Bleeding During Pregnancy

Vaginal bleeding can occur frequently in THE

FIRST TRIMESTER of pregnancy and may not be a
sign of problems.

But bleeding that occurs in the SECOND AND
THIRD TRIMESTER of pregnancy can often be a
sign of a possible complication.

Bleeding can be caused by a number of reasons.
Bleeding
in
First Half of Pregnancy
Miscarriage
Ectopic Pregnancies
Molar Pregnancies

Miscarriage
~ spontaneous abortion
Spontaneous abortion (SAB), or miscarriage, is
the term used for a pregnancy that ends on its
own, within the first 20 weeks of gestation.
The medical name spontaneous abortion
(SAB) gives many women a negative feeling, so
we will refer to any type of spontaneous
abortion or pregnancy loss under 20 weeks as
miscarriage.

10-25% of all clinically recognized pregnancies
will end in miscarriage.

Chemical pregnancies may account for 50-75% of
all miscarriages ; a pregnancy is lost shortly after
implantation, resulting in bleeding that occurs
around the time of her expected period.

Most miscarriages occur during the first 13
weeks of pregnancy.

WHY DO MISCARRIAGES OCCUR?
Is varied, and most often cannot be identified.
During the First Trimester , the most common
cause of miscarriage is CHROMOSOMAL
ABNORMALITY (meaning that something is
not correct with the baby's chromosomes).
Most chromosomal abnormalities are the
cause of a DAMAGED EGG or SPERM CELL, or
are due to a problem at the time that the
zygote went through the DIVISION PROCESS.
OTHER CAUSES FOR MISCARRIAGE
(but are not limited to):
1. Hormonal problems - infections or maternal
health problems
2. Lifestyle (i.e. smoking, drug use, malnutrition,
excessive caffeine and exposure to radiation or
toxic substances)
3. Implantation of the egg into the uterine lining
does not occur properly
4. Maternal age
5. Maternal trauma
What are the chances of having a
Miscarriage?
An increase in maternal age affects the chances of miscarriage
under the age of 35 yrs old have about a 15% chance of
miscarriage
35-45 yrs old have a 20-35% chance of miscarriage
over the age of 45 can have up to a 50% chance of
miscarriage
has had a previous miscarriage has a 25% chance of having
another (only a slightly elevated risk than for someone who
has not had a previous miscarriage)
Warning signs of Miscarriage
Mild to severe back pain Weight loss
White-pink mucus
True contractions (very painful happening every
5-20 minutes)
Brown or bright red bleeding with or without
cramps (about 50% of those resulting in normal
pregnancies)
Tissue with clot passing from the vagina
Sudden decrease in signs of pregnancy

The different types of Miscarriage
1. Threatened Miscarriage
2. Inevitable Miscarriage
3. Incomplete Miscarriage
4. Complete Miscarriage
5. Missed Miscarriage
6. Recurrent Miscarriage (RM)
7. Blighted Ovum
Threatened Miscarriage
~ Abortus Iminen
Some degree of early pregnancy uterine
bleeding accompanied by cramping or lower
backache.
The cervix remains closed. This bleeding is
often the result of implantation.
Inevitable Miscarriage
Abortus Insipien
Abdominal or back pain accompanied by
bleeding with an open cervix.
There is a dilation or effacement of the cervix
and/or there is rupture of the membranes.
Bleeding and cramps may persist if the
miscarriage is not complete.
Complete Miscarriage
A completed miscarriage is when the embryo
or products of conception have emptied out of
the uterus.

Bleeding should subside quickly, as should any
pain or cramping.

Can be confirmed by an ultrasound or by
having a surgical curettage (D&C) performed.
Missed Miscarriage
Missed Abortion
A missed miscarriage is when embryonic
death has occurred but there is not any
expulsion of the embryo.
Signs of this would be a loss of pregnancy
symptoms and the absence of fetal heart
tones found on an ultrasound.
Recurrent Miscarriage
Habitual Abortion
Defined as 3 or more consecutive first
trimester miscarriages.
This can affect 1% of couples trying to
conceive.
BLIGHTED OVUM
an anembryonic pregnancy.
A fertilized egg implants into the uterine wall, but fetal
development never begins.
Often there is a gestational sac with or without a yolk
sac, but there is an absence of fetal growth.
Is the cause of about 50% of first trimester
miscarriages and is usually the result of chromosomal
problems.
This can be caused by :
abnormal cell division, or
poor quality sperm or egg.
ECTOPIC PREGNANCY
Ectopic Pregnancy : the fertilized egg attaches
itself in a place other than inside the uterus.
Almost all ectopic pregnancies occur in a
fallopian tube (tubal pregnancies )
The fertilized egg in a tubal pregnancy cannot
develop normally and must be treated.
An ectopic pregnancy happens in 1 out of 50
pregnancies.
WHAT CAUSES AN ECTOPIC
PREGNANCY?
An infection or inflammation of the fallopian
tube can cause it to become partially or entirely
blocked.
Scar tissue left behind from a previous infection
or an operation on the tube may also impede the
egg's movement.
Previous surgery in the pelvic area or on the
tubes can cause adhesions.
An abnormality in the tube's shape can be
caused by abnormal growths or a birth defect.

SITES
OF
ECTOPIC PREGNANCY
WHO IS AT RISK FOR HAVING AN
ECTOPIC PREGNANCY?
1. Are 35-44 years of age
2. Have had a previous ectopic pregnancy
3. Have had pelvic or abdominal surgery
4. Have Pelvic Inflammatory Disease (PID)
5. Have had several induced abortions
6. Women who get pregnant after having a tubal ligation
or while an IUD is in place
7. Women who smoke
8. Have endometriosis
9. Have undergone fertility treatments or are using
fertility medications

WHAT ARE THE SYMPTOMS OF AN
ECTOPIC PREGNANCY?
Sharp or stabbing pain that may come and go
and vary in intensity.
The pain may be in the pelvis, abdomen or even
the shoulder and neck (due to blood from a
ruptured ectopic pregnancy gathering up under
the diaphragm).
Vaginal bleeding, heavier or lighter than your
normal period
Gastrointestinal symptoms
Weakness, dizziness, or fainting

HOW IS AN ECTOPIC PREGNANCY
DIAGNOSED?
PELVIC & ABDOMINAL EXAMINATION
an ULTRASOUND to determine whether the uterus
contains a developing fetus.
The measurement of hCG levels.
An hCG level that is lower than what would be expected is
one reason to suspect an ectopic pregnancy.
Low levels of progesterone may also indicate that a
pregnancy is abnormal.
a CULDOCENTESIS :
The presence of blood in this area may indicate bleeding
from a ruptured fallopian tube.

HOW IS AN ECTOPIC PREGNANCY
TREATED?
METHOTREXATE (depending on how far the pregnancy
has developed.
If the tube has become stretched or it has ruptured
and started bleeding, all or part of the fallopian tube
may have to be removed.
Laparoscopic OR laparotomy surgery under general
anesthesia may be performed.
This procedure involves a surgeon using a laparoscope to
remove the ectopic pregnancy and repair or remove the
affected fallopian tube.
If the ectopic pregnancy cannot be removed by a
laparoscope procedure, then another surgical procedure
called a laparotomy may be done.

WHAT ABOUT THE FUTURE?
The hCG level will need to be rechecked on a regular
basis until it reaches zero if you did not have your
entire fallopian tube removed.
An hCG level that remains high could indicate that the
ectopic tissue was not entirely removed, which would
require surgery or medical management with
methotrexate.

The chances of having a successful pregnancy after an
ectopic pregnancy may be lower than normal
If the fallopian tubes have been left in place, there are
approximately a 60% chance of having a successful
pregnancy in the future.

MOLAR PREGNANCY
MOLAR PREGNANCY
A molar pregnancy : an abnormality of the
placenta, caused by a problem when the egg
and sperm join together at fertilization.
Molar pregnancies are rare, occurring in 1 out
of every 1,000 pregnancies.
Molar pregnancies are also called :
gestational trophoblastic disease (GTD),
hydatidiform mole or simply referred to as a
mole.
What is a molar pregnancy?
A molar pregnancy is the result of a genetic error
during the fertilization process that leads to
growth of abnormal tissue within the uterus.
Molar pregnancies rarely involve a developing
embryo, and the growth of this material is rapid
compared to normal fetal growth.
It has the appearance of a large and random
collection of grape-like cell clusters.
There are two types of molar pregnancies,
complete, and
partial.

WHAT IS A PARTIAL MOLAR
PREGNANCY?
PARTIAL MOLE occurs when the mass contains
both the abnormal cells and an embryo that has
severe defects.
In this case the fetus will be overcome by the growing
abnormal mass rather quickly.
An extremely rare version of a partial mole is
when twins are conceived but one embryo
begins to develop normally while the other is a
mole.
In these cases, the healthy embryo will very quickly be
consumed by the abnormal growth.

WHO IS AT RISK FOR A MOLAR
PREGNANCY?
1. In the US, approximately 1 out of 1,000
pregnancies is a molar pregnancy
2. Mexico, Southeast Asia, and the Philippines have
higher rates than the US for molar pregnancies
in women
White women in the US are at higher risk than black
women
3. Women over the age of 40
4. Women who have had a prior molar pregnancy
5. Women with a history of miscarriage

What are the symptoms of a molar
pregnancy?
Vaginal spotting or bleeding
Nausea and vomiting
Develop rare complications like thyroid
disease
Early preeclampsia (high blood pressure)
Increased hCG levels
No fetal movement or heart tone detected

HOW TO DIAGNOSED
A PELVIC EXAM may reveal a larger or smaller
uterus, enlarged ovaries, and abnormally high
amounts of the pregnancy hormone hCG.

A ULTRASOUND will often show a cluster of
grapes appearance, signifying an abnormal
placenta.

How is a molar pregnancy treated?
1. Most molar pregnancies will spontaneously end and the expelled tissue
will appear grape-like.
2. Molar pregnancies are removed by
suction curettage,
dilation and evacuation (D & C), or sometimes through
medication.
3. Approximately 90% of women who have a mole removed require no
further treatment.
4. Follow-up procedures that monitor the hCG levels can occur monthly for
six months or as your physician prescribes.
5. Follow-up is done to ensure that the mole has been removed
completely.
Traces of the mole can begin to grow again and may possess a cancerous-
type threat to other parts of the body.
6. Pregnancy should be avoided for one year after a molar pregnancy.
7. Any birth control method is acceptable with the exception of an
intrauterine device.

THANK YOU
dr.Bambang Widjanarko, SpOG
Head of Departement Obstetric and Gynaecology
FKK UMJ
Jakarta