Bleeding in Early Pregnancy Flashcards
What are the seven variations of pregnancy loss
1) Threatened miscarriage 2) Inevitable miscarriage 3) Incomplete Miscarriage 4) Complete miscarriage 5) Missed miscarriage 6) Ectopic Pregnancy 7) Molar pregnancy
How common are miscarriages?
How many miscarriages occur in the first trimester?
Common with a rate of 20-40% in pregnancies
60-80% of these occur in 1st trimester. In fact 25% of pregnancies end so early that the are not even recognised.
Miscarriage: the definition is?
“spontaneous loss of pregnancy before 20 weeks gestation”
After 20 weeks it is considered stillbirth
Miscarriages <6weeks “chemical pregnancies” or “early pregnancy loss”
6-20 weeks “clinical spontaneous miscarriage”
Causes of Miscarriages are?
- Chromosomal anomalies (50%)
- Structural anomalies
- Maternal Factors; fibroids, adhesions, diabetes
What is a Threatened Miscarriage?
Minor vaginal bleeding no/little pain
Cervix closed
Pregnancy symptoms
no tissue passed
*if fetal heartbeat heard, 95% will continue to term
*puts these patients more at risk for miscarriage
What is an inevitable miscarriage?
Heavy vaginal Bleeding
Pain
No tissue passed
may still have vaginal symptoms
Open cervical os
Management is indicated, USS confirms non-viable pregnancy and reveals products of conception in utero
empty sac at 7+ weeks means miscarriage is inevitable
What is an incomplete miscarriage?
Passage of products has started but not complete.
Heavy bleeding/clots
pain/cramps
tissue passed
cervical os open
May have pregnancy symptoms
Complete Miscarriage
Has occured
Light brown spotting
minimal pain
no more tissue passing
Cervical os closing
symptoms of preg reducing
Missed Miscarriage
When pregnancy ends but uterus does not expel its contents.
Light brown spotting
minimal pain
no more tissue passing
Cervical os closed
symptoms of preg reducing
Management of incomplete, inevitable or missed miscarriage?
Expectant: wait and see, review 1/52, usually within 2-6/52 will have passed
Natural/private at home: successful in 65% of early miscarriage
Medical:
- Misoprostol (800micrograms) -
- if not complete 72/24 second dose may be required
- F/U day 8/7
Surgical:
- Suction curettage (ERPOC) under GA/LA
What is an ectopic pregnancy?
When embryo implants at a site other than the endometrium of the uterine cavity.
1/50 pregnancies, mainly in fallopian tube.
- Small amount of dark red blood
- if ruptured massive haemorrhage, pale, sweaty, unwell, possibly collapsed
- After rupture, entire abdo tense and tender
- Unilateral pelvic pain (shoulder tip if ruptured)
Management of Ectopic Pregnancy includes?
Surgical: gold standard.
- laparotomy if in shock, or if laprascopy going to be difficult (inc BMI, previous surgery)
- Salpingectomy if other tube looks normal.
- **give anti-D to all Rh neg women
Medical:
- IM Methotrexate: only if haemodynamically stable, bhcg <5000 and USS are within limits (no fetal HR, gestational sac in adnexum, not ruptured/no free fluid)
Expectant: occassionallly appropriate
What is a molar pregnancy?
When a non-viable fertilized egg implants in the uterus and will fail to come to term.
no bleeding
no pain
Sometimes “grape like” tissue (swollen chorionic villi)
Exaggerated pregnancy symptoms
closed cervical os
Management of a molar pregnancy
Surgical evacuation via suction curettage
- THis carries a risk of heavy bleeding
- FU required at specialist clinic
- FU serum bhcg every 1-2 weeks till non-detectable, then monthly for 6/12
- ANTI D for all Rh neg
What are Braxton Hicks Contractions, are they a cause of concern?
“false labour contractions” Occur <8 times/hour or <4 times/20 mins; these contractions are not accompanied by bleeding or vaginal discharge and are relieved by resting. No increased risk in preterm labour
What do we want to know about with a history /assessment of early pregnancy bleeding/pain
