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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
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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 • 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
BLEEDING AND THE FIRST 20 WEEKS • Three primary causes: • ABORTION • ECTOPIC PREGNANCY (EP) • TROPHOBLASTIC DISORDERS
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
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
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
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.)
Septic Abortion: uterine infection during any stage of abortion. • Missed Abortion : Embryo larger than 5 mm without cardiac activity.
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
THREATENED MISCARRIAGE • THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
THREATENED MISCARRIAGE - Treatment • SUCCESS RATES ARE SIMILAR (93%) FOR BOTH UTERINE CURETTAGE VS. EXPECTANT MANAGEMENT
THREATENED MISCARRIAGE • DISCHARGE HOME IS SAFE • MUST INCLUDE MANDATORY OB FOLLOW UP • SERIAL BHCG IN 48 HRS
INEVITABLE / INCOMPLETEMISCARRIAGE • BOTH HAVE EARLY PREGNANCY LOSS • BOTH PRESENT AND ARE TREATED SIMILARLY
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
INEVITABLE / INCOMPLETEMISCARRIAGE TREATMENT OF CHOICE: UTERINE CURETTAGE (D&C)
COMPLETE MISCARRIAGE • OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
MISSED MISCARRIAGE • OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
SEPTIC MISCARRIAGE • UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS • OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE • LATE COURSE: SEPTIC SHOCK
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
Ectopic Pregnancy • Pregnancy anywhere outside uterine cavity • Fallopian tube most common location • Second leading cause of maternal mortality • COMMON THEME IS SCARRED FALLOPIAN TUBE
GREATEST RISK PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS & STD. Ectopic Pregnancy Risk Factors
Ectopic Pregnancy Risk Factors MODERATE RISK -PREVIOUS PID -IN VITRO FERTILIZATION -MULTIPLE SEXUAL PARTNERS
Ectopic Pregnancy Risk Factors LESS RISK: • PREVIOUS PELVIC/ABDOMINAL SURGERY • CIGARETTE SMOKING • AGE OF FIRST INTERCOURSE <18
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.
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
ECTOPIC PREGNANCY • CLINICAL PRESENTATION CLASSIC HX : - ABDOMINAL PAIN -VAGINAL BLEEDING -AMENORRHEA -SYNCOPE +/- ( SHOCK).
ECTOPIC PREGNANCY • ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ECTOPIC PREGNANCY • PHYSICAL FINDINGS • Vaginal bleeding • Hypotension, tachycardia(shock) • Adnexal mass or tenderness in one sided adnexa • Uterus-normal size • Peritoneal Signs
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.
ECTOPIC PREGNANCY DIAGNOSTIC MODALITIES – LABS • PROGESTERONE -SINGLE LEVEL >25 CORRELATES TO A VIABLE GESTATION -LEVEL<5 MAY INDICATE A NONVIABLE GESTATION
ECTOPIC PREGNANCY • ULTRASOUND SINGLE MOST VALUABLE MODALITYAVAILABLE -BHCG DISCRIMINATORY THRESHOLD FOR : TVU: 1500 FOR TAU: 5000
ECTOPIC PREGNANCY • ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP) • GESTATIONAL SAC • YOLK SAC • EMBRYONIC POLE • FETAL CARDIAC ACTIVITY
ECTOPIC PREGNANCY • ED ULTRASOUND • SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG > THE DISCRIMINATORY THRESHOLD
ED ULTRASOUND • Echogenicadenexal mass. • Empty uterus. • Free fluids in pelvis. • Cardiac activity outside the uterus .
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
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
ECTOPIC PREGNANCY Treatment • SURGICAL TREATMENT - MAINSTAY OF TREATMENT • Laparoscopy • Salpingostomy • Salpingectomy • Laparotomy LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY
Ectopic Pregnancy-Unusual Variants • Heterotopic Pregnancy • Simultaneous IUP and ectopic gestations • Rare- 1 in 4,000 pregnancies • More in women on fertility drugs.
TROPOBLASTIC DISORDERS • ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE • E.G.: COMPLETE/PARTIAL MOLE, INVASIVE HYADTIFORM MOLE, CHORIOCARCINOMA
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”
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
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
BLEEDING AND SECOND 20 WEEKS OF GESTATION • ABRUPTIO PLACENTA • PLACENTA PREVIA • UTERINE RUPTURE
ABRUPTIO PLACENTA • PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA • MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE • MOST COMMONLY OCCURS SHORTLY BEFORE LABOR