fantastic approach to deal with patients of early pregnancy bleeding

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VAGINAL BLEEDING
IN
EARLY PREGNANCY
Fg Offr P K Dixit MBBS, AFMC
7 AF Hospital, Kanpur

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4. • Definition
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• Differential diagnosis
• Definition of entities
• Clinical approach to a patient
• Brief management

5. DEFINITION 7 We Care
Any vaginal bleeding
before 20 wks period of
gestation is defined as
early pregnancy bleeding

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Causes of bleeding in early pregnancy
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Ectopic pregnancy
Abortion Hydatidiform mole

7. Related to pregnant state
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• Abortion
• Ectopic pregnancy
• Molar pregnancy

8. Associated with the pregnant
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• Cervical lesions like
• Ruptured varicose veins

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CERVICAL EROSION

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CERVICAL POLYP

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CERVICAL MALIGNANCY

12. Pathology
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• Haemorrhage into the decidua basalis.
• Necrotic changes in the tissue adjacent
to the bleeding.
• Detachment of the conceptus.
• The above will stimulate uterine
contractions resulting in expulsion.

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ABORTION-DEFINITION
Termination of pregnancy before the fetus
is capable of extra-uterine survival i.e. 20
wks or 500gm birth wt

14. •
Types of abortion
Threatened abortion.
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• Incomplete abortion.
• Complete abortion.
• Missed abortion
 Septic abortion: Any type of
abortion, which is complicated
by infection

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20. MOLAR PREGNANCY 7 We Care

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22. • History
CLINICAL APPROACH
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• Examination
• Special Investigations

23. History
• VAGINAL BLEEDING
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• Slight and bright red
• Associated with fleshy mass
• Associated with fowl smell and discharge
• Associated with grape like vesicle
• Sanguinous or dark coloured and continuous
• ‘White currant in red currant juice’

24. Pain abdomen
• Minimal
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• Acute , agonising or colicky
• Shoulder pain
• Fever

25. Symptoms of early pregnancy
• Amenorrhoea
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• Morning sickness
• Frequency of micturition
• Breast discomfort
• Fatigue

26. • Hyperemesis
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• Breathlessness
• Thyrotoxic features
• Syncopal attack

27. • Careful menstrual history
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• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use

28. • Classical triad of ectopic pregnancy
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– Amenorrhoea
– Pain abdomen
– Irregular vaginal bleeding

29. EXAMINATION
• General look
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– Lies quiet and conscious, perspires and looks blanched
– Looks more ill than accounted for- molar pregnancy

30. • Temperature
VITALS
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– Febrile/afebrile
• Pulse
– Tachycardia/normal
• Blood pressure
– Low/normal

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•Empty bladder

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GUARDING AND REBOUND TENDERNESS

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Size of uterus

34. • Trauma
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• Cervical pathology
• Open cervical os-
incomplete abortion

35. • Bimanual examination
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• Extreme tenderness on fornix palpation or rocking of
cervix
• Palpation of bilateral or unilateral enlargement of ovary -
molar pregnancy
• Palpation of adnexal mass- Ectopic pregnancy

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Urine pregnancy test
positive

37. • Hb
INVESTIGATIONS
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• TLC
• DLC
• Platelet
• PCV
• ABO and Rh grouping
• Thyroid function test

38. • hCG- rapidly increasing values of serum hCG
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39. ULTRASONOGRAPHY
• Routinely used
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• Main modality of diagnosis
• Transvaginal and Transabdominal

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BLIGHTED OVUM

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INCOMPLETE ABORTION COMPLETE ABORTION

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ECTOPIC PREGNANCY

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HYDATIFORM MOLE
(Snow storm appearance)

44. DIAGNOSIS
• Threatened abortion
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– Positive UPT
– Intrauterine pregnancy
– Viable fetus
• Incomplete abortion
• Positive UPT
• Product of conception in-situ
• Non viable fetus

45. • Complete abortion
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– Positive UPT
– Absent product of conception
• Ectopic pregnancy
– Positive UPT
– USG confirmation
– Product of conception absent in uterus
• Molar pregnancy
– Positive UPT
– Typical USG findings

46. Management of Threatened
Abortion 7 We Care
• Advise woman to avoid strenuous activity and sexual intercourse;
bed rest not necessary
• If bleeding stops, follow up in antenatal clinic. Reassess if bleeding
recurs
• If bleeding persists, assess for fetal viability.

47. Incomplete Abortion
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• If bleeding light to moderate, use fingers or ring (or sponge) forceps to
remove products of conception protruding through cervix
• If bleeding heavy, evacuate uterus:
– Manual vacuum aspiration (MVA) is preferred method
– If evacuation not immediately possible, give ergometrine OR
misoprostol
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48. Incomplete Abortion
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• Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of
products of conception occurs
• Evacuate any remaining products of conception from uterus by dilatation
and curettage
• If necessary, give misoprostol 200 µg vaginally every 4 hours until
expulsion
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49. Management of Complete
Abortion 7 We Care
• Evacuation of the uterus usually not necessary
• Observe for heavy bleeding
• Ensure followup of woman after treatment
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50. Follow up After Abortion
• Tell woman that spontaneous abortion is common
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• Reassure woman that chances for subsequent successful pregnancy are
good
• Encourage her to delay next pregnancy until completely recovered
• Advise on contraception

51. Immediate Management of
Molar Pregnancy
• If diagnosis is certain, evacuate uterus:
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– If cervical dilatation is needed, use a paracervical block
– Use vacuum aspiration (MVA preferred)
• Infuse oxytocin 20 units in I L IV fluids at 60 drops per min.

52. ECTOPIC PREGNANCY
• Expectant
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• Medical
• Surgical

53. THANK YOU 7 We Care

54. THANK YOU
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