1. King Khalid University Hospital Department of Obstetrics & Gynecology
Course 482
BLEEDING IN EARLY PREGNANCY

2. SPONTANEOUS ABORTION Definition:
Abortion termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks)
Incidence: 15%
It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups:
1. Threatened Missed
2. Inevitable Recurrent abortion
3. Incomplete Septic Abortion

4. Threatened Abortion: 25% of pregnancies
This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy. In practice any case of bleeding before the 24th wks may be classed as threatened abortion in the absence of any other explanation.

7. Management:
Slight bleeding which may persist for weeks, mild pain, internal os closed. It is then essential to decide whether there is any possibility of continuation of the pregnancy by vaginal ultrasound gestation sac can be seen by scan days after LMP

8. Serial qualitative HCG level:
BHCG level – 1000 miu/ml
if gest. Sac seen  BHCG less than 1000  unlikely to survive.
Qualitative BHG level should ↑ 65% every 48 hours.
S. Progesterone level
The 5 ng/ml associated dead fetus
> 25ng/ml associated with alive fetus
Expectant observation
No benefit from use of progesterone or bed rest although it is often advised.

9. Inevitable Abortion
Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental  fetus is dead.
Pain usually more.
Dilated internal os. USS – Non viable fetus. P.T. +ve
Emergency suction: D & C

10. Complete Abortion
Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding
Examination confiremd dilated os of Cx.
Minimal current bleeding
TVU – empty uterus
R/O ectopic pregnancy by serial BHCG level
until P.T. -ve
Anti D injection if patients RH – ve to prevent sensitization

12. Incomplete Abortion
If the internal cervical os is open and patient has passed some tissue.
Management:
Emergency suction and curettage

14. Missed Abortion
It is defined as retention of dead products of conception in utero for several weeks.
Symptoms of early pregnancy disappear
Uterus not only has ceased to enlarge but also has become smaller.
Occasionally serious coagulation defect may develop.
Abnormal sonographic finding:
Irregular gest. Sac
Trophoblastic reaction
Irregular and thin
Yolk sac not seen
Absent embryo or amorrphous

15. Septic Abortion Uterine infection at any stage of abortion causes:
Delay in evacuation of uterus
Delay seeking advice
Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours:
Anaerobic streptococcus
Clostridium welchin
Bacterial fragilis
Coliform bacilus

16. Trauma: Treatment: Perforation or cervical tear Criminal abortion
Should be active to minimize risk of septic shock
Cervical & HVS, blood culture
Blood spectrum antibiotic
Evacuation – perforation is common
Hystrectomy

17. Induced Abortion
Therapeutic abortion – termination of pregnancy before time of fetal viability for the purpose of safe guarding the health of the mother. Heat disease, invasive Ca of Cx.
A certificate of opinion is given by 2 heart consultant obstetrician.
Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of inpaired maternal health or fetal disease.

18. Cont:
Illegal abortion usually performed in unsterile condition by operators with little or nor medical training.
It is often incomplete and complicated by:
 Hemorrhage
 Infection
Infertility tubal occlusions
Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

19. Recurrent Miscarriage
When a woman has had 3 consecutive miscarriage.
Risk of abortion for next pregnancy:
1 abortion  15%
1 Normal pregnancy  15%
1 Abortion
1 Normal  25%
2 Abortion
2 abortion  40%

20. Etiology and Investigation:
1. Genetic factors
Karyotyping of both partners will reveal chromosome anomalies
2. Anatomical factors
Uterine anomalies
Cervical incompetence
Hysteroscopy & HSG – Septum / Fibroid
3. Endocrine problem
↑ LH in PCO
4. Immunological factors
Recurrent miscarriage is common in couples with similar HLA types
Common in women with antiphopholipid
antibodies syndrome
Anticardiolipid ant. & Lupus anticoagulant
Maternal disease
SLE, Renal disease
Encironmenta factor: Smoking / Alcohol

21. Abortion Technique: Surgical / Medical
Medical : Oxytocin
Prostaglandins
Anti progesterone Ru 486
(Mifepristone)
Surgical : Suction, D & C
Prostaglandin vaginal suppressions applied to Cx. To ripen or soften and dilated cervix before termination by curettage or as adjunct for mifepristone termination

23. 1. Confirm diagnosis – history examination
MANAGEMENT OF ABORTION
1. Confirm diagnosis – history examination
If unsure of date of LMP
And /or irregular cycle
Take serum hCG
If sure of date of LMP and /
Or regular cycle, i.e.>
6 weeks’gestation, arrange
TV ultrasound and classify
Miscarriage according to
RCOG guidelines
If hCG > 1000,
Use protocol for
Suspected ectopic
pregnancy
If hCG (?miscarriage/
? Early intrauterine/
? Ectopic pregnancy
If viable pregnancy (threatened miscarriage)
 Reaasure
 Check whether pregnancy is wanted or not and give appropriate
written info and arrange follow-up.
 Offer repeat scan in 2 weeks if further significant bleeding, otherwise
offer nuchal thickness scan between 11 and 14 weeks followed by
detailed anomaly scan at 20 weeks.
 Give anti-D if >12 weeks and Rhesus negative

24. 2. If complete miscarriage (bleeding settled and endometrium <15mm)
 Reassure and give appropriate written information
 Give anti-D if> weeks and Rhesus negative
 Home pregnancy test in 2 weeks
Spontaneous incomplete or delayed (missed) or inevitable
(cervical os open) miscarriage
Exclude
 Haemodynamically unstable (BP 90/50 mmHg pulse > 100 bpm
 Septic (temp >37.50C)
 Anaemic (Hb <10g/Dl)
 Significant medical disorder
Inform consultant and admit to gynecology ward for surgical
management
Discuss surgical and conservative treatment and give written
information

25. Conservative management Review weekly clinically and serum hCG
Surgical management
Organize ERPC
Emergency admission to
Ward or to DSU
Rescan if still bleeding in 2 weeks
to confirm complete miscarriage
(endometrium <15mm)
Complete miscarriage
Home pregnancy test
2 weeks later
Incomplete miscarriage
Consider surgery

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