Bleeding in early pregnancy Flashcards
(37 cards)
Benign causes of bleeding in early pregnancy
- Infection: cervix, vagina or STI
- Cervical changes: progesterone influence
- Sex
- Implantation bleed
Serious causes of bleeding in early pregnancy
- Miscarriage
- Ectopic
- Gestational trophoblastic diseases
How can miscarriage be classified?
Threatened: body shows signs that indicate miscarriage may occur, os closed
Inevitable: heavy vaginal bleeding and cramping, os open
Complete/ incomplete: all pregnancy tissue has been expelled/ pregnancy tissue remains in uterus but no foetus or no viable foetus (no heartbeat)
Missed/ silent: baby died in uterus, signs of pregnancy may have faded but otherwise nothing unusual
Definition and epidemiology of micarriage
Spontaneous loss of the pregnancy before foetus reaches viability
- Up to 20% of all clinically recognised pregnancies (80% within 1st trimester)
- 50,000 admissions in the UK annually
- Significant distress to patient
- UK viability is 23+6 weeks
Causes of miscarriage
- Foetal chromosomal abnormalities (trisomy 21 - Down’s, trisomy 12, Patau’s, trisomy 18 - Edward’s)
- Hormonal factors: PCOS, inadequate luteal function, diabetes, thyroid dysfunction
- Immunological causes: auto or alloimmune
- Uterine anomalies: septated, Asherman syndrome, fibroids
- Infections
- Environmental factors: alcohol, smoking
- Unexplained
Management of miscarriage
- Emotional time so sensitive empathic approach
- Medical or surgical management or expectant management which entails waiting for the miscarriage to complete spontaneously
- Woman’s preference takes precedence
- Expectant management is an option for women who aren’t bleeding heavily but this can take weeks
- Medication: miscarriage is induced by prostaglandins e.g. misoprostol oral or vaginal. Use of progesterone antagonist mifepristone administered 12-48hr before prostaglandin increases success rate
- Surgery: dilation of the cervix and suction of uterus
- Emergency surgery required if: profuse bleeding, tachycardia, anaemia, need for immediate fluid resuscitation
Viable pregnancy
- Reassure
- If bleeding getting worse or >14 days - reassess
- Continue or start antenatal care
- Anti-D if required
Confirmed incomplete, missed or inevitable miscarriage
- First line is expectant management over 7-14 days if accepted by mother
- Exclude complicated factors
- Reassess after 14 days if no bleeding
Complete miscarriage
Pregnancy test at home in 3 weeks and return for assessment if +
Retained products of conception
If small and minimal bleeding can be managed conservatively
Medical management of miscarriage
- Misoprostol - synthetic prostaglandin E1
- Evacuation of retained products of contraception
Epidemiology of ectopic pregnancy
1/100 pregnancies
1/30 in high risk population
Risk factors:
- Pelvic infection
- Previous ectopic
- Previous surgery
- Endometriosis
- IVF
50% occur with no risk factors
What is a heterotopic pregnancy?
Combined intrauterine and ectopic - rare
Define recurrent miscarriage
3+ miscarriages in a row
Investigations and management for recurrent miscarriage
Investigations
- Antiphospholipid antibodies: anticardiolipin
- Cytogenic analysis
- USS to check uterine anatomy: fibroids, congenital uterine anomaly
- Inherited thrombophilia screen
- Parental karyotype
Treatment
- Low dose aspirin + heparin]genetic counselling
- Assisted conception
- Surgery
What is the most common cause of bleeding in early pregnancy?
Miscarriage
What is the evidence for intervention in the reduction of incidence of miscarriage?
- Little evidence to suggest that any intervention reduces incidence
- Women with antiphospholipid syndrome: low dose aspirin and low molecular weight heparin improves live birth rate of future pregnancies to 70%
- Cases of excessive shortening of the cervix can be alleviated by placement of a cervical suture
What investiations are done if a woman presents with suspected miscarriage?
- Urinary pregnancy test - serial measurements of hCG are more useful than a single measurement, decreasing levels generally indicates miscarriage
- USS - is foetal heartbeat not heard of pregnancy <12 weeks a USS is done
Aetiology of ectopic pregnancy
- Damage to Fallopian tube = key risk factor
- Common risk factors: PID, previous ectopic, tubal surgery, IUD, smoking, IVF failed emergency contraceptive
- Key to maintain high index of suspicion
Clinical features of ectopic pregnancies
- Unilateral lower abdo pain is most common presenting complaint
- Often vagina bleeding
- Irritation of diaphragm >> innervated by phrenic nerve can cause shoulder tip pain
- Fainting or collapse suggest intra-abdo bleeding
- Examination: unilateral tenderness, cervical excitation &/ adenexal mass
- Clinical signs of haemodynamic compromise or peritoneal irritation, tachycardia, hypotension, abdo guarding suggest tubal rupture and haemorrhage
Diagnosis of ectopic pregnancy
Empty uterus + positive pregnancy test = ectopic until proven otherwise
Investigations for ectopic pregnancy
- Transvaginal USS: empty uterus, adnexal mass and free fluid in rectouterine pouch. If live, the adnexal mass might have a heartbeat.
- Serial hCG measurements: in a viable uterine pregnancy levels double every 48hrs. If levels rise slowly or remain static this suggests ectopic
Management of ectopic pregnancy
- Expectant management providing pain is minimal and serum hCG is falling and the ectopic isn’t visible on USS - women are monitored to make sure hCG levels fall
- Medication: if pain is minimal, adnexal mass is <4cm and hCG = <1500IU/L. Methotrexate causes tubal abortion before tube ruptures. Given as single IM injection. hCG levels initially rise and then fall. 15% require second dose. Women must avoid pregnancy for 3mo because methotrexate is teratogenic
- Surgery: if haemodynamic compromise, salpingectomy
**Expectant management of methotrexate are only given if woman can attend for follow up**
Gestational trophoblastic disease
- Rare in UK - 0.1% of pregnancies
- South east Asia - 1% of pregnancies
Gestational trophoblastic disease includes:
- Benign disorders of trophoblastic proliferation such as complete or partial hydatidiform moles
- Neoplastic trophoblastic disease does example invasive moles, choriocarcinoma and placental site trophoblastic tumours
Trophoblastic disease more common in teenagers and >45
What is a hydatidiform molar pregnancy?
- A complete hydatidiform mole is created when two separate spermatozoa fertilise an empty ovum (an egg with no functional DNA). Makes a diploid conceptus 46 XX. Mass forms but no foetus
- Partial hydatidiform mole results when two spermatozoa fertilise a normal egg. Makes a triploid conceptus 69 XX. Abnormal foetus forms but cannot survive or develop into baby
Clinical features of a molar pregnancy
- Vaginal bleeding in first or second trimester in often the only the presenting complaint
- USS: multiple cystic areas are visible within placental mass and contain either no recognisable foetus (complete mole) or grossly abnormal foetus (partial mole)
- Serum hCG extremely high
Management of molar pregnancy
- Surgical evacuation of pregnancy is recommended
- Follow up carried out at regional trophoblastic screening centres where hCG levels are monitored until undetectable
- Persistent trophoblastic disease warrants chemo
What is hyperemesis gravidarum?
Can cause dehydration and malnutrition which can cause hyponatremia and thiamine deficiency which can cause Wernicke’s encephalopathy
35% of women have symptoms that reduce their QoL
1% have hyperemesis gravidarum wand require hospital treatment for dehydration
