Bleeding in early pregnancy

-25%bleeding before 20 weeks gestate -implantation bleed :spot of blood occur 5-7 days after blast cyst implantation .

Causes of bleeding in early pregnancy : -miscarriage 2 –ectopic pregnancy 3–benign lesion lower genital tract 4 –hyditidform mole 1 -cervical pregnancy 5

Spontaneous miscarriage Definition :termination of pregnancy prior to 24 weeks gestation ,fetal weight less than 500 gm -survival rate 50% 23weeks (extremely premature less 26 weeks infant )

-incidence 15-20 % end by miscarriage -most of miscarriage occur prior to 13 weeks -1-2 %miscarriage occur between 13-24 weeks Etiology : 1-genetic abnormalities 50% - chromosomal abnormalities failure to develop embryo -trisomy 21 down syndrome Mongol -polyploidy monosomy

2-endocrinefactors -early failure of corpus luteum due to progesterone deficiency -PCOS –poor un-controlled DM -untreated thyroid disease Lead to miscarriage ,fetal malformation 3-maternal illness : maternal cardio-vascular , hepatic , renal problem

4-maternal infections -syphilis ,listeria,toxoplasmosis,maternal febrile illness ( influenza,pyelitis ) ,malaria, bacterial vaginosis ( second trimester ) 5- abnormalities of uterus -uterine anomalies :-bicornuate –subseptate 15-30% causes of miscarriage –sub mucosal fibroid –asherman syndrome adhesion between endometrium & inner uterine walls

6-cervical incompetence : painless dilatation of the cervix ,lead to SORM, miscarriage ,or PTL Dx:history of recurrent abortion -u\s TVs –funnel internal cervical os ,shortening of the cervical canal less25 mm.

Causes of cervical incompetence 1-congenital anomalies of genital tract 2-physical damage D&C,E&C 3-birth trauma 7-auto immunes -antiphospholipid syndrome{ aps} -LA lupus anticoagulant -aCL anticardiolipin antibody

8-thrombophilic defect -defect antithromin III -protein C,S deficiency -defect factor V Leiden -formation of thrombosis ,uteroplacental blood vessels ,defect trophoblast function ,lead to 1-miscarriage 2-IUGR 3-pre-eclampsia 4-DVT

9-alloiummuno factors Immune defect cytotrophoblast reject fetal allograft Types of miscarriage ; 1-threatened miscarriage -bleeding in early pregnancy -uterine size normal corresponding with gestational age -cervix closed . -minimal lower abdominal pain . -80%willcontinue pregnancy . -no specific treatment reassurance & support -bed rest??

2-inevitable / incomplete : - more abdominal pain -heavy vaginal bleeding . -cervix open -product of conception ,passed through vagina

-incomplete ; -heavy bleeding . -cervix open -sever abdominal pain -part of conception remain in the uterus Treatment: medical management Surgical evacuation E&C under local or general anesthesia to curette the retained tissue.

complete miscarriage : All of conception expel out of uterus cervix closed ,involution of the uterus treated by blood replacement

5-septic miscarriage : Any type of miscarriage with infection -infection presented in the uterus Clinical picture : Incomplete abortion -adenexial pain -

tenderness of abdomen. -purulent vaginal discharge -pyrexia -sepsis ,endotoxic shock {septic shock }renal failure, DIC , petechial Hge . - Types of micro-organism ,Ecoli, staphili coccus facalis, staphylucous all albus aures , kllebsella, clostrium welchi: & c. perfringens

7- Recurrent miscarriage : - Three or more successive miscarriage, prior to viability Diagnosis: 1-karyotype of both parents { geneticist} 2-fetal product. 3-maternal blood sample for LA, aCA{ during 6 weeks of miscarriage }done twice to be sure of the result . 4-u\s for @ ovarian morphology { PCOS} @ uterine cavity

Treatment :-aspirin or heparin -cervical cerclage {shourtkhar } done on 14-16 weeks gestation under general anesthesia, & remove at 38 weeks gestation or at the onset of labor .

DX : as general for all types of miscarriage : clinical assessment. Haemodynamic stability. Assessment of blood loss. Distension of cervical canal by conception. Hypotension – Brady cardia "cervical shock" Rupture ectopic pregnancy need abd, examination . V. E is open to distinguish the type. TVs to confirm the DX.

Gestational sac less than 20 mm, fetal pole less than 6 mm No evidence of cardiac activity. Urine BHCG, +ve 9-10 days of conception. HCG level double every 48 hrs [4-6 weeks]

Indication for E & C : Persistent excessive bleeding . haemmodynamic instability. infected retained tissue give A/ B 12- 24 hrs before E&C . suspicion gestational trophablastic disease

preoperative management :- treat infection if present by A\B. Give prostaglandin to dilate cx. Consent form. CBC & blood group ,canula IV fluid . V/E & uls. Emptying bladder. Wearing gowns ,v/S. PCR, endo- cervical swabs for STIS.

Complications of E & C : Cervical / uterine Trauma, Tears. uterine perforation. Intra abd. Trauma . Intra. uterine adhesion. Internal bleeding. death increase Mortality rate. increase a chance to develop of PID who has syphilis ,gonorrhea, & or BV.

Over all management : history passage of conception. Medical Management : PG " Antiprogesrone ".prostaglandin dose according to size of Gestational sac. type of Miscarriage . gestational weeks.

Anti- D Immune globulin: -Mother RH –ve should take Anti D after 12 weeks gestation . -Indication to give Anti- D before 12 weeks gestation heavy bleeding. pain. Don’t forget to document Anti D.

* psychological aspect of miscarriage : anger ,grief ,guilt feeling continue up to six weeks after miscarriage . loss in the second trimester liable to mood disorder ,like post partum depression . grief up to 6 months

induced abortion : -named pregnancy termination . -two doctor at least should decide induced abortion when these are greater risk physically & mentally on mother & child , also there is risk of abnormality . -termination prior to 24 weeks or before 20 weeks gestation . -counseling includes social ,medical , & psychological aspect .

Methods of termination of pregnancy :

-screening for STIs & give antibiotic . -anti-D for RH –ve ,after termination . -after termination check physical &contraceptive measures. -12 % who need termination if does not given antibiotic can develop PID & c.trachomatis

Surgical termination of pregnancy ; Most common used in the 1st trimester -use of dilator to open the cervix this called suction curette -E&C in the second trimester under GA if 10 weeks or less under local anesthesia to decrease the incidence of hospitalization .

Medical termination of pregnancy : -used after 14 weeks gestation instead of E&C -progesterone antagonist { mifepristone} given orally then 36-48 hours orally or vaginal pessary ,success rate more than 35 %. -in the second trimester : vaginal prostaglandin every 3 hours

-extra amniotic infusion –{use of mifepristone through folly catheter fitted in the cervix, then do E&C to remove placenta, remember this procedure need to be client in single room ,with maintenance privacy ,& analgesia .this referred to legal abortion .

Complications of termination : ** early complication: Bleeding –uterine perforation –damage pelvic viscera –cervical laceration –retained product & sepsis-small failure rate **late complications: -infertility –cervical incompetence –isoimmunization –psychiatric disease NB; unsafe abortion one cause of maternal death which lead to septic abortion ( commonly illegal & used in non sterile technique

psychological sequelae of termination : ?-fatal abnormality -?pregnancy wanted or not . -?previous diagnosis of the problem -feeling of distress & traumatic experience -need support from Dr,midwife husband –family support

** role of midwife ; -primary caring of mother -provide well care to mother -prevent harm -assist in blood test ,& amniocentesis -give advice & necessary information . -ready to care with her in case of emergency

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