Definition of early pregnancy bleeding. Differential diagnosis. Miscarriage types and Management

1. Haneen Hassan Shaker.
Baghdad university/Alkindy college of
Medicine.
hassanhaneen13@gmail.com

2. EARLY PREGNANCY BLEEDING
 Definition
 Differential diagnosis.
 Miscarriage types and Management.

3. Definition
Any vaginal bleeding before
20 Weeks period of gestation
is defined as early pregnancy
bleeding.
EARLY PREGNANCY BLEEDING

4. Causes &Differential diagnosis:
Local causes like polyp ,
Cervical ectropian , rupture
Varicose vein and carcinoma.
 miscarriage
Ectopic pregnancy
Molar pregnancy
Implantation bleeding

6. MISCARRIAGE
• It is a pregnancy that ends spontaneously before the
fetus has reached a viable gestational age.
• the legal definition of miscarriage in UK is spontaneous
loss of pregnancy at or before 24 weeks gestation.
 Spontaneously Miscarriage
 Induced Abortion

7. MISCARRIAGE
• First - trimester miscarriage occurs below 12 weeks’ gestation
and accounts for the majority , The overall rate is 20%.
• Second - trimester miscarriage is less common, occurring for 1 -
4% of all miscarriage.

8. ETIOLOGY:
1. General maternal factors
2. Local maternal causes
3. Fetal causes
4. Immunological factors

9. 1. GENERAL MATERNAL FACTORS
 Maternal medical and endocrine disorder as DM,
antiphospholipid syndrome, SLE, and thyroid disease.
The risk of abortion increases with maternal age. The
probable explanation is the increased incidence of
chromosomally abnormal conceptus.
Drugs: methotrexate, some antiepileptic drugs.

10.  Infection: Mycoplasma, Listeria, varicella, rubella and other
viral illnesses, they are all treated with antibiotics.
 Maternal smoking and alcohol consuming are associated
with increased risk of abortion.
A little evidence that a sudden physical or emotional shock
can cause pregnancy loss.

11. 2. LOCAL MATERNAL CAUSES:
Cervical incompetence
Congenital abnormalities of the uterus
• a mid - trimester pregnancy lost
• sudden unexpected rupture of
the membranes
• followed by painless expulsion of
the products of conception
• Sequential U/s
• Hysterosalpingiogra
m
• Hystroscope
• laproscope

12. Acquired uterine abnormalities:
 Intrauterine adhesions:
• result from trauma.
• When most of the uterine cavity
has been obliterated (Ashermane
syndrome), amenorrhea results
• A surgical correction.

13. 3. FETAL CAUSES:
the most common cause is a significant genetic abnormality
of the conceptus.
2/3 of spontaneous first- trimester miscarriage has a
significant chromosomal anomalies,
4. Immunological factors

14. 4. CHROMOSOMAL ABNORMALITIES
• Chromosomal abnormalities in 50-70% of cases.
• As in trisomies (mainly trisomy 16, 21 and 22),
triploidy and monosomy (XO, Turners syndrome).
5. Immunological factors

15. TYPES

16. THREATENED MISCARRIAGE:

17. Treatment:
simple reassurance
Bed rest.
Avoid strenuous work.
Avoid sexual intercourse.
Tocolytics are of no role.
Followed by us at antenatal visits.
Available evidence suggest that the pregnancy with
less than 5% risk of miscarriage if the fetal heartbeat
is normal and bleeding resolve.
If the bleeding not not resolved the pregnancy may end with
inevitable miscarriage. 0

18. INEVITABLE MISCARRIAGE:

19. INCOMPLETE MISCARRIAGE

20. Treatment
1. Expectant management:
Up to 85% of miscarriages will resolve spontaneously within 3
weeks of diagnosis.
Expectant management allows for the avoidance of surgery &
general anesthesia.

22. 3. Surgical intervention;
By evacuation of products of conception.
After failure of medical treatment.
Increase risk of perforation and anesthetic complication

23. COMPLETE MISCARRIAGE

24. Treatment;
No further management is needed as miscarriage is complet
and there is no retained products of conception or suggestion
of sepsis.
There is no need for anti_D even if the mother is RH negative
if the GA is less than 12 weeks gestation.

25. MISSED MISCARRIAGE:
• the fetus has died but is retained in the uterus.
• Absent of the pregnancy signs & symptoms.
• Absent pain.
• Slight brownish vaginal discharge.
• Absent fetal movement in multiparous.
• Discovered by Routine U/s.
• Os closed by speculum ex.
• u/s showing a non viable fetus.

26. Investigations;
u/s to confirm the viability.
Hb ,blood group and cross matching
platelet count & plasma fibrinogen.
RBS
GUE.
Treatment
1. Expectant management:
Up to 85% of miscarriages will resolve spontaneously within 3
weeks of diagnosis.
Expectant management allows for the avoidance of surgery &
general anesthesia‫ك‬

27. 2.Medical management;
By administration of mifepristone followed by
misoprostol intra-vaginally 48h later.
Medical management avoid the risk of surgical
intervention and anesthesia.
Explain to the patient that she may need surgical
intervention after failure of medical treatment.

28. `
3. Surgical intervention;
By evacuation of products of conception.
After failure of medical treatment.
Increase risk of perforation and anesthetic complication

29. RECURRENT MISCARRIAGE:
• three or more successive pregnancy loss before viability
(before 24 weeks)

30. CAUSES OF RECURRENT MISCARRIAGE
1. Structural genetic factors: these include:
a. Fetal chromosomal abnormalities
b. Paternal chromosomal abnormality
2. Anatomical factors:
a. Congenital uterine anomaly
b. Cervical weakness
c. Acquired uterine anomaly:

31. 3. Prothrombotic factors:
a.Antiphospholipid syndrome (APS)
b. Thrombophilia
4. Endocrinological factors:
a.Polycystic ovarian syndrome.
B. Abnormalities of glucose metabolism and thyroid disorders
5. Immunological factors
6. Idiopathic recurrent miscarriage: 50%

32. DIAGNOSIS:
1. History – taking:
• LMP: remember to confirm the length of cycle, regularity and the use of contraception
around time of conception
• Symptoms: pain and/ or bleeding.
• Past medical history: as in poorly controlled DM is associated with miscarriage
• Medications: prescribed or non-prescribed drugs.

33. 3. Vaginal examination:
will reveal whether the cervix is open or if products of
conception are identifiable at cervical os.
4. Speculum examination
exclude local causes of bleeding in addition to the quantity of
loss at presentation.
2. Examination:
General examination : to assess the immediate well – being of the patient.
Abdominal examination;
 Determine the fundal height: fibroid or multiple pregnancy
 Examine for the evidence of other pelvic masses, which may explain the presence
of pain (e.g. ovarian torsion, degenerating fibroids).
 Look for evidence of intra – abdominal bleeding or generalized distension of the
abdomen.
 Confirm location of pain.

35. MANAGEMENT
1. Expectant management:
Up to 85% of miscarriages will resolve spontaneously within 3
weeks of diagnosis.
Expectant management allows for the avoidance of surgery &
general anesthesia
patient also potentially feels more in control. Women undergoing
expectant care may require unplanned admission if they start to
bleed heavily.

36. 2. Medical management:
œAbout 20% of patients with miscarriage will respond to medical
treatment.
œ Prostaglandins are used in single dose or divided doses
administered orally (misoprostol) or vaginally (Gemeprost).
œMisoprostol is cheap and effective in both oral and vaginal forms.
œSide effects nausea, vomiting and diarrhea, which can be
problematic.
œOften, mifepristone (a progesterone antagonist) is used together
with prostaglandin to increase the success rate of medical treatment.
œwomen undergoing medical management of miscarriage need to
understand that they may need surgical treatment if medical
treatment fails.

37. 3. Surgical management:
• Surgical management or evacuation of products of conception
(ERCP) has a high success rate 0f 95 - 100%.
• The procedure can be performed under local or general anesthesia.
• Cervical dilatation can be assisted by cervical priming with a
prostaglandin (e.g. misopristol) a minimum of one hour prior to the
procedure and it is strongly recommended when the patient has no
vaginal delivery before.

38.  Cervical polyp:

39.  Cervical erosion

40. Cervical ectropian :

41. Cervical malignancy :