sexual partners Previous genital infections Slight Risk Cigarrette smoking Previous pelvic / abdominal surgery
  • 47. Pregnancy testing Urine pregnancy test – Sensitive radioimmunoassays are widely available – +ve at approximately 23 menstrual days (9 days postconception)
  • 48. Pregnancy testing Beta hCG quantitation (serum B hCG) Normal intrauterine pregnancy – hCG doubling time of 2 days (66%) – Intrauterine GS (US Scan) with hCG 1000 – 2000 mIU/ml
  • 49. Pregnancy testing Beta hCG quantitation (serum B hCG) Ectopic pregnancy – hCG doubling time is different – hCG doubling time increased – disproportionately high level of hCG in correlation ultrasound findings
  • 50. Diagnosis of Ectopic Pregnancy Clinical Biochemical Ultrasound Diagnostic laparoscopy ~ GOLD STANDARD
  • 51. SONOGRAPHY Early intrauterine pregnancy Earliest sign ~ small fluid collection in the endometrium
  • 52. SONOGRAPHY Gestational sac Early intrauterine pregnancy intradecidual sign with echogenic ring formed by chorionic villi double decidua sac sign (DSS) eccentric to the endometrial cavity Uterus Bladder
  • 53. SONOGRAPHY Gestational sac Early intrauterine pregnancy presence of yolk sac & the embryo Yolk Sac
  • 54. No identifiable intrauterine GS One of three possibilities – Very early intrauterine pregnancy – recent spontaneous miscarriage – Ectopic pregnancy Bladder Cervix Uterus
  • 55. Sites of Ectopic Pregnancy
  • 56. Sites of Ectopic Pregnancy
  • 57. SONOGRAPHY Ectopic Pregnancy Empty uterus Normal ovary**Normal pelvic sonogram doesnot exclude Ectopic pregnancy~ 26%
  • 58. SONOGRAPHY Ectopic PregnancyPseudogestational sac20% of ectopic pregnancy
  • 59. SONOGRAPHY Ectopic Pregnancy Uterus UterusAdnexal ring“doughnut sign”
  • 60. SONOGRAPHY Ectopic Pregnancy UterusAdnexal mass Mass
  • 61. SONOGRAPHY Ectopic Pregnancy LIVERLIVER Kidney Kidney Free fluid at Morrison’s Pouch Normal
  • 62. MANAGEMENT OF ECTOPIC PREGNANCY Surgical option – Laparotomy VS Laparoscopy – Salpingotomy VS salpingectomy• Nonsurgical treatment – Expectant management – Metrotrexate• Combined medical-surgical treatment
  • 63. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY Laparoscopy VS Laparotomy A laparoscopic should be the surgical management of tubal pregnancy, in the haemodynamically stable patient.
  • 64. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY Laparoscopy VS Laparotomyshorter operation times,less intraoperative blood loss,shorter hospital staylower analgesic requirements
  • 65. MANAGEMENT OF TUBAL ECTOPIC PREGNANCY Laparoscopy VS Laparotomy  no difference in overall tubal patency rates  Similar subsequent intrauterine pregnancy rates  Lower repeat ectopic pregnancy rates in laparoscopic approach  laparoscopic salpingotomy was less successful than an open approach in elimination of the tubal pregnancy (higher rates of persistent trophoblast)
  • 66. MANAGEMENT OF TUBAL ECTOPIC PREGNANCYIn haemodynamically unstable, management should beby the most expedient method.In most cases, this will be laparotomy.
  • 67. MANAGEMENT OF TUBAL ECTOPIC Medical Management – Methotrexate Patient selection : Compliant Adnexal mass < 3.5 cm Beta hCG < 3000 mIU/ml Absent fetal heart activity Minimal symptom  15% of women will require more than one dose of methotrexate  7% will experience tubal rupture during follow up.  75% will experience abdominal pain following treatment
  • 68. MANAGEMENT OF TUBAL ECTOPIC Medical Management – Methotrexate im methotrexate as a single dose calculated from patient body surface area (50 mg/m2) – 75 mg and 90 mg. Serum hCG levels checked on days four and seven a further dose is given if hCG levels have failed to fall > than 15% between day four and day seven. < 10% of women treated with this regimen will require surgical intervention
  • 69. MANAGEMENT OF TUBAL ECTOPIC Medical Management – Methotrexate 2 X weekly hCG measurements (ideally < than 50% of its initial level within seven days) weekly transvaginal US examinations (reduction in the size of adnexal mass by seven days) Thereafter, weekly hCG and transvaginal US examinations until serum hCG levels are < than 20 mIU/ml
  • 70. Pregnancy of unknown location Conservative Management  clinically stable women with minimal symptoms  Beta hCG level < 1500 to 2000 mIU/ml  44–69% of pregnancies of unknown location resolve spontaneously with expectant management – small ectopic pregnancies which were : spontaneously absorbed or resolved by tubal abortion. – early intrauterine pregnancies that miscarried.  14-28% lead to ectopic pregnancy
  • 71. Remember !!!Rhesus Negative women  Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.
  • 72. WORK-UP FOR ECTOPIC PREGNANCY Qualitative Beta HCG (UPT) negative positive TVS Pregnancy excludedIntrauterine pregnancy(normal / abnormal) No IUP & Tubal mass No IUP & stable unstable No adnexal mass / Free Fluid Laparoscopy / Laparotomy Medical Follow up
  • 73. WORK-UP FOR ECTOPIC PREGNANCY Empty uterus & no adnexal mass / Free fluid Serum Beta HCG Serum Beta HCG < 1500Serum Beta HCG > 1500 Repeat 48 hours laterLaparoscopy 66% or more rise Rise by < 66% or condition worsen Repeat scan in 1 week unless condition worsen