This document discusses various causes of haemorrhage in early pregnancy, including abortion, ectopic pregnancy, hydatidiform mole, and implantation bleeding. It provides details on the types, signs, symptoms, causes, investigations, and management of threatened abortion, incomplete abortion, complete abortion, missed abortion, and septic abortion. Recurrent miscarriage is discussed including its etiology and management. Ectopic pregnancy, its causes and clinical features of acute, unruptured and chronic cases are outlined. Finally, hydatidiform mole is summarized including its etiology, clinical features, complications and management.
2. Cause may be
Related to pregnant
state
Abortion
Ectopic pregnancy
Hydatidiform mole
Implantation bleeding
Associated with
pregnancy
Cervical lesions like
Vascular erosion
Polyp
Ruptured varicose
veins
Malignancy
3. Abortion: expulsion or extraction from its mother of embryo or fetus weighing 500g or less
when it is not capable of independent survival (WHO) i.e. at approximately 22 weeks(154
days) of gestation.
Abortion
Spontaneous (miscarriage) induced
isolated recurrent legal(MTP) illegal(unsafe)
Threatened inevitable complete incomplete missed septic
4. Spontaneous abortion(miscarriage)
Etiology(embryonic or fetal)
1.Genetic factors:autosomal trisomy,polyploidy,monosomy,structural
chromosomal rearrangements.
2.Endocrine and metabolic factors:luteal phase defect, thyroid abnormalities,
diabetes mellitus
3.Anatomical abnormalities: cervical incompetence,congenital malformation
of uterus, intrauterine adhesions(synechiae).
4.Infections:toxoplasma,malaria,rubella,variola,cytomegalovirus,brucella.
5.Immunological disorders:
Autoimmune disease: Anti-nuclear antibodies, Anti DNA antibodies,Anti
phospholipid antibodies.
Alloimmune disease
Antifetal antibodies:Rh-negative mother with anti-D antibodies
6.Premature rupture of membranes: sperm chromosomal anomaly(paternal
factor),inherited thrombophilia, protein C resistance.
7.Environmental factors:cigarette smoking, alcohol
consumption,contraceptive agents, anesthetic
gases,arsenic,lead,aniline,formaldehyde.
8.Unexplained:in 40 to 60% of cases.
5.
6. Threatened miscarriage: Is a clinical identity where the
process of miscarriage has started but has not progressed
to a state from which recovery is impossible.
Clinical features: Bleeding per vaginum, pain following hemorrhage.
Investigations: blood for hemoglobin, hematocrit,ABO and Rh
grouping;ultrasonography.
Treatment: rest and medicines. After 3-4weeks following indicate
unfavourable outcome ,Falling serum hcg, decreasing size of fetus, irregular
shape of gestational sac, decreasing fetal heart rate.
Prognosis: in about two-third pregnancy continues beyond 28 weeks,in the
rest terminates either as inevitable or missed miscarriage.
7. Inevitable miscarriage: Is the clinical type of abortion where
changes have progressed to a state from where
continuation of pregnancy is impossible.
• Clinical features: patient having features of threatened miscarriage
develops following -Increased vaginal bleeding,aggravation of lower
abdomen pain,dilated internal os of uterus through which products of
conception are felt on internal examination.
• Management: control excessive bleeding,correct blood loss.
• Treatment: before 12 weeks-D&C
after 12weeks-uterine contraction is accelerated by oxytocin drip.
9. Complete miscarriage: when the products
of conception are expelled en masse.
Clinical features: expulsion of a complete fleshy mass per
vaginum followed by; subsidence of abdominal pain, vaginal
bleeding becomes trace or absent, on internal examination
uterus is smaller than the period of amenorrhea.
Management: transvaginal sonography to see that uterine
cavity is empty; if not uterine curettage should be done.
10. Incomplete miscarriage: when the entire products of
conception are not expelled,instead a part of it is left
inside uterine cavity.
Clinical features: history of expulsion of fleshy mass
per vaginum followed by;
1.Continuation of lower abdominal pain.
2.Persistence of vaginal bleeding.
3.On internal examination:uterus smaller than period of
amenorrhea,patulous cervical os admitting tip of finger,
varying amount of bleeding.
4.Expelled mass found incomplete on examination.
Management:in recent cases evacuation of retained
products of conception. She should be resuscitated
before any active treatment is undertaken.
11.
12. Missed miscarriage: when fetus is dead and retained
inside uterus for a variable period.
Pathology:cause of prolonged retention of dead fetus unclear. Beyond 12weeks
retained fetus becomes macerated or mummified,before 12weeks pathological
process differs
when the ovum is more or less completely surrounded by chorionic villi.
Clinical features: patient presents with features of threatened miscarriage
followed by;
1.Persistence of brownish vaginal discharge.
2.Subsidence of pregnancy symptoms.
3.Retrogression of breast changes.
4.Cessation of uterine growth which in fact becomes smaller in size.
5.Non audibility of fetal heart sound even with doppler USG if it had been audible
before.
6.Cervix feels firm.
7.Immunological test for pregnancy becomes negative.
Management: expectant-many women expel conceptus spontaneously.
medical management
13. Septic abortion: any abortion associated with clinical evidences
of infection of uterus and its contents.
Abortion is septic when there are:
1.Rise of temperature to at least 100.4F for 24hours or more.
2.Offensive or purulent vaginal discharge.
3.Other evidences of pelvic infection such as lower abdominal pain and tenderness.
In majority of cases infection occurs following illegal induced abortion.
Microorganisms: bacteroides group, streptococci, Cl.welchii, tetanus bacillus, E.coli,
klebsiella,staphylococcus.
Clinical features:
Pyrexia, pain abdomen, rising pulse rate, purulent vaginal discharge, tender uterus.
Investigation: cervical or high vaginal swab, blood for hemoglobin, urine analysis, USG
pelvis abdomen.
Management:
Hospitalisation is essential.
investigations: cervical/high vaginal swab for culture. blood and urine examination
Line of treatment: control sepsis,remove source of infection, give supportive therapy.
14. Recurrent miscarriage: a sequence of 3 or more consecutive
spontaneous abortion before 20 weeks.
Etiology: balanced translocation (genetic), poorly controlled diabetes, thyroid auto
antibodies, luteal phase defect, hypersecretion of LH as seen in PCOS, infection
, inherited thrombophilia, uterine fibroid, cervical incompetence, uncontrolled
diabetes with arterioscletoric changes, hemoglobinopathies, syphilis,
toxoplasmosis.
Management:
Interconceptional period
Counsel the couple.should be assured that chance of successful pregnancy is
high even after 3 consecutive miscarriages.
Hysteroscopic resection of uterine septa,metroplasty for bicornuate uterus.
Preimplantation genetic diagnosis for chromosomal anomaly.
Control DM and thyroid disorders.
15.
16. During pregnancy:
Reassurance and tender loving care.
Patient to take adequate rest,avoid strenuous activities.
Mcdonald circlage operation to be performed for cervical incompetence
at b14 weeks or atleast 2 weeks earlier than the lowest previous
wastage.
Procedure reinforces the cervix by a non absorbable tape around cervix at
level of internal os. Stitch removed at 37th week.
18. Ectopic pregnancy: one in which the fertilized ovum is implanted and develops outside
normal endometrial cavity.
Commonest 97% tubal.
Etiology: history of PID, history of tubal ligation, contraception failure, previous ectopic pregnancy,
tubal reconstructive surgery, history of infertility, ART particularly if tubes are patent but damaged,
IUD use, previous induced abortion, tubal endometriosis.
Clinical features :ACUTE-triad of abdominal pain, preceded by amenorrhea &lastly appearance of
vaginal bleeding
signs; lies quiet &conscious, pallor, feeble& rapid pulse, cold clammy extremities, tender abdomen.
UNRUPTURED-delayed period or spotting, uneasiness on 1 side of flank continuous or colicky in
nature.
signs; uterus soft showing evidence of early pregnancy, pulsatile small, well circumscribed tender
mass may be felt through one fornix separated from uterus.
CHRONIC OR OLD-amenorrhea, low abdomen pain, vaginal bleeding.
signs: ill look, pallor, pulse persistently high, features of shock absent ,temperature slighlty
elevated to 38C, tenderness & muscle guard on affected side, cullen’s sign, cervical movement
tender, an ill defined, boggy, tender mass felt through posterolateral fornix extending to POD.
Investigations: blood examination, culdocentesis, UPT, sonography, laparoscopy, D&C, serum
progesterone.
21. Hydatidiform mole: an abnormal condition of placenta where there are partly degenerative &
partly proliferative changes in the young chorionic villi. Regarded as benign neoplasia of
chorion.( incidence:1 in 400 in India).
Etiology: teenage pregnancies& those in women over 35 years of age, faulty nutrition, disturbed maternal
immune mechanisms, androgenesis.
Clinical features: vaginal bleeding, low abdomen pain, hyperemesis, breathlessness, thyrotoxic features,
expulsion of grape like vesicles per vaginum.
Signs: patient looks more ill than can be accounted for, pallor, features of pre-eclampsia.
per abdomen-size of uterus more than that expected, feel elastic, fetal parts &fetal movement not felt,fetal heart
sound absent.
per vaginum-internal ballottement can not be elicited, unilateral or bilateral enlargement of the ovary, finding of
vesicles.
Investigation: blood examination, LFT,KFT, thyroid function test, sonography (snow storm appearance), serum
hcg, X-ray abdomen.
Complications: hemorrhage & shock, sepsis, perforation of uterus, pre-eclampsia, acute pulmonary insufficiency,
coagulation failure, development of choriocarcinoma.
Management: suction evacuation of the uterus, supportive therapy & counselling for regular follow up.
The end
