Prof.

Robinson MBU

09/09/16

Professor Robinson MBU, 2009.

Introduction
Objectives
Causes of bleeding in early pregnancy
Discussion of the causes
Conclusion
Summary

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Professor Robinson MBU, 2009.

Early pregnancy includes the 1st and 2nd

trimesters, i.e, the first 22 weeks
About 15 20% of pregnancies will be
complicated with bleeding within the 1st
22 weeks
The causes of bleeding during the 1st and
2nd trimesters are the same
In some cases as in ectopic gestations,
maternal prognosis may be poor

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Professor Robinson MBU, 2009.

At the end of this lecture, M2 students

will be able to:
Define bleeding in early pregnancy
Understand the various causes
Manage these causes

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Professor Robinson MBU, 2009.

Implantation bleeding
Abortion
Ectopic pregnancy
Molar pregnancy

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Professor Robinson MBU, 2009.

Bleeding caused by the penetration of

trophoblasts into the uterine wall during
implantation (nidation)
Mild, painless bleeding usually between 4
5 weeks of gestation
Requires only counseling as treatment

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Professor Robinson MBU, 2009.

Termination of pregnancy before the

foetus is matured (22 weeks, weight <
500gm)
Two clinical forms:
Spontaneous
Induced

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Professor Robinson MBU, 2009.

Occurs in about 10 15% of pregnancies

There is always the desire to keep the
pregnancy
The triad of symptoms are:
Amenorrhoea
Bleeding
Pain

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Professor Robinson MBU, 2009.

Clinical forms:

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Threatened (mild pain and bleeding, closed

cervix, bed rest)
Inevitable (severe pain, profuse bleeding,
dilated cervix)
Complete (uterus empty, cervix closed)
Incomplete (retention of products of
conception, uterine evacuation)
Septic (infected incomplete abortion)
Missed (foetus dead and retained in the
uterus)
Professor Robinson MBU, 2009.

Before 12 weeks:

Evaluate the state of the patient

She may needs transfusion
Empty the uterus

After 12 weeks:

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Evaluate patient
Allow spontaneous expulsion or facilitate
expulsion with oxytocine
Verify if expulsion is complete
Uterine evacuation if expulsion is incomplete
Professor Robinson MBU, 2009.

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24 hours antibiotic treatment

Followed by uterine evacuation

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The foetus is dead and retained in the

uterus
Before treatment, do a FBC and clotting
profile, preserve fresh blood
Empty the uterus if pregnancy is < 12
weeks
After 12 weeks, induce contractions with
prostaglandins

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1st trimester

About 50 60% are caused by chromosomal

abnormalities mostly non disjunction of ch. 18
Congenital malformations

2nd trimester

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Uterine origin (cervical incompetence,

fibroids)
Maternal disease (diabetes, pyelonephritis,
malaria, TORCHE,
Foetal (multiple gestations, polyhydramnios)
Professor Robinson MBU, 2009.

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Carried out either as treatment

(therapeutic) or voluntarily (TOP)
Indications for therapeutic abortion:
Foetal malformation incompatible with life
Maternal health that can not support
pregnancy

Nb: address a letter to the minister through your

hierachy explaining why you intend to carry out

the abortion
Proceed with the abortion

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This is willful termination of pregnancy

using any method, usually by untrained
personnel
Results in complications:

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Bleeding
Infection
Uterine perforation
Cervical laceration
bladder/bowel injury
Peritinitis
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Pregnancy not located in the normal uterine

cavity
Could be cornual, cervical, tubal, ovarian, or

abdominal

Tubal, ovarian and abdominal pregnancies are

extra uterine
The prevalence is 2%
95% are tubal
10 11% occur as repeat ectopic

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Chronic PID
Repeated STIs
Multiple partners
History of previous ectopic pregnancy
Infertility
Reproductive age (15 45 years)
Tubal surgery

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STIs that cause tubal damage

Previous ectopic pregnnacy 10 11%
Tubal surgery (11 13%)
Transmigration
IUCD
Progesterone therapy
Estrogen therapy

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Tubal 95 96%:
Ampullary 76% ,
Isthmic 20%,
Interstitial 2%,
Infundibular 2%

Ovarian 0.5 1%
Abdominal 1 2%

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Rupture
Non rupture
Chronic
Tubal abortion
Carneous mole
Spontanous absorption

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Ruptured
Non ruptured
Chronic

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Abdominal pain and distension, fainting,

shoulder pain, spotting, 2e amenorrhoea
(80%)
Tachycardia, hypotension, pallor, paraumbilical echymoses (Culens sign)
Positive paracentesis abdominis and
culdocentesis
Abdominal ultrasound will reveal
haemoperitoneum

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Correct anaemia, then laparotomy

Clamp bleeding site first and drain
haemoperitoneum
Salpingectomy or tubal resection

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Mild pain, spotting, amenorrhea

Uterus increased in volume and tender
Cervical motion tenderness
Tender adnexal mass
Blood stained fingers

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Pregnancy test
Ultrasound (empty uterus, para-uterine
mass)
Beta HCG
Lesser than normal pregnancy of the same
age
Does not increase by 100% in 48hrs as in
normal pregnancy of the same age

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Ampullary, close to the infundibulum

Blood leaks out slowly from the
abdominal os of the tube, into the pouch
of Douglas, causing a haematoma (pelvic
heamatocoele)
12 weeks amenorrhoea or more with
vague LAP and spotting
Abdominal tenderness, palpable
abdominal mass, anaemia, bulging pouch
of Douglas

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20% of tubal pregnancies:

>Ruptures before the expected date of
menstruation, without amenorrhoea
Bleeding is massive, because the isthmus
is thick-walled, and highly vascular
Very lethal when it ruptures

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ovarien cyst ( torsion ,rupture, intracystic

bleeding, infection)
Acute appendicitis, PID, pelvic abscess,
tube-ovarian abscess
Endometriosis, complicated uterine
fibroids
Pyo/hydrosalapinx
Mekels diverticulitis
Appendicular abscess

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Similar to chronic chronic ectopic, pelvic

mass, full or bulging POD
Different from chronic ectopic only at
laparotomy using the criteria of
SPIEGELBERG

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Normal ipsilateral tube

Mass irrigated by ipsilateral ovarian
artery
Ovarian tissue at histology

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Ftus floats in the peritoneal cavity

Could be primary
Or secondary

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Both tubes normal

Walls of the uterus normal
Foetus free in the peritoneum

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Characterized by excessive proliferation

of trophoblasts
With (partial or incomplete) or without
featal tissue (complete)
Frequency is low in Cameroon (1/700
800 pregnancies) but high in the Asian
continent (1/80 200 pregnancies)
because of marriages among family
members.

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Part of gestational trophoblastic diseases

(GTDs):
Molar pregnancy
Invasive mole (chorioadenoma destruense)
choriocarcinoma

Pregnancy symptoms are exaggerated

uterine size is exaggerated in 50% of
cases
Bleeding may contain vesicles

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Complete mole
Genotype is xx
No foetal parts are
present
Uterine size is
exaggerated
30% present with
bilateral ovarian
cysts

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Incomplete (partial
mole)
Foetal parts
present
Uterus is normal
size or even
smaller
Genotype is
triploidy xxy, xyy.

Professor Robinson MBU, 2009.

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Ultrasound (snow storm or starry cavity)

Beta HCG, usually very high

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Work up:
Full blood count
Chest XR
Beta HCG
Liver function test
Kidney function test (urea, creatinine)

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Pregnancy no more desired

Hysterectomy (radical treatment)

Pregnancy still desired

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Suction curettage (conservative treatment)

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Beta HCG level weekly until normal and

normal for two other weeks
Beta HCG every 3 months for 6 months
and every 6 months for one year
No pregnancy during follow-up
Patient should be on combined oral
contraceptive

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