This document discusses hemorrhage in early pregnancy, miscarriage, ectopic pregnancy, and hydatidiform mole. It provides definitions, risk factors, clinical features, management, and pathogenesis for each condition. Key points include: - Miscarriage (spontaneous abortion) occurs in 10-20% of pregnancies and is often due to fetal chromosomal abnormalities or maternal factors like age. Management depends on severity from expectant to surgical evacuation. - Recurrent miscarriage is defined as 2 or more losses and can be caused by genetic, endocrine, immune, or inherited factors. - Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Risk factors

1. Hemorrhage in Early
Pregnancy
Dr. M. GOKUL RESHMI,
post graduate,
Obg.

2. Etiology…
• Those related to the pregnant state:
• Abortion (95%),
• Ectopic pregnancy,
• Hydatidiform mole
• Implantation bleeding.

3. Etiology…
• Those associated with the pregnant state:
• The lesions are unrelated to pregnancy—either pre-existing or
aggravated during pregnancy.
• Cervical lesions such as vascular erosion, polyp, ruptured varicose
veins and malignancy are important causes.

4. Abortion
Spontaneous Induced
Isolated Recurrent MTP Unsafe
Septic abortion
Threatened inevitable complete Incomplete Missed septic

5. SPONTANEOUS ABORTION (MISCARRIAGE)
• DEFINITION:
Abortion is the expulsion or extraction from its mother, of an
embryo or fetus weighing 500 g or less when it is not capable of
independent survival, ie., approximately at 22 weeks (154 days) of
gestation.
• INCIDENCE:
10–20% of all clinical pregnancies end in miscarriage,
10% are induced illegally.
75% abortions occur before the 16th week and of these, about
75% occur before the 8th week of pregnancy.

6. MISCARRIAGE
• CAUSES:
Fetal Factors Maternal Factors Paternal Factors

7. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Fetal factor :
Euploidy
50%
Chromosomal
abnormalities
50%
Maternal
95%

8. MISCARRIAGE - Etiology…
• Fetal factor :
• Trisomy 50 to 60 percent;
• Trisomy's of chromosomes 13, 16, 18, 21, and 22 are most common.
• Monosomy X 09 to 13 percent;
• Monosomy X (45,X) is the single most frequent specific chromosomal abnormality.
Autosomal monosomy is rare and incompatible with life.
• Triploidy 11 to 12 percent .
• Triploidy is often associated with hydropic or molar placental degeneration.
• Tetraploid fetuses most often abort early in gestation, and rarely liveborn.

9. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Fetal factor :
• Trisomies typically result from isolated nondisjunction, rates of
which rise with maternal age.
• Balanced structural chromosomal rearrangements may originate
from either parent and are found in 2 to 4 percent of couples with
recurrent pregnancy loss.

10. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Fetal factor :
• The fetus within a partial hydatidiform mole frequently aborts
early, and the few carried longer are all grossly deformed.
• Advanced maternal and paternal ages do not increase the
incidence of triploidy.

11. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Maternal Factors:
• In chromosomally normal pregnancy losses, maternal influences
play a role.
• The rate of euploid abortion peaks at approximately 13 weeks .
• In addition, the incidence of euploid abortion rises after maternal
age exceeds 35 years.

12. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Genitic
• Infections :
• viral, parasitic, bacterial.
• Endocrine :
• luteal phase defect, thyroid disorder, diabetes mellitus.

13. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Immunological:
• Antiphospholipid antibodie syndrome – lupus anticoagulant, anticardiolipin
antibodies, and beta – glycoprotein 1 antibodies.
• cytokines response – Th1 response (proinflammatory cytokines), Th2
response (anti inflammatory cytokines).

14. SPONTANEOUS ABORTION (MISCARRIAGE)
Etiology…
• Nutrition
• Social and Behavioral Factors
• Occupational and Environmental Factors .

15. SPONTANEOUS ABORTION (MISCARRIAGE)
• Paternal Factors:
• Increasing paternal age is significantly associated with an greater
risk for abortion.
• Risk lowest before age 25 years, after which it progressively
increased at 5-year intervals.
• chromosomal abnormalities in spermatozoa likely play a role.

17. SPONTANEOUS ABORTION (MISCARRIAGE)
…

18. SPONTANEOUS ABORTION (MISCARRIAGE)…
THREATENED MISCARRIAGE: It is a clinical entity where the process of
miscarriage has started but has not progressed to a state from which
recovery is impossible .
INEVITABLE MISCARRIAGE: It is the clinical type of abortion where the
changes have progressedto a state from where continuation of
pregnancy is impossible.

19. SPONTANEOUS ABORTION (MISCARRIAGE)
• COMPLETE MISCARRIAGE: When the products of conception are
expelled en masse, it is called complete miscarriage.
• INCOMPLETE MISCARRIAGE: When the entire products of conception
are not expelled, instead a part of it is left inside the uterine cavity, it
is called incomplete miscarriage.
• MISSED MISCARRIAGE: When the fetus is dead and retained inside
the uterus for a variable period, it is called missed miscarriage or early
fetal demise.

20. SPONTANEOUS ABORTION (MISCARRIAGE)
• SEPTIC ABORTION: Any abortion associated with clinical evidences of
infection of the uterus and its contents, is called septic abortion.
• Consider septic abortion :
(1) rise of temperature of at least 100.4°F (38°C) for 24 hours or
more .
(2) Offensive or purulent vaginal discharge and
(3) Other evidences of pelvic infection such as lower abdominal pain
and tenderness.

21. SEPTIC ABORTION…
CLINICAL FEATURES:
• Sick look and anxious
• Temperature > 38degree c
• Chills and rigor (suggest-bacteremia)
• Persistent tachycardia > 90bpm
• Hypothermia <36 degree(entotoxic shock)
• Abdominal and chest pain
• Tachypnoea > 20 /min

22. SEPTIC ABORTION…
CLINICAL FEATURES:
• Impaired mental state
• Diarrhoea
• Vomiting
• Renal angle tenderness
• Pelvic examination:
• Offensive, purulent vaginal discharge
• Uterine tenderness
• Boggy feel in POD(pelvic abcess)

23. SEPTIC ABORTION…
• A rising pulse rate of 100–120/min or more is a significant finding
than even pyrexia. It indicates spread of infection beyond the uterus.
• P/V: Offensive purulent vaginal discharge or a tender uterus usually
with patulous os or a boggy feel of the uterus associated with variable
pelvic findings depending upon the spread of infection.

24. SEPTIC ABORTION…
• CLINICAL GRADING:
• Grade–I: The infection is localized in the uterus.
• Grade–II: The infection spreads beyond the uterus to the
parametrium, tubes and ovaries or pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or endotoxic shock or
jaundice or acute renal failure.

25. SEPTIC ABORTION…
• Grade-I The commonest and is usually associated with
spontaneous abortion.
• Grade-III Almost always associated with illegal induced
abortion.

26. TYPES SYMPTOMS UTERINE SIZE CERVIX
THREATENED VAGINAL BLEEDIGNG
PELVIC PAIN
CORRESPONDS TO GA OS CLOSED
INEVITABLE VAGINAL BLEEDIGNG
PELVIC PAIN
SAME / SMALLER OPEN WITH PALPABLE
CONCEPTUS
INCOMPLETE VAGINAL BLEEDIGNG
(HEAVY)
SMALLER OPEN
COMPLETE VAGINAL BLEEDING
(TRACE/ABSENT)
SMALLER CLOSE
MISSED VAGINAL BLEEDING
(TRACE/BROWINSH)
SMALLER CLOSE
SEPTIC VAGINAL DISCHARGE-
PURULENT AND FOUL
SMELLING WITH
FEATURES OF SEPSIS
VARIABLE/MAY BE
LARGER
OPEN

27. TYPES USG MANAGEMENT
THREATENED FOETUS ALIVE
RETROPLACENTAL HAEMORRHAGE
CONSERVATIVE MANAGAMENT
INEVITABLE FOETUS OFTEN DEAD
RETROPLACENTAL HAEMORRHAGE
RESUSCITATION OF THE PATIENT
FOLLOWED BY EVACUATION
INCOMPLETE PARTLY RETAINED POC EVACUATION
COMPLETE UTERINE CAVITY EMPTY NO ACTIVE INTERVATION
MISSED BELIGHTED OVUM/ FOETUS
WITHOUT CARDIAC ACTIVITY
EVACUATION
SEPTIC POC RETAINED, PRESENCE OF
FOREIGN BODY+ , FREE FLUID IN
THE PERITONEAL CAVITY/ POD
EVACUATION
TO REMOVE SEPTIC FOCUS

28. RECURRENT PREGNANCY LOSS…
• DEFINITION:
Two or more spontaneous abortions as documented by either
sonography or on histopathology before 20 weeks.

29. RECURRENT PREGNANCY LOSS…
ETIOLOGY:
• Genetic factor :
• m/c balanced translocation
• Endocrine and metabolic:
• poorly controlled diabetic,
• presence of thyroid autoantibodies,
• luteal phase defect,
• polycystic ovarian syndrome.

30. RECURRENT PREGNANCY LOSS…
ETIOLOGY:
• Inherited thrombophilia:
• protein c resistance (factor V Leiden mutation) is the most common cause.
• Deficiency of protein c, s, antithrombin III.
• Hyperhomocystinemia and prothrombin gene mutation are also the known
cause of recurrent miscarriage.

31. RECURRENT PREGNANCY LOSS…
• Immune factors:
• Antibodies – Anti Nuclear Antibody, Anti Phospholipid Antibody, Anti DNA
Antibody.
• Anti Phospholipid Antibody- lupus anticoagulant, anti cardiolipin antibody,
anti beta glycoprotein I .
• Unexplained: in majority of the cases.

32. Clinical and Laboratory Criteria for Diagnosis of
Antiphospholipid Antibody Syndrome

33. METHODS OF TERMINATION OF PREGNANCY
First Trimester (Up to 12 Weeks)
• Medical
• Mifepristone
• Mifepristone and Misoprostol
(PGE1)
• Methotrexate and
Misoprostol
• Tamoxifen andMisoprostol
• Surgical
• Menstrual regulation
• Vacuum Aspiration
• Suction evacuation and/or
curettage
• Dilatation and evacuation

34. ECTOPIC PREGNANCY
• DEFINITION: fertilized ovum is
implanted and develops outside
the normal endometrial cavity

35. ECTOPIC PREGNANCY
•RISK FACTORS:
• PID
• Tubal Ligation
• Contraception Failure
• Previous Ectopic Pregnancy
• Tubal Recostructive Sx
• H/O Infertility
• ART
• Iud
• Previous Induced Abortion
• Tubal Endometriosis

36. ECTOPIC PREGNANCY
• Site of implantation:
• Uterine
• Extrauterine

37. ECTOPIC PREGNANCY
•Uterine
• Cervical <1%
• Angular
• Cornual
• Cesarian scar<1%
•Extra uterine
• Tubal 97%
• Ovarian 0.5%
• Abdominal 1%

38. ECTOPIC PREGNANCY
• Tubal:
• Ampulla 55%
• Isthumus 25%
• Infundibulum 18%
• Intrestitial 2%
• Abdominal :
• Primary ( rare)
• Secondary
Intraperitoneal extraperitoneal
(common) broad ligament
(rare)

39. Algorithm for evaluation of a woman with a
suspected ectopic pregnancy.

40. ECTOPIC PREGNANCY
• A. Transvaginal sonography of an
anechoic fluid collection (arrow)
in the retrouterine cul-de-sac.
• B. Culdocentesis: with a 16- to
18-gauge spinal needle attached
to a syringe, the cul-de-sac is
entered through the posterior
vaginal fornix as upward traction
is applied to the cervix with a
tenaculum.

41. Interstitial ectopic pregnancy
• A. This parasagittal view using
transvaginal sonography shows an
empty uterine cavity and a mass that
is cephalad and lateral to the uterine
fundus (calipers).
• B. Intraoperative photograph during
laparotomy and before cornual
resection of the same ectopic
pregnancy. In this frontal view, the
bulging right-sided interstitial ectopic
pregnancy is lateral to the round
ligament insertion and medial to the
isthmic portion of the fallopian tube.

42. Cesarean scar pregnancy.

43. Cervical pregnancy
• (1) an hourglass uterine shape and
ballooned cervical canal;
• (2) gestational tissue at the level of
the cervix;
• (3) absent intrauterine gestational
tissue .
• (4) a portion of the endocervical canal
seen interposed between the
gestation and the endometrial canal.

45. HYDATIDIFORM MOLE

46. Features of Partial and Complete Hydatidiform
Moles

47. Typical pathogenesis of complete and partial
moles.
• A 46,XX complete mole may be
formed if a 23,X-bearing haploid
sperm penetrates a
23,Xcontaining haploid egg
whose genes have been
“inactivated.”
• Paternal chromosomes then
duplicate to create a 46,XX
diploid complement solely of
paternal origin.
• A partial mole may be formed if
two sperm—either 23,X- or 23,Y-
bearing—both fertilize
(dispermy) a 23,X-containing
haploid egg whose genes have
not been inactivated.
• The resulting fertilized egg is
triploid with two chromosome
sets being donated by the father.
This paternal contribution is
termed diandry..

48. Typical pathogenesis of complete and partial
moles.

49. Sonograms of hydatidiform moles
• A complete hydatidiform mole.
The characteristic “snowstorm”
appearance is due to an
echogenic uterine mass, marked
by calipers, that has numerous
anechoic cystic spaces.
• partial hydatidiform mole, the
fetus is seen above a multicystic
placenta.

50. Theca-lutein cysts

51. MANAGEMENT OF HYDATIDIFORM MOLE
• PREOPERATIVE:
• laboratory-haemogram, sr. beta HCG, creatinine, electrolyte,
hepatic aminotransferase level, TSH, free T4 level
• blood grouping & typing, screening and cross matching
• chest radiography
• consider hygroscopic dilator

52. MANAGEMENT OF HYDATIDIFORM MOLE
• INTRAOPERATIVE:
• large bore IV catheter
• regional/GA
• oxytocin 20 U in 1000ml RL for cont.inf
• karmans cannula – 10/14mm
• consider sonography machine

53. MANAGEMENT OF HYDATIDIFORM MOLE
one or more other uterotonic agents:
methergine 0.2 mg im every 2 hrs
carboprost 250 mcg im every 15 to 90 min
misoprostol 200 mcg PR 800 to 1000mcg

54. MANAGEMENT OF HYDATIDIFORM MOLE
• Post evacuation:
• anti D immunoglobulin if Rh negative
• initiate effective contraception
• review HPE report
• Sr. HCG levels: within 48 hrs of evacuation, weekly until
undectectable, mnthly for 6 mnths.

55. Thank you…