1 / 68

VAGINAL BLEEDING IN PREGNANCY

VAGINAL BLEEDING IN PREGNANCY . Dr Sattam Alenezi ED Consultant. VAGINAL BLEEDING DURING PREGNANCY . 1. DURING PREGNANCY -FIRST 20 WEEKS -SECOND 20 WEEKS. PREGNANCY AND VAGINAL BLEEDING. By the Numbers: 40% EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY

malik-harper
Download Presentation

VAGINAL BLEEDING IN PREGNANCY

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. VAGINAL BLEEDING IN PREGNANCY Dr Sattam Alenezi ED Consultant

  2. VAGINAL BLEEDING DURING PREGNANCY 1. DURING PREGNANCY -FIRST 20 WEEKS -SECOND 20 WEEKS

  3. PREGNANCY AND VAGINAL BLEEDING • By the Numbers: • 40% EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY • Up to 20% OF PREGNANCIES TERMINATE IN MISCARRIAGE • 2% OF PREGNANCIES ARE ECTOPIC • 9%-13% OF FIRST TRIMESTER MATERNAL DEATHS ARE DUE TO ECTOPIC PREGNANCIES

  4. BLEEDING AND THE FIRST 20 WEEKS • Three primary causes: • ABORTION • ECTOPIC PREGNANCY (EP) • TROPHOBLASTIC DISORDERS

  5. Abortion • Incidence-1 in 5 pregnancies • 80% occur in the first trimester • Incidence decreases with gestational age • If fetal heart activity/viability is noted on ultrasound, the loss rate is only 2-3% • Loss rate is 20% in those with first trimester bleeding • Risk increases with increasing maternal age, paternal age, and parity

  6. Abortion Etiology- • Maternal factors • Infectious-Mycoplasma, Toxoplasmosis,Listeria • Environmental-Alcohol abuse, Smoking • Uterine - Septum, Fibroids, Cervical Incompetence • Systemic Disease-Thyroid, Diabetes 􀂋 • Paternal factors-Chromosomal translocation • Fetal Factors-Chromosomal • 50% of 1st trimester abortions caused by chromosomal anomalies

  7. Symptoms Vaginal bleeding in almost all patients • Cramping and pelvic pain very common • Hemorrhage can lead to syncope from hypovolemia/shock • Often discovered when fetal heart activity cannot be detected on exam

  8. Abortion Differential Diagnosis • Threatened Abortion - bleeding, cervix closed • Inevitable Abortion - cervix open or membranes ruptured • Incomplete Abortion - passed some of the P.O.C. • Treatment – Suction, Dilitation and Curettage or Observation • Complete Abortion - passed all products of conception (P.O.C.)

  9. Septic Abortion: uterine infection during any stage of abortion. • Missed Abortion : Embryo larger than 5 mm without cardiac activity.

  10. THREATENED MISCARRIAGE • UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION • ULTRASOUND MAY DETECT AN IUP, INDETERMINATE OR EMPTY UTERUS. CORRELATE WITH BHCG TO RULE OUT EP

  11. THREATENED MISCARRIAGE • THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

  12. THREATENED MISCARRIAGE - Treatment • SUCCESS RATES ARE SIMILAR (93%) FOR BOTH UTERINE CURETTAGE VS. EXPECTANT MANAGEMENT

  13. THREATENED MISCARRIAGE • DISCHARGE HOME IS SAFE • MUST INCLUDE MANDATORY OB FOLLOW UP • SERIAL BHCG IN 48 HRS

  14. INEVITABLE / INCOMPLETEMISCARRIAGE • BOTH HAVE EARLY PREGNANCY LOSS • BOTH PRESENT AND ARE TREATED SIMILARLY

  15. INEVITABLE / INCOMPLETEMISCARRIAGE • INEVITABLE: VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION: OPEN CERVIX IS AN IMPORTANT FINDING • INCOMPLETE: INCOMPLETE PASSAGE OF TISSUE

  16. INEVITABLE / INCOMPLETEMISCARRIAGE TREATMENT OF CHOICE: UTERINE CURETTAGE (D&C)

  17. COMPLETE MISCARRIAGE • OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

  18. Products of Conceptoin

  19. MISSED MISCARRIAGE • OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

  20. SEPTIC MISCARRIAGE • UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS • OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE • LATE COURSE: SEPTIC SHOCK

  21. SEPTIC MISCARRIAGE • INFECTION IS POLYMICROBIAL • TRIPLE ANTIBIOTIC COVERAGE IS REQUIRED • GRAM (+) COVERAGE: PENICILLIN, AMPICILILN OR CEPHALOSPORIN • GRAM (-) AREOBIC COVERAGE: AMINOGLYCOSIDE OR AZTREONAM • GRAM(-) ANAEROBIC COVERAGE: CLINDAMYCIN OR METRONIDAZOLE

  22. Ectopic Pregnancy • Pregnancy anywhere outside uterine cavity • Fallopian tube most common location • Second leading cause of maternal mortality • COMMON THEME IS SCARRED FALLOPIAN TUBE

  23. GREATEST RISK PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS & STD. Ectopic Pregnancy Risk Factors

  24. Ectopic Pregnancy Risk Factors MODERATE RISK -PREVIOUS PID -IN VITRO FERTILIZATION -MULTIPLE SEXUAL PARTNERS

  25. Ectopic Pregnancy Risk Factors LESS RISK: • PREVIOUS PELVIC/ABDOMINAL SURGERY • CIGARETTE SMOKING • AGE OF FIRST INTERCOURSE <18

  26. ECTOPIC PREGNANCY -PATHOPHYSIOLOGY TROPHOBLAST IMPLANTS ON THE TUBAL WALL, GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT IT’S SIZE.

  27. ECTOPIC PREGNANCY • MEAN GESTATIONAL AGE OF RUPTURE IS 7.2 WEEKS • UP TO 23 % OF EP RUPTURE • UP TO 11% OF EP RUPTURED AT BHCG <100

  28. ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

  29. ECTOPIC PREGNANCY • CLINICAL PRESENTATION CLASSIC HX : - ABDOMINAL PAIN -VAGINAL BLEEDING -AMENORRHEA -SYNCOPE +/- ( SHOCK).

  30. ECTOPIC PREGNANCY • ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

  31. ECTOPIC PREGNANCY • PHYSICAL FINDINGS • Vaginal bleeding • Hypotension, tachycardia(shock) • Adnexal mass or tenderness in one sided adnexa • Uterus-normal size • Peritoneal Signs

  32. ECTOPIC PREGNANCY • DIAGNOSTIC MODALITIES – LABS HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66%) EVERY 48 HOURS NORMALLY • IN EP, BHCG LEVELS FALL, PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION.

  33. ECTOPIC PREGNANCY DIAGNOSTIC MODALITIES – LABS • PROGESTERONE -SINGLE LEVEL >25 CORRELATES TO A VIABLE GESTATION -LEVEL<5 MAY INDICATE A NONVIABLE GESTATION

  34. ECTOPIC PREGNANCY • ULTRASOUND SINGLE MOST VALUABLE MODALITYAVAILABLE -BHCG DISCRIMINATORY THRESHOLD FOR : TVU: 1500 FOR TAU: 5000

  35. ECTOPIC PREGNANCY • ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP) • GESTATIONAL SAC • YOLK SAC • EMBRYONIC POLE • FETAL CARDIAC ACTIVITY

  36. ECTOPIC PREGNANCY • ED ULTRASOUND • SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG > THE DISCRIMINATORY THRESHOLD

  37. ED ULTRASOUND • Echogenicadenexal mass. • Empty uterus. • Free fluids in pelvis. • Cardiac activity outside the uterus .

  38. ECTOPIC PREGNANCY • PREVENTING MISDIAGNOSIS • EP CAN RUPTURE AT BHCG AS LOW AS 100 • UP TO 40% OF EP WERE MISDIAGNOSED AT 1ST ED VISIT • ABOUT 50% OF TRANSABDOMINAL ULTRASOUND WERE NONDIAGNOSTIC • ED US – If non diagnostic – need “official” study • PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

  39. ECTOPIC PREGNANCYTreatment • MEDICAL MANAGEMENT • METHOTREXATE: DRUG OF CHOICE • unruptured, small, no cardiac activity, compliant patient CONTRAINDICATIONS: -OBVIOUS SIGNS OF RUPTURE -BHCG > 2000 -SUSPECTED HETEROTOPIC PREGNANCY

  40. ECTOPIC PREGNANCY Treatment • SURGICAL TREATMENT - MAINSTAY OF TREATMENT • Laparoscopy • Salpingostomy • Salpingectomy • Laparotomy LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

  41. Ectopic Pregnancy-Unusual Variants • Heterotopic Pregnancy • Simultaneous IUP and ectopic gestations • Rare- 1 in 4,000 pregnancies • More in women on fertility drugs.

  42. TROPOBLASTIC DISORDERS • ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE • E.G.: COMPLETE/PARTIAL MOLE, INVASIVE HYADTIFORM MOLE, CHORIOCARCINOMA

  43. TROPHOBLASTIC DISORDERS • VAGINAL BLEEDING, SEVERE OR PERSISTENT HYPERMESIS, EARLY DEVELPOMENT OF PREECLAMPSIA • LARGE FOR DATES UTERUS IS PALPATED • BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY • ULTRASOUND WILL SHOW A “SNOWY PATTERN”

  44. Molar Pregnancy US

  45. RHESUS FACTOR • UP TO 15% OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD • SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION • <12 WEEKS OF GESTATION, ADMINISTER RHOGAM 50 MCG • >12 WEEKS OF GESTATION, ADMINISTER RHOGAM 300 MCG

  46. Bleeding in First 20 weeks Evaluation • Hx (specific OB Hx) and Px (w/ pelvic exam), VITALS! • IV • May need 2 large bore IV if hypotensive etc. • Labs • BHCG quant • Type and Rh • CBC +/- • Coags +/-, Type and Cross • U/A • Rad: Pelvic US

  47. BLEEDING AND SECOND 20 WEEKS OF GESTATION • ABRUPTIO PLACENTA • PLACENTA PREVIA • UTERINE RUPTURE

  48. Abrutio Placentae

  49. ABRUPTIO PLACENTA • PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA • MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE • MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

More Related