Bleeding with pregnancy

Dr.Hany Maged
 Bleeding with pregnancy
• Early • Late
- Before age of viability (20week) - AFTER age of viability
- Causes: - APHGE
Miscarraige (common cause) -Causes
Ectopic Placenta previa
Gestational trophoplastic dis. Placental abrubtion
local causes ( cervical polyp) vasa previa
local causes
GTD
MISCARRAIGE
Dr.Hany Maged
 MISCARRAIGE

• OBJECTIVES
At the end of this session you should be able to:
-Define various types of abortions.
-Outline the causes and management approach for various types of
abortions.
-Describe the relation between complications of abortions and
maternal mortality
 Definition

Expulsion or extraction
Clinically recognised
of an embryo or fetus Synonymous with
pregnancy loss before
weighing 500gm or abortion
20th week of gestation
less(WHO)
 Incidence

50 - 60% of all pregnancies end in spontaneous abortion (SAB) since 2-4 wk pregnancies
will often go unnoticed.

15% of all recognized pregnancies 4-20 wks end in SAB.

80% spontaneous abortion :< 12 wks

30% lost between implantation and the 6th wk.

70% of first trimester losses are due to chromosomal abnormalities

Risk factors
• Advanced maternal age
• Previous spontaneous abortion
• Medications & substances (smoking)
• Mechanisms responsible for abortion: not apparent
Maternal age
• Most important risk factor in healthy women

• 30yrs:9-17%
• 35yrs:20%
• 40yrs:40%
• 45yrs: 80%
Previous spontaneous abortion
• Previous successful pregnancy: 5% risk

• 1 miscarriage: 20%
• 2 consecutive miscarriages:28%
• ≥3 consecutive miscarriages:43%
Medications or substances
• Heavy smoking(>10 cigarettes/day) : vasoconstrictive &
antimetabolic effects of tobacco smoke
• Moderate to high alcohol consumption(>3 drinks/week)
• NSAIDS use(acetaminophen) :abnormal implantation & pregnancy
failure due to antiprostaglandin effect
Other factors
• Low plasma folate levels(≤2.19ng/ml): no specific evidence to
support
• Extremes of maternal weight: prepregnancy BMI<18.5 OR >25kg/m2
• Maternal fever:100°F(37.8°C), no evidence to support
Etiology

Fetal Maternal unexplained

Etiology
• Foetal factors
• Chromosomal abnormalities(70% ),
• aneuplodies ,monosomy X,Triploidy
• Trisomy 16 : mc autosomal trisomy,lethal
• Abnormalities arise de novo
• Congenital anomalies
• Trauma: invasive prenatal diagnostic procedures
 • Maternal endocrinopathies: hypothyroidism,
insulin dependant diabetes
Aetiology: • Anatomical
Maternal -Incompetent cx
-Congenital or acquired uterine
factors abnormalities interfere with implantation
& growth
• Maternal diseases: acute maternal infection
(listeria, toxo, parvo B19,rubella,CMV) :
inconclusive
• Radiation in therapeutic doses
• Hypercoagulable state(thrombophillias)
Clinical presentation
• Vaginal bleeding
• Scant brown spotting to heavy vaginal bleeding
• Amount /pattern does not predict outcome
• May be accompanied by passage of fetal tissue
• Pelvic pain
• Crampy /dull in character
• Constant/intermittent
• Incidental finding on pelvic ultrasound in asymptomatic patient
Diagnostic evaluation
• History
• Period of amenorrhea ,LMP/USG
• Physical examination: Complete pelvic examination:
• P/S,:source, amount of bleeding, dilated cervix, POC visible at Os/in vagina
• P/V: uterine size(consistent with GA)
• Pelvic ultrasound
 Pelvic ultrasound
• Most useful test in diagnostic evaluation
of women with suspected spontaneous
abortion
• Foetal cardiac activity: most important
(5.5-6wks)
• Foetal heart rate
• Size & contour of G.sac
• Presence of yolk sac
• Best evaluated ,transvaginal
approach(TVS)
Pelvic USG: criteria for
spontaneous abortion
• Gestational sac ≥ 25mm in mean
diameter that does not contain
a yolk sac or embryo

• An embryo with CRL ≥7 mm with

no cardiac activity

If the GS or embryo is smaller

than these dimensions: repeat
pelvic USG in 1-2 weeks
 TYPES OF ABORTIONS

Induced Threatened Inevitable Incomplete

Complete Missed Septic Recurrent

inevitable
 Miscarraige : complications
• Hemorrhage
• Uterine perforation
• Retained products of conception (POC)
• Endometritis
• Septic abortion: intrauterine infection
1. INDUCED ABORTION
• Intentional medical or surgical
termination of a pregnancy

• Types
– Elective: if performed for a
woman’s desires

– Therapeutic: if performed for

reasons of maintaining health of
the mother
INDUCED ABORTION – MEDICO-
LEGAL ASPECTS

• Only allowed for medical indications

– If continuation of pregnancy is risk to life
of the woman

• At least two medical doctors should

reach the decision and sign
• Elective abortions – are unlawful
INDUCED ABORTIONS - COMPLICATIONS

Because most induced abortions are done by

less skilled persons they are usually associated
with fatal complications including:

1. Perforation of uterus, intestines, etc

2. Severe haemorrhage,
3. Sepsis and its associated complications,
4. Asherman’s syndrome, etc
 2-Threatened abortion
• Vaginal bleeding has occurred
• The cervical os is closed
• Diagnostic criteria for spontaneous abortion has not met
• Managed expectantly: until symptoms resolve or progresses
Threatened abortion: m/m
• Expectant
• Progestin treatment: most promising, efficacy not established
• Bed rest: randomised trials have refuted the role
• Avoid vigorous activity
• Avoid heavy lifting
• Avoid sexual intercourse
 3-Inevitable abortion
• Vaginal bleeding, typically accompanied by crampy pelvic pain
• Dilated cervix( internal os)
• Products of conception felt or visualised through the internal os
• MNGM Expectant ± Misoprostol ± ANTIBIOTIC
 4-Incomplete abortion
• Vaginal bleeding and/or pain present
• Cervix is dilated
• Products of conception partially expelled out
• Uterine size less than period of amenorrhea
• MNGM Medical ± Surgical
 5-Missed abortion
• Non viable intrauterine pregnancy
• Cervical os is closed
• POC not expelled
• May notice that symptoms associated with early pregnancy
disappear
Comp
1- Septic abortion
2- DIC
3- Complication of surgical
Evacuation perforation
Management
• Complete evacuation of uterine contents(POC)
• Surgical methods: suction evacuation/suction curettage/dilation &
evacuation
• Medical methods: Misoprostol ± ANTIBIOTIC
• All have similar efficacy
Surgical evacuation
• Performed under IV sedation & paracervical block
• Prophylactic antibiotics
• Operating room/procedure room
• Potential complications
• Anaesthesia related,
• uterine perforation, cervical trauma,
• infection, intrauterine adhesions
Medical methods
• Misoprostol: drug of choice
• Efficacy depends on dose & route of administration
• 400mcg vaginally every 4 hours for 4 doses
• Expulsion rate : 50-70%
• Low cost, low incidence of side effects, stable at room temperature,
readily available, timing of use can be controlled by patient
Misoprostol
• WHO consensus report on misoprostol regimen
• Missed abortion: 800mcg vaginally,or 600 mcg sublingually
• Incomplete abortion: 600mcg orally
• Expulsion rate: 70-90%
Choosing the method
• Surgical evacuation : heavy bleeding, intrauterine sepsis, medical co
morbidities, misoprostol is contraindicated
• Shorter time to completion of treatment
• Lowers risk of unplanned admissions
• Lower need for subsequent treatment
Expectant m/m
• Stable vital signs
• No evidence of infection
• Offered after proper counseling
• If unsuccessful after 4 wks ,surgical evacuation is needed
 6. SEPTIC ABORTION
• An abortion complicated by infection
• Occurs 2ry to missed or incomplete abortion or incomp evacuation with
reminant of conception (common cause)
• Symptoms
-Abdominal pain
-Fever
-Vaginal discharge (foul smelling)
• Signs
-Sick looking, febrile or jaundiced
-Tender uterus
-Offensive vaginal discharge or bleeding
-Cervix is usu. soft and may be dilated
 Complications of septic abortions
Immediate cpx Late cpx
• Haemorrhage • PID
• Peritonitis • Pelvic adhesions
• Pelvic abscess, endometritis, • 2° Infertility
• Septicemia, • Chronic LAP
• Septic/haemorrhagic shock
 Management
• Resuscitation
• IV fluids: RL, NS
• Insert urethral catheter
• Monitor Input/output
• Blood grouping & Cross matching
• Antibiotics:
• Preferably cephalosporins, if not available ampicilin and metronidazole
• Evacuation
• Haematenics
 7-Complete abortion
• POC expelled completely from uterus & cervix
• Cervical os is closed
• Uterus small in size (GA)
• Resolved or minimal vaginal bleeding & pain
• Aim of t/t: ensure that bleeding is not excessive & all POC have
expelled
• Theoretically does not need treatment
 8.Recurrent abortion
Recurrent miscarriage
Recurrent pregnancy loss (RPL)
 Defnition
• Recurrent abortions is traditionally defined as three or more
consecutive miscarriages occurring before 20 weeks.
• May affect as many as 1% to 2% of women of reproductive age
• Some guidelines use the definition of two or more miscarriages for
offering an evaluation of etiologic causes. (ASRM
2008)
• An earlier evaluation( investigation) may be indicated
-fetal cardiac activity was identified prior to a loss,
- Woman older than 35 years,
- Couple had difficulty in conceiving. (infertility)
 Etiology of RPL
• Unexplained 50%
• Genetic Factors
• Endocrine Factors
• Anatomic Causes
• Congenital anomalies, in competencies,
• Infectious causes
• Immunologic problems
Causes of Recurrent Pregnancy Loss
 Management of recurrent miscarraige
• Most Imp. Item is diagnosis of Etiology
• Diagnosis of Etiology
1- History taking (v imp)
2- HSG , 3D US, hysteroscopy for anatomical causes
3- Parenteral chromosomal study, karyotyping of POC for genetic causes
4- TSH , Glycated HB , Hormonal profile (PCO , LPD) FOR Endocrinal causes
5- Immunological work up
6- Thrombophilia work up
7- TORCH (least significant)
 INVESTIGATIONS
• Etiology Investigation
• Genetic/Chromosomal---------------Karyotype both partners
• Anatomical------------------------------HSG or Sonohysterography or USG
• Endocrine-------------------------------TSH
Luteal phase duration, Blood sugar
• Immunological--------------------------Anticardiolipin Antibody ,Lupus
anticoagulant , Anti-β2- glycoprotein 1
• antibody
• Thrombophilias-------------------------Antithrombin III, Protein C,
Protein S, prothrombin gene,
factor V leiden,prothrombin gene
mutation,Activated protein C resistance
• Infectious-------------------------------- Endocervical swab to detect infection
 GENETIC FACTORS
• Repetitive first trimester losses

• Anembryonic pregnancies

• History of malformations or mental retardation

• Advanced maternal age

• Genetic etiology less likely with late first trimester or second trimester
losses
 MANAGEMENT
• Genetic counselling

• Assisted reproductive technologies, including PGD (preimplantation

genetic diagnosis)

• Use of either donor oocyte or donor sperm depending on the

affected partner ( religious restriction)
 ANATOMIC FACTORS-
UTERINE FACTORS
• Acquired or congenital anomalies

• Congenital uterine anomalies: 6 - 7 % in women with RPL vs. 2 % in all

women.

• Pathogenesis uncertain but attributed to :

Reduced intrauterine volume
Poor vascular supply
Congenital
• Septate uterus 65 %
• Unicornuate uterus 50% loss
• Uterus didelphys 40% loss
• Bicornuate uterus 30 % loss
• DES exposure - many have abnormal uterine structure (T shaped uterus+/-
cervical changes)-24 %
Acquired
• Uterine Leiomyomas
• Intrauterine Adhesions(Asherman’s Syndrome)
• Incompetent cervix
 UTERINE ASSESSMENT
• Sonohysterography (SIS)
• More accurate than HSG
• Differentiate septate & bicornuate uterus

• Hysterosalpingogram (HSG)
• Does not evaluate outer contour
• Not ideal for the cavity

• Hysteroscopy
• Gold standard for Dx + Rx intrauterine lesions
 SEPTATE UTERUS
• Most common developmental
anomaly
• Poorest outcome
• Miscarriage 65 %
• The mechanism
• Not clearly understood
• Implantation on Poorly
vascularised septum
Uterine septa not always associated with
a poor pregnancy outcome but their
presence in a woman with RPL is an
indication for surgical correction
(Hysteroscopic septoplasty,usually only
incision required)
 Uterine leiomyoma
• Pregnancy outcomes adversely affected by submucous myomas, or
Large fibroids distort the cavity or occupy a large subendometrial area

• Surgery not indicated when myomas do not distort the uterine cavity
or when specific symptoms are not attributable to them

• Treatment options:
Hysteroscopic/Abdominal myomectomy, hysteroscopic
myomectomy
INTRAUTERINE
ADHESIONS/ASHERMAN’SYNDROME/AMENORRHOEA
TRAUMATICA

• Excessive curettage for pregnancy complications or AUB

• Traumatize basalis layer  granulation tissue

• Insufficient endometrium to support fetoplacental growth

• Menstrual irregularities (hypomenorrhea, amenorrhea), cyclic pelvic pain,

infertility.
• Diagnosis primarily on high index of suspicion,based on history
• Scanty or no withdrawl bleeding after sequential treatment with
exogenous estrogen and progestin
• Operative hysteroscopy primary method of treatment
• Most advocate insertion of an intrauterine balloon catheter (left in
place for approx 7-10 days) after adhesiolysis
• Treatment with broad spectrum antibiotic and a non-steroidal anti
inflammatory drug minimize the risk of infection and uterine
cramping while catheter is in place

• High dose exogenous estrogen for approx 4 weeks after surgery

encourage rapid endometrial re-epithelialization and proliferation
with a progestin in the final week

• Recurrence rates 20-60%

Cervical insufficiency/Cervical incompetence

• Defnition- Inability of the cervix to retain a pregnancy in the second

trimester,in the absence of uterine contractions.

• Presents as acute, painless dilatation of the cervix which causes

recurrent mid trimester pregnancy loss
Cervical insufficiency- Causes
Congenital
 Mullerian tube defects (bicornuate uterus, septate uterus, unicornuate uterus)
 Diethylstilbestestrol exposure in utero
 Abnormal collagen tissue(Ehlers Danlos syndrome, Marfans syndrome )
Acquired
Forceful mechanical cervical dilatations
Cervical lacerations
Cervical cone or LEEP procedure
 Diagnosis during pregnancy
Ultrasound Diagnosis (Transvaginal )-Following USG features are suggestive of
cervical in competence

Cervical length<3cm

Internal os width>1.5cm in first trimester >2.0cm in second

trimester

Bulging/funneling of membranes into internal os and endocervical canal.

Diagnosis During Interconceptional Period

• Passage of no. 8 Hegar’s dilator beyond internal os without resistance and pain
and absence of internal os snap on withdrawl in premenstrual phase.
• hystero-cervicography; funnel shape shadow in premenstrual phase.
• Foley’s catheter no.16 passed into uterine cavity and bulb filled with 2cc normal
saline can be pulled out easily.
• Shirodkar’s test; passage of uterine sound without resistance or pain is
‘diagnostic’ of an incompetent cervix.
SURGICAL TREATMENT

• Shirodkar operation

• McDonald operation

• Abdominal cerclage

• Espinosa Flores operation

• Wurm operation
Cerclage operation
• Shirodkar operation- opening the anterior fornix and dissecting away the
adjacent bladder before placing the suture submucosaly, tied interiorly and the
knot buried by suturing the anterior fornix mucosal opening

• Mac Donald technique- requires no bladder dissection and the cervix is closed by
purse string sutures around the cervix
 Autoimmune Abnormalities
Antiphospholipid Antibody Syndrome
• The most treatable cause of RPL which is well accepted and
evidence based.

• Up to 15–20% of women with recurrent pregnancy loss

have antiphospholipid antibodies (aPL).

• In 5% second or third trimester losses occur.

• About 5-10% of all pregnancies are complicated by

preeclampsia or fetal growth restriction and up to 75% into
preterm births.
Antiphospholipid Syndrome Criteria
(Sydney revision of Sapporo criteria -2006)
Definite APS: 1 Clinical + 1 Lab criteria
CLINICAL CRITERIA LABORATORY CRITERA

 Vascular Thrombosis-arterial or  Anti-Cardiolipin IgG and IgM

venous
 Lupus anticoagulant (LAC)
 Pregnancy Morbidity:
 Anti β2-glycoprotein1 IgG and
a) 1 or more death of normal IgM
fetus at > 10 wks
b)1or more premature birth at
< 34 wks due to severe medium - high titer(40 GPL or
preeclampsia or placental MPL or higher than 99th
insufficiency
percentile) at least 12 wks apart
c) >3 consecutive abortions Positive test should be repeated at
at <10wks with other causes least 12 apart
being ruled out
 When to start treatment
• Heparin with low dose aspirin is preferred regime .

• Aspirin is started when pregnancy is being

attempted or documented.

• Heparin is started as soon as cardiac activity is

documented on TVS.
APLA/APS-Treatment
dose
1. Unfractionated Heparin 5000-10000 IU subcutaneous twice a day
Or Low molecular weight Heparin is better option

+
2. Low dose Aspirin (75-85mg/day)
Coagulation factors:

• Factors that favour clotting when increased

Fibrinogen
Factors VII,VIII,X
•Factors that favour clotting when decreased
Antithrombin III
Protein C
Protein S
Inherited thrombophilic defects

• Activated protein C resistance (most commonly due to factor V Leiden

gene mutation)

• Deficiencies of protein C/S and antithrombin III

•Hyperhomocystenemia- Probably interference in embryonic development through
defective chorionic villous vascularization

•Prothrombin gene mutation- Higher plasma prothrombin concentrations, augmented

thrombin generation
Mechanism of action
• Thrombosis on maternal side of the placenta  impaired placental
perfusion

• Late fetal loss, IUGR, abruption, or PIH

• Relationship with early loss is less clear

Antithrombotic Therapy
• The combined use of low-dose aspirin (75-80mg/dl)
and subcutaneous unfractionated heparin (5000unit
twice daily)
Thank you