Bleeding in Early Pregnancy

LIRA UNIVERSITY, FACULTY OF HEALTH SCIENCES, DEPARTMENT OF NURSING AND MIDWIFERY.
CLINICAL PRACTICEFOR ABNORMAL MIDWIFERY: FIRST CLERKSHIP

MSL 4104 , 20th august 2019
BLEEDING IN EARLY PREGNANCY

BY MS. ACHEN BARBARA KELLY, BSM
MISCELLANEOUS CAUSES OF VAGINAL BLEEDING
 Implantation Bleeding- this occurs about 7th day

after fertilization, when the syncytial layer of the
primary trophoblast, which has invasive
properties, erodes the uterine epithelium, stroma
and blood vessels to form a ragged implantation
cavity. The bleeding settles within 3-4 days when
the blastocyst is completely embedded and
covered by decidual cells.
 Cervical lessions / erosion- Eversion occrs when the
endocervical columnar epitheliueum pouts out through
the external cervical os. This is due to increased levels of
oestrogen and progesterone which produces swelling and
softening of the cervical tissues. There is blood-stained
due to rupture of capillaries of endocervical epithelium,
following sextual intercourse. This can be diagnosed on
speculum examination.
 Carcinoma of the cervix- here, bleeding may be
severe due to increased vascularity in pregnancy.
CONTINUATION
 Polyps- these are bright red, fleshy , peduculated,
benign growths which may cause bleeding. The
bleeding originates from the cervical canal. This
is diagnosed on speculum examination. Polyps
removed and sent for microscopic exam.
Physiologically the blood supply to the cervical
area increases during preg which is why polyps
tend to bleed.
MISCARRIAGES
ABORTIONS
OUTLINE OF PRESENTATION
 DEFINITION
 AETIOLOGY
 PATHOPHYSIOLOGY
 CLASSIFICATIONS
 INVESTIGATIONS
 DIFFERENTIAL DIAGNOSIS
 TREATMENT
DEFINITION
 Cessation or termination of pregnancy before the

fetus is capable of extra uterine life (WHO):
 28 weeks ( ? 22,20, weeks)
 Fetal weight of less than 500 grams /0.5KGS

AETIOLOGY
 Genetic factors,
 Environmental factors,
 Anatomic causes,
 Infectious causes,
 Immunologic problems.
AETIOLOGY-1
 20-25% of fertilized ovum end up in miscarriage
 Maternal Causes
 Congenital anomalies
 Infections- malarial parasites, gonorrhoea, syphilis
causes acute fever- interferes with placental
oxygenation
 Chronic medical conditions- renal disease,
hypertension
 Drugs- large doses of drugs are poisonous, avoid
working in industries- toxic substances
AETIOLOGY-2
 Fetal
 Ovum abnormalities
 Developmental abnormalities of zygote, embryo, fetus,
placenta
 Sperm anomalies
 Chromosomal anomalies- >30% of 2nd trimester
abortions
 Combined
 Stress and exhaustion affect functioning of the
hypothalamic region of the puituary gland- affects
uterine activity and causes abortion.
 Haemorrhage into decidua basalis causes necrosis
CONT
 Immunological factors- ABO incompatibility
 Anatomical causes- congenital anomalies like a
retroverted uterus is not able to rise out the pelvis
may occasionally predispose to abortion. This
anomaly can be detected on abnominal ultrasound
scan. Early detection allows correction.
 Developmental defects like bicornuate uterus and
myomas distort uterine cavity and inhibit uterine
enlargement may cause mid-trimester abortion.
CONT
 Cervical incompetence- may be present due to
congenital weakness, trauma resulting from
previous dilatation and curettage.
 Cervical cerclage /Shirodkar suture- a purse-string
suture of strong non- absorbable material is
inserted beneath the cervicovaginal mucosa to
encircle the cervix at the level of internal os and
then tied, and can be removed btn 38th-39th weeks
of gestation.
PATHOPHYSIOLOGY
 Improper fertilization
 Failure of development of the fertilized ovum
 Failure of implantation
 Detachment from endometrium
 Hostile endometrium
 Cervical incompetence
CLASSIFICATION/TYPES
 According to Onset
 Spontaneous
 Induced
 Medical
 Criminal
 According to Stage of abortion
 Threatened abortion: bleeding without opening of the cervix
and/or evacuation of POC; it resolves by itself with no medical
treatment
 Inevitable- bleeding with contractions and dilation of cervix and
POC are visible, pregnancy will not continue and will proceed to
incomplete or complete abortion
 Incomplete-products of conception partially passed
 Complete abortion: POC are completely expelled
Light bleeding*
Closed cervix
Uterus corresponds to date
Cramping Lower abdominal pain
Uterus softer than normal
• Heavy bleeding
• Dilated cervix
• Uterus corresponds to dates
• Cramping Lower abdominal
pain
• Tender uterus
• No expulsion of products of
conception
Heavy bleeding**
Dilated cervix
Uterus smaller than
dates Cramping
Lower abdominal
pain
Partial expulsion of
products of
conception
Light bleeding
Closed cervix
Uterus smaller than dates
Uterus softer than normal
Light cramping
Lower abdominal pain
History of expulsion of products
of conception
CLASSIFICATION
 Missed- Dead fetus retained without expulsion
 Blighted ovum->50% degenerated or absent embryo
 According to complications
 Septic –fever over 38 due to infection/parametritis-
septicemia
INDUCED ABORTION
 Termination of pregnancy through a deliberate
intervention intended to end the pregnancy
 Can be conducted in either a safe or an unsafe
medical setting according to legal and health
policy guidelines, or it may occur outside the
medical system.
DISTINCTION BETWEEN SAFE AND UNSAFE ABORTION
Safe abortion
 is a procedure and technique performed by trained health-care
providers with proper equipment, correct technique, and
sanitary standards.
Unsafe abortion
 a procedure performed either by persons lacking necessary
skills or in an environment lacking minimal medical standards
or both.
 Sepsis conditions are a frequent complication of unsafe
abortion involving unsterilized instrumentation and procedure.
CLINICAL FEATURES
 Major
 PV Bleeding
 Lower abdominal pain
 Period of amennorhoea
 Associated
 Fever
 Shock
 Anaemia
DIFFERENTIAL DIAGNOSIS
 Urinary Tract Infection
 Pelvic Inflammatory Disease
 Ectopic Pregnancy
 Lower Genital tract conditions
 General Causes of bleeding

INVESTIGATIONS
 General
 Full blood count
 Urea and electrolytes
 Specific
 B-hcg
 Ultrasound
TREATMENT
 Supportive
 Correct complications
 Specific (Remove retained products)

 Medical
 Mifegyne/misoprostol
 Surgical
 Evacuation
 D&C
 MVA
 Septic Incomplete
 Antibiotics
 Fluid management
 Evacuation
 May require hysterectomy/ICU care

MNGT
Threatened Abortion
 Medical treatment is usually not necessary.
 advise to avoid strenuous activity and sexual intercourse
but bed rest is not necessary.
 If bleeding stops, follow up in antenatal clinic. Reassess
if bleeding recurs.
 If bleeding persists, assess for fetal viability (pregnancy
test/ultrasound) or ectopic pregnancy (ultrasound).
 Persistent bleeding, particularly in the presence of a
uterus larger than expected, may indicate twins or molar
pregnancy.
 Do not give hormones, as they will not prevent
miscarriage.
MANAGEMENT (CONT)
Inevitable Abortion
If pregnancy is less than 16 weeks,
 plan for evacuation of uterine contents (MVA).
 If evacuation is not immediately possible: give ergometrine 0.2%
mg IM (repeated after 15 minutes if necessary) OR
 misoprostol 400 mcg by mouth (repeated once after 4 hours if
necessary).
 Arrange for evacuation of uterus as soon a possible.
If pregnancy is greater than 16 weeks:
 Await spontaneous expulsion of products of conception and then
evacuate the uterus to remove any remaining products of
conception.
 If necessary, infuse oxytocin 40 units in 1L IV fluids (normal
saline or Ringer’s lactate at 40 drops per minute) to help achieve
expulsion of the products of conception.
 Ensure follow-up of the woman after treatment.
MANAGEMENT (CONT)
Incomplete Abortion
 If bleeding is slight to moderate and pregnancy is less
than 16 weeks, use fingers or ring (or sponge) forceps to
remove products of conception protruding through the
cervix.
 If bleeding is heavy and pregnancy is less than 16 weeks,
evacuate the uterus: MVA is the preferred method of
evacuation. Evacuation by sharp curettage should only
be done if MVA is not available.
 If evacuation is not immediately possible, give
ergometrine 0.2 mg IM (repeated after 15 minutes if
necessary) or misoprostol 400 ug orally (repeated once
after 4 hours if necessary).
MANAGEMENT (CONT)
Incomplete Abortion
 If pregnancy is greater than 16 weeks:
 infuse oxytocin 40 units in 1 L IV fluids (normal saline
or Ringer’s lactate) at 40 drops per minute until
expulsion of POC occurs.
 if necessary, give misoprostol 200 mcg vaginally every 4
hours until expulsion, but do not administer more than
800 mcg.
 evacuate any remaining POC from the uterus.
 ensure follow-up of the woman after the treatment.
MANAGEMENT(CONT)
Complete Abortion
 Evacuation of the uterus is usually not necessary.
 Observe for heavy bleeding.

 Ensure follow-up.
MNGT OF INDUCED ABORTION PERFORMED IN AN UNSAFE
ENVIRONMENT
 Woman may suffer from shock, severe vaginal bleeding,

infections/sepsis, or intra-abdominal injury including uterine
perforation.
 Initial assessment to confirm the presence of abortion complications.
 Support woman while assessing her condition and explaining the
treatment.
 Medical evaluation (brief history; limited physical and pelvic
examinations; history of excessive bleeding, easy bruising, or known
blood disorder/ coagulopathy).
 Prompt referral and transfer if the woman requires treatment beyond
the capacity of the facility where she is seen.
 Stabilization of emergency conditions and treatment of any
complications, complications present before treatment and those
occurring during or after the treatment procedure.
EMERGENCY TREATMENT FOR POST-ABORTION COMPLICATIONS INCLUDES
 Assessment of the signs and symptoms of septic abortion such as:

fever >38.5°C, 48 hours following abortion, chills or sweats, foul-
smelling vaginal discharge, lower abdominal tenderness/pain,
mucous from the cervix, prolonged bleeding +8 hrs, general
discomfort, flu-like symptoms, hemodynamic and acid-based
equilibrium changes.
 As the condition worsens, the patient is less alert with tachycardia,
hypotension, peripheries pale and clammy, nausea, vomiting and
diarrhea.
 If a septic abortion with hypotension out of proportion of the
blood loss, septic shock should be suspected (see Chapter 8,
Infections - Management of septic shock).
 Uterine evacuation to remove retained products of conception.
FOLLOW-UP OF WOMAN POST-ABORTION
 Women who have had a spontaneous abortion:
 Must be supported psychologically and informed that
spontaneous abortion is common and occurs in at least 15%
(1 in every 7) of clinically recognized pregnancies.
 Must be reassured that their chances for a subsequent
successful pregnancy are good unless there has been sepsis
or a cause of the abortion is identified that may have an
adverse effect on future pregnancies (this is rare).
 Should be encouraged to delay the next pregnancy until
they are completely recovered.
 Women who have had an unsafe abortion:
 Must be counselled on family-planning methods that can be
started immediately (within 7 days).
 Must be referred to any other reproductive health services that
may be needed: tetanus prophylaxis or tetanus booster;
treatment for sexually transmitted infections; cervical cancer
screening, etc.
 Must be invited to express their feelings and fears due to the
circumstances that surround pregnancy, such as rape, failed
contraception, lack of contraception, etc.
SUMMARY
 Should be able to define miscarriage, discuss
causes, complications, pathophysiology, clinical
features, differential diagnosis investigations and
be able to manage miscarriages.
 Remember miscarriages are very common.

FEMALE PELVIC ORGANS
D&C

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LIRA UNIVERSITY, FACULTY OF HEALTH SCIENCES, DEPARTMENT OF NURSING AND MIDWIFERY.

CLINICAL PRACTICEFOR ABNORMAL MIDWIFERY: FIRST CLERKSHIP

BLEEDING IN EARLY PREGNANCY

 Implantation Bleeding- this occurs about 7th day

 Cessation or termination of pregnancy before the

 28 weeks ( ? 22,20, weeks)

 Fetal weight of less than 500 grams /0.5KGS

 Pelvic Inflammatory Disease

 Lower Genital tract conditions

 General Causes of bleeding

 Specific (Remove retained products)

 May require hysterectomy/ICU care

 Observe for heavy bleeding.

 Woman may suffer from shock, severe vaginal bleeding,

 Assessment of the signs and symptoms of septic abortion such as:

 Remember miscarriages are very common.

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