Bleeding in Early

Pregnancy, Abortion
 Introduction
• Causes :
1.Abortion.
2.Ectopic pregnancy.
3.Vesicular mole.
4.Local gynaecological lesions e.g. cervical
ectopy, polyp, dysplasia, carcinoma and
rupture of varicose vein.
 ABORTION
Definition:
• Termination of pregnancy before viability of
the foetus i.e. before 28 weeks (in Britain)
and before 20 weeks or if the foetal weight
is less than 500 gm ( in USA and Australia).
• When the abortion occurs spontaneously,
the term " miscarriage" is often used.
• Incidence: about 15% of all pregnancies.
 Etiology:
1) Chromosomal abnormalities: cause at
least 50% of early abortions e.g. trisomy,
monsomy X (XO) and triploidy.
2) Blighted ovum (anembryonic gestational
sac): where there is no visible foetal tissues
in the sac.
3) Maternal infections : e.g. listeria
monocytogenes, mycoplasma hominis,
ureaplasma urealyticum, cytomegalovirus
and toxoplasma gondii
 Cont…..
4) Trauma: external to the abdomen or during
abdominal or pelvic operations.
5) Endocrine causes:
A. Progesterone deficiency ( causes abortion between 8-
12 weeks).
B. Diabetes mellitus.
C. Hyperthyroidism.
6) Drugs and environmental causes:e.g. quinine ,
ergots, severe purgatives, tobacco, alcohol,
arsenic, lead, formaldehyde, benzene and radiation.
 Cont…..
7) Maternal anoxia and malnutrition.
8) Overdistension of the uterus: e.g. acute
hydramnios.
9) Immunological causes:
A. Systemic lupus erythematosus.
B. Antiphospholipid antibodies that are directed
against platelets and vascular endothelium
leading to thrombosis, placental destruction and
abortion.
C. Histocompatibility between the mother and father
and in turn the foetus.
 Cont…..
10) Ageing sperm or ovum.
11) Uterine defects e.g. Septum ,
Asherman's syndrome (intrauterine
adhesions) and submucous myomas.
12) Nervous, psychological conditions
and over fatigue.
13) Idiopathic.
 Mechanism of Abortion
• Up to 8 weeks:The gestational sac tends
to be expelled complete and the decidua is
shed thereafter.
• From 8-12 weeks: The decidua capsularis
ruptures and the embryo is expelled either
entire or after rupture of the amnion.
• After 12 weeks: The placenta is
completely formed and the process of
abortion is like a miniature labour.
Differential Diagnosis of Different
Types of Abortion
 (A) Threatened Abortion
• Clinical picture:
1.Symptoms and signs of pregnancy coincide
with its duration.
2.Vaginal bleeding slight or mild, bright red in
colour
3.Pain is absent or slight.
4.Cervix is closed.
5.Pregnancy test is positive.
6.Ultrasonography shows a living foetus
 Cont…
• Prognosis:
– If the blood loss is less than a normal
menstrual flow and is not accompanied
by pain of uterine contraction there is a
reasonable chance for continuing
pregnancy.
– This occurs in 50% of cases while other
half will proceed to inevitable or missed
abortion.
 Cont…
• Treatment:
1.Rest in bed until one week after stoppage of
bleeding.
2.No intercourse
3.Sedatives: if the patient is anxious.
4.Treatment of controversy
A. Progestrone 250mg IM twice weekly
B. Gonadotrophins
C. Sympathomimetics, antiprostaglandins and folic acid
 (B) Inevitable Abortion
• Clinical picture:
1.Symptoms and signs of pregnancy
2.Vaginal bleeding is excessive
3.Pain is colicky felt in the suprapubic region
radiating to the back.
4.The internal os of the cervix is dilated and
products of conception may be felt through it.
5.Rupture of membranes between 12-28 weeks
is a sign of the inevitability of abortion.
 Cont…
• Treatment:
1.Any attempt to maintain pregnancy is useless.
2.Resuscitation and ergometrine 0.5 mg is given by IM
or IV route to induce tetanic uterine contraction and
stop bleeding.
A. If pregnancy is less than 12 weeks: Termination is
done by vaginal evacuation and curettage or suction
evacuation under general anaesthesia.
B. If pregnancy is more than 12 weeks: Oxytocin is given
by intravenous drip to expel the uterine contents.
• Cervical abortion: is a variety of inevitable
abortion in which the products of conception has
been separated from the uterine cavity but retained
in the cervical canal causing its distension.
• Clinical picture:
– The patient complains of considerable bleeding
and severe lower abdominal pain referred to the
back.
– On examination, the products of conception is
felt through the dilated cervix.
 Cont….
• Treatment:
– Under anaesthesia, the cervix is dilated,
contents is removed and cavity is
curetted to remove the decidua.
 (C) Incomplete Abortion
• Retention of a part of the products of
conception inside the uterus.
• It may be the whole or part of the placenta
which is retained.
• Treatment: As inevitable abortion.
 Cont….
• Clinical picture:
1.The patient usually noticed the passage of a
part of the conception products.
2.Bleeding is continuous.
3.On examination, the uterus is less than the
period of amenorrhoea but still large in size.
The cervix is opened and retained contents
may be felt through it.
4.Ultrasonography: shows the retained contents
 (D) Complete Abortion:
• All products of conception have been expelled
from the uterus.
• Clinical picture:
1.The bleeding is slight and gradually diminishes.
2.The pain ceases.
3.The cervix is closed.
4.The uterus is slightly larger than normal.
5.Ultrasound : shows empty cavity
 (E) Missed Abortion
• Retention of dead products of conception
for 4 weeks or more.
• Carneous mole is a special variety of
missed abortion in which the dead ovum in
early pregnancy is surrounded by clotted
blood.
 Cont…
• Clinical picture:
(A) Symptoms:
– Symptoms of threatened abortion may or may not be
developed.
– Regression of pregnancy symptoms as nausea, vomiting
and breast symptoms.
– The abdomen does not increase and may even decrease in
size.
– The foetal movements are not felt or ceases if previously
present.
– Milk secretion may start particularly in second trimester
abortion
 Cont…
(B) Signs:
– The uterus fails to grow or even
decreases in size and becomes firmer.
– The cervix is closed.
– The foetal heart sounds cannot be
heard by the doptone.
 Cont…
• Investigations:
• Pregnancy test becomes negative within two
weeks from the ovum death
• Ultrasound shows either a collapsed
gestational sac, absent foetal heart movement
or foetal movement.
• Complications:
1. Disseminated intravascular coagulation
(DIC)
2. Superadded infection
 Cont..
• Treatment:
• The dead conceptus is expelled spontaneously
in the majority of cases. Evacuation of the uterus
is indicated in the following conditions:
1.spontaneous expulsion does not occur within
four weeks,
2.there is bleeding,
3.infection or DIC developed or ,
4.patient is anxious.
 Cont…
• Evacuation is carried out as following:
1.If the uterine size is less than 12 weeks’ gestation:
vaginal or suction evacuation is done
2.If the uterine size is more than 12 weeks' gestation :
evacuation can be done by:
A. Prostaglandins: given intravaginally (PGE2),
intravenously
B. Oxytocin infusion.
C. Combination: starting with prostaglandin and completed
with oxytocin.
D. Hysterotomy
 (F) Septic Abortion
• It is any type of abortion, usually criminal
abortion, complicated by infection.
• Microbiology: General examination:
•Pyrexia and
1. E.Coli, tachycardia
2. bacteroids, •Rigors suggest
bacteraemia
3. anaerobic •subnormal temperature
streptococci, with tachycardia
4. clostridia, •Malaise, sweating ,
5. streptococci headache, and joint
pain
and •Jaundice and /or
6. staphylococci haematuria
 Cont….
• Abdominal examination:
– Suprapubic pain and tenderness.
– Abdominal rigidity and distension indicates peritonitis.
• Local examination:
– Offensive vaginal discharge.
– Uterus is tender.
– Products of conception may be felt.
– Local trauma may be detected.
– Fullness and tenderness of Douglas pouch indicates
pelvic abscess
 Cont….
• Complications:
1. acute renal failure and
2. DIC
• Management :

1. Isolate the patient . Bed rest in semi-sitting

position
2. An intravenous line is established for therapy
3. Observation for vital signs: pulse, temperature
and blood pressure
4. A cervico-vaginal swab is taken for culture
 5- Antibiotic therapy: Ampicillin or
cephalosporin ( as a broad spectrum)
+gentamycin (for gram -ve organisms) +
metronidazole (for anaerobic infection)
6- Fluid therapy: e.g. glucose 5% normal
saline and/or lactated ringer solutions
7- Blood transfusion
8- Anti-gas gangrene (in Cl.welchii) and
antitetanic serum (in Cl. tetani).
9- Oxytocin infusion
10- Surgical evacuation of the uterus
11-hysterectomy
 Cont….
(G) Therapeutic Abortion:
• Abortion induced for a medical indication.

(H) Criminal Abortion:

• Illegal abortion induced for a non-medical
indication.
 (I) Recurrent (Habitual)
Abortion:
• Definition: Three (two by some authors) or
more consecutive abortions.
• Aetiology:
(I) Chromosomal abnormalities:
• Can be detected in
• Foetus : e.g. autosomal trisomy, sex
chromosome monosomy (X), and polyploidy.
• Parents : e.g. balanced translocation.
 Cont…
(II) Uterine abnormalities:
1.Congenital anomalies: e.g. hypoplasia,
bicornuate, septate and subseptate uterus.
2.Intrauterine synechiae (Asherman’s
syndrome).
3.Cervical incompetence: whether congenital
or acquired.
4.Uterine myomas.
5.Deficiency of endometrial oestradiol and
progesterone receptors
6.Divided uterine artery
 Cont…
(III) Infections:
1.Toxoplasma.
2.Mycoplasma hominis.
3.Ureaplasma urealyticum.
4.Listeria monocytogenes.
5.Brucella.
6.Chlamydia.
7.Syphilis.
 Cont….
(IV) Hormonal:
1.Hypothyrodism,
2.Diabetes.
3.Luteal phase deficiency.
(V) Immunological:
1.Human leucocyte antigens (HLA)
2.Antiphospholipid antibodies: antibodies cause
placental vessels thrombosis resulting in infarction
and placental insufficiency.
3.SLE
 Cont…
(VI) Miscellaneous:
1. Chronic malnutrition.
2. Chronic anaemia.
3. Chronic cardiac and renal diseases.
4. Cigarette smoking and alcohol abuse.
Diagnosis of recurrent abortion
A- History taking:
Abortion due to cervical incompetence is
characterised by:
1-History of a previous operation as dilatation or
amputation of the cervix
2-It is a midtrimester abortion; occurs usually
between 16-28 weeks of pregnancy
3-preceded by spontaneous rupture of membrane
4-abortion process takes a short time
 Cont……

5-usually associated with slight pain and

bleeding,
6-the expelled foetus shows no
abnormalities,
7-the duration of pregnancy is decreasing
each time due to weakness of the isthmus
by successive pregnancies
 Cont..
• Cervical incompetence.
• Ask about:
– Consanguinity between the couple.
– History of in utero exposure to
diethylstilbestrol (DES) that causes
uterine anomalies..
– Exposure to radiation, infections or
environmental pollutants.
 Cont….
(B) General examination:
• may reveal:
1. malnutrition,
2. anaemia,
3. thyroid disorder.
(C) Local examination:
• may reveal
1. fibroid,
2. cervical incompetence
 Cont…
(D) Special investigations:
1. Urine analysis for chronic renal disease and
diabetes.
2. Blood for:HB,GLUCOSE, RFT,TFT ,VDRL ,
toxoplasmosis and brucellosis, HLA
3. Microbiological investigations for chlamydia
and mycoplasma
4. Cytogenetic study to detect chromosomal
abnormalities
5. Hysterosalpingography and / or hysteroscopy
Treatment of recurrent abortion
(A) Medical treatment:
• Treatment of the cause as :
1.anaemia and malnutrition,
2.diabetes,
3.renal diseases,
4.infections as chlamydia and mycoplasma (tetracycline
or doxycycline) and toxoplasma (spiramycin)
5.Luteal phase defect treated by progestrone or
progestogens
 Cont…
(B) Surgical treatment:
1.Cervical cerclage
2.Vaginal cerclage (Shirodkar operation, Mc
Donald operation)
3. Abdominal cerclage
4.Metroplasty
A. Bicornuate uterus: Strassman operation is
done to unify the two corns.
B. Septate uterus: Jones operation: involves
excision of the uterine septum through a wedge
 Cont….
• Tompkin's operation: involves dissection
of the uterine septum.
• Hysteroscopic excision of the septum is
the preferred management nowadays
C-Asherman's syndrome: Hysteroscopic
dissection of the intrauterine adhesions
is the preferred management
D-Myomectomy:hysteroscopy
 POST-ABORTIVE BLEEDING
• Persistent or recurrent bleeding within the
first 4 weeks after abortion.
 Cont…
• Causes:
1. Perforation of the uterus or cervical laceration.
2. Retained products of conception.
3. Infection leading to sloughing of a septic debris.
4. Submucous myoma or a fibroid polyp.
5. Choriocarcinoma.
6. Local gynaecological lesion as cervical polyp or
carcinoma.
7. Haemorrhagic blood disease.
8. Dysfunctional uterine bleeding.