Vaginal Bleeding in Early Pregnancy Dr Dalya Alhamdan Consultant Ob/ Gyn Salmaniya Medical Complex

Detailed Hx: Present pregnancy: LMP, Gx, previous USS Obstetric Hx Medical, surgical, Systemic review Physical exam Ultrasound β-hCG

Miscarriage Pregnancy loss occurring before 24 completed weeks of gestation or of a fetus less than 500gm weight if gestation is unknown Threatend Miscarriage Any vaginal bleeding: spotting, brownish, bleeding Products of conception are intact and Cx os is closed

Inevitable miscarriage Miscarriage is imminent or is in the process of happening Threatened miscarriage with an open cervical os and/or rupture of the membranes

Incomplete miscarriage A miscarriage where some of the fetus or placenta are unable to be spontaneously expelled by the mother complete miscarriage A miscarriage needing no medical or surgical interventions Products of conception have been passed; USS shows no apparent products; bleeding generally settles

Miscarriage

Threatened Miscarriage

Missed Miscarriage  TVS showing no FH with fetal pole >7mm or GS >25mm without fetal pole or lack of sac/fetal growth over 7 days period

Incomplete Miscarriage Hx: Woman c/o PVB and lower abdominal pain, passed clots or tissue P/E: Cervical os open, products in cervix

Causes of miscarriage 1. Embryonic abnormalities/chromosomal 2. Immunological diseases 3. Uterine abnormalities

4. Cervical incompetence

5. Maternal disease o Hypertension o Renal disease o Infection: CMV, rubella, toxo, listeriosis o Diabetes Mellitus o Severe malnutrition

Septic Miscarriage Ascent of organisms from vagina to uterus, seen commonly in illegal abortions done under non-sterile conditions Woman presents with abdominal pain, abnormal PVB with fever and endotoxic shock Commonest organisms: E. Coli; Streptococcus faecalis

Ectopic pregnancy Clinical: – History of amenorrhea – Pelvic pain and/or abnormal bleeding in the first trimester – Shoulder tip pain – Dizziness or spells of fainting – Other evidence of blood in the peritoneum. Bio-chemical: – Positive pregnancy test (urine or serum)

On TVS ultrasound: An adnexal mass will not be found in 15-35% of women with an ectopic pregnancy at presentation, pregnancy of unknown location

Management of Ectopic pregnancy Offer expectant or medical Tx if: - Clinical stabe, stable hemoglobin level on two measurements (0 and h apart) -Absence of acute abdomen -Serum hCG < 3,500 IU/L, adnexal mass measure < 30 mm -Absence of fetal cardiac activity on TVS -Absence of significant hemoperitoneum, defined as blood above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space). -Subsequent management: based upon hCG ratio at 0 h/48 h. -Compliance Otherwise: SURGERY

Molar pregnancy

Benign lesion of cervix Ectropion/erosion Central ( endocervical) columnar epithelium protrudes out through the external os

Cervical polyp

Cervical cancer

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