Bleeding in early pregnancy

1. Bleeding in early pregnancy • 25%bleeding before 20 weeks gestation • -implantation bleed : • spot of blood occur 5-7 days after blast cyst implantation .

2. Causes of bleeding in early pregnancy • 1-miscarriage • 2 –ectopic pregnancy • 3–benign lesion lower genital tract • 4 –hyditidform mole • 5-cervical pregnancy

3. Spontaneous miscarriage • Definition : • -termination of pregnancy prior to 24 weeks gestation • ,fetal weight less than 500 gm • N.B: • -survival rate 50% • - extremely premature less than 26 weeks infant ) • -incidence 15-20 % end by miscarriage • -most of miscarriage occur prior to 13 weeks • -1-2 %miscarriage occur between 13-24 weeks

4. Etiology : • 1-genetic abnormalities 50% • - chromosomal abnormalities failure to develop embryo • -trisomy 21 down syndrome {Mongol} • -polyploidy monosomy • 2-endocrinefactors • -early failure of corpus luteum due to progesterone deficiency • -PCOS (poly cystic ovarian syndrome) • –poor un-controlled DM • -untreated thyroid disease • Lead to miscarriage ,fetal malformation

5. 3-maternal illness : maternal cardio-vascular , hepatic , renal problem • 4-maternal infections • -syphilis ,listeria,toxoplasmosis,maternal febrile illness ( influenza,pyelitis ) ,malaria, bacterial vaginosis • 5- abnormalities of uterus • -uterine anomalies :- • 1-bicornuate • 2- –subseptate 15-30% causes of miscarriage • 3 –sub mucosal fibroid

6. Anatomical defect:

7. 4 –asherman syndrome :adhesion between endometrium & inner uterine walls 6-cervical incompetence : painless dilatation of the cervix ,lead to SORM (spontaneous rupture of membrane), miscarriage ,or PTL(preterm labor) Dx:history of recurrent miscarriage -u\s (TVS) –funnel internal cervical os ,shortening of the cervical canal less 2 .5 mm.

8. Causes of cervical incompetence • 1-congenital anomalies of genital tract • 2-physical damage after ( D&C,E&C ) • 3-birth trauma

9. 7-auto immune disease: • -antiphospholipid syndrome{ APS} • - lupus anticoagulant {LA} • - anticardiolipin antibody {ACL} • 8-thrombophilic defect • -defect antithromin III • -protein C,S deficiency • -defect factor V Leiden

10. Action:- • formation of thrombosis ,uteroplacental blood vessels ,defect trophoblast function ,lead to • 1-miscarriage 2-IUGR 3-pre-eclampsia 4-DVT • 9-alloiummuno factors • Immune defect cytotrophoblast reject fetal allograft

11. Types of miscarriage • 1-threatened miscarriage • -bleeding in early pregnancy • -uterine size normal corresponding with gestational age • -cervix closed . • -minimal lower abdominal pain . • -80%will continue pregnancy . • -no specific treatment reassurance & support • -bed rest??

12. 2-inevitable / incomplete : • - more abdominal pain • -heavy vaginal bleeding . • -cervix open • -product of conception ,passed through vagina

13. 3-incomplete ; • -heavy bleeding . • -cervix open • -sever abdominal pain • -part of conception remain in the uterus • Treatment: medical management • Surgical evacuation E&C under local or general anesthesia to curette the retained tissue

14. 4-complete miscarriage : • All of conception expel out of uterus cervix closed ,involution of the uterus • treated by blood replacement • 5-septic miscarriage : • Any type of miscarriage with infection • -infection presented in the uterus

15. Clinical Findings Amenorrhea Bleeding Pain

16. Clinical picture : • Incomplete miscarriage • -adenxial pain • -tenderness of abdomen. • -purulent vaginal discharge • -pyrexia • -sepsis ,endotoxic shock {septic shock }renal failure, DIC , petechial Hge . • - Types of micro-organism ,Ecoli, staphili coccus facalis, staphylucous albus , aures , kllebsella, clostrdium welchi & c. perfringens.

17. 6- Missed or silent miscarriage : • - fetal demise , ultrasound no fetal heart rate. • - fetal pole presence of gestational sac by uls. • - regress of abdominal Size. • -regress signs of pregnancy . • - blighted ovum

18. 7- Recurrent miscarriage : • - Three or more successive miscarriage, prior to viability • Diagnosis: • 1-karyotype of both parents { geneticist} • 2-fetal product. • 3-maternal blood sample for LA, aCA{ during 6 weeks of miscarriage }done twice to be sure of the result . • 4-u\s for @ ovarian morphology { PCOS} • @ uterine cavity

20. Threatened Abortion Inevitable Incomplete Missed

21. Laboratory Findings Gestational sac and viable embryo with heart motion Ultrasonography Pregnancy tests HCG Blood count Anemic

22. Treatment :-aspirin or heparin • -cervical cerclage {shourtkhar } done on 14-16 weeks gestation under general anesthesia, & remove at 38 weeks gestation or at the onset of labor .

23. DX : as general for all types of miscarriage • clinical assessment. • Haemodynamic stability. • Assessment of blood loss. • Distension of cervical canal by conception. • Hypotension – Brady cardia "cervical shock" • Rupture ectopic pregnancy need abd, examination . • V. E is open to distinguish the type.

24. TVS to confirm the DX. • Gestational sac less than 20 mm, fetal pole less than 6 mm • No evidence of cardiac activity. • Urine BHCG positive 9-10 days of conception. • HCG level double every 48 hrs [4-6 weeks]

25. Indication for E & C : • Persistent excessive bleeding . • haemmodynamic instability. • infected retained tissue give A/ B(antibiotics) 12- 24 hrs before E&C . • suspicion gestational trophablastic disease

26. preoperative management :- • treat infection if present by A\B. • Give prostaglandin to dilate cx. • Consent form. • CBC & blood group ,canula IV fluid . • V/E & uls. • Emptying bladder. • Wearing gowns ,v/S. • PCR, endo- cervical swabs for STIS.

27. Complications of E & C : • Cervical / uterine Trauma, Tears. • uterine perforation. • Intra abd. Trauma . • Intra. uterine adhesion. • Internal bleeding. • death increase Mortality rate. • increase a chance to develop of PID who has syphilis ,gonorrhea, & or BV(bacterial vaginosis).

28. DILATATION & EVACUATION (D and E) ABORTION -Used for 2nd trimester abortions, at which point in fetal development the fetal bones become calcified.

29. Over all management : • history • passage of conception. • Medical Management : • PG " Antiprogesrone ".prostaglandin dose according to • size of Gestational sac. • type of Miscarriage . • gestational weeks. • Anti- D Immune globulin: • -Mother RH –ve should take Anti D after 12 weeks gestation . • -Indication to give Anti- D before 12 weeks gestation • heavy bleeding. • pain. • Don’t forget to document Anti D.

30. * psychological aspect of miscarriage : • anger ,grief ,guilt feeling continue up to six weeks after miscarriage . • loss in the second trimester liable to mood disorder ,like post partum depression . • grief up to 6 months .