Tutorial 2: Bleeding in Early Pregnancy

Question 1

What are the different terminologies for an early loss of birth?

Answer 1

1. <6 weeks LMP : Chemical pregnancy or an early pregnancy loss
2. <20 weeks LMP: Clinical Cpontaneous Miscarriage
3. >20 weeks LMP: Still Birth

Question 2

What is the definition of a miscarriage?

Answer 2

A spontaneous end of a pregnancy at a stage when the embryo or fetus is incapable of surviving (6-20 weeks)

Question 3

What are some statistics regarding miscarriage?

Answer 3

20-40% of pregnancies are miscarried.
Most (60-75%) occur in 1st trimester
Miscarriages are more common in 1st pregnancies.
Chromosomal abnormalities are the most common cause of a miscarriage
Chromosomal abnormalities are the cause of >50% of miscarriages in the first 13 weeks

Question 4

What are the 5x different types of miscarriages?

Answer 4

1. Threatened M: Presents with bleeding and there may be pelvic pain but cervix is closed, ultrasound indicates an ongoing pregnancy within the uterus.
2. Inevitable M: The pregnancy is certain not to continue
3. Complete M: Inevitable abortion, uterus completely empties itself.
4. Incomplete M: Inevitable abortion with products of the pregnancy still present in the uterus.
5. Missed M: Usually no pain and products of conception retained (woman has no indication that pregnancy many be failing, discovers empty sac and absence of heart beat at scan

Question 5

What are some risk factors for miscarriage?

Answer 5

Ectopic implantation;

Maternal health issues: endometrioisis, DM, thyrotoxicosis, immunocompromise, antiphospholipid syndrome, infection, other chronic disease;

Maternal factors: age>35, high gravity, BMI<18.5 or >25, weak cervix, uterine abnormalities;

Maternal lifestyle: malnutrition, excess caffeine, excess exercise.

Question 6

What are some risk factors for miscarriage in early pregnancy?

Answer 6

1. Parental genetic abnormality
2. PCOS
3. Chromosomal abnormality (Most common)
4. Chlamydia/rubella (infection)
5. Smoking
6. High BP

Question 7

What are some causes of light bleeding during early pregnancy?

Answer 7

1. Cervical inflammation, common cause of post-coital spotting

2. Uterine fibroids
3. Polyps
4. Cervical or vaginal infection.
5. Inherited disorders of haemostasis (e.g. Von Willebrand’s Disease)
6. Trauma (nb screen for domestic violence)

Question 8

What are features of light bleeding?

Answer 8

Light bleeding or ‘spotting’ is actually fairly common in early pregnancy

1/4 women experience some bleeding in the first 3 months of pregnancy.

Spotting however is similar to but lighter than a period and varies in colour from red to brown.

Benign spotting may be a normal consequence of pregnancy, such as hormone-induced breakthrough bleeding around the time a woman would normally menstruate.

The embedding of the embryo into the endometrium may also trigger an ‘implantation bleed’ which usually lasts a day or two.

Question 9

What are features of sinister bleeding?

Answer 9

Usually heavier, accompanied by pain and/or cramping, and possibly the passage of products of conception (POC).

POC may resemble large clots or pieces of liver.

Question 10

What are your differentials for sinsiter bleeding?

Answer 10

A. Miscarriage (4 types) 1) Threatened miscarriage, on-going pregnancy 2) Complete miscarriage 3) Incomplete miscarriage 4) Missed miscarriage

B. Ectopic Pregnancy

C. Molar Pregnancy

Question 11

What do you ask as a part of a bleeding/discharge history?

Answer 11

 Onset (sudden? Previous spotting)

 Recent trauma, intercourse, vigorous exercise, stress, illness

 Duration and timing, association with periods

 Pattern: Distinguish this from normal menstrual bleeding- a regular or irregular bleeding pattern?

 Quantify loss: number of sanitary pads, need to use two at once?

 Consistency, colour, odour, presence of clots, products of conception (i.e. tissue)

 Associated itching or irritation

Question 12

What do you ask as part of a abdominal pain history?

Answer 12

 Site
 Onset and duration
 Nature/Character of Pain (like period pain? Like contractions?)
 Relationship to menstrual cycle
 Radiation
 Associated symptoms: vomiting, nausea, fever, dysuria, dyspareunia, pallor, dizziness, sweats
 Aggravating and relieving factors
 Severity

Question 13

What details of her current pregnancy do you ask?

Answer 13

 Her health since LMP, fetal health

 Details of any medical check-ups, pregnancy tests, antenatal blood tests, scans, laboratory tests, ultrasound scans

 Symptoms of pregnancy (breast tenderness, nausea)

Question 14

What examination would you do for bleeding during pregnancy?

Answer 14

 General: Obvious distress, pallor, perspiration

 Vital signs: Pulse, blood pressure

 Abdomen: Soft? Masses? Tender? Guarding? Peritonitic? Uterus palpable?

 Speculum and vaginal examination: Visualize cervix, take swabs from endocervix and vagina. Check for presence of ectropion or cervical carcinoma. Observe if cervical os is open or closed (vital until scan is available).

 Refer to Table

Question 15

What are features of a Threatened miscarriage?

Answer 15

Minimal vaginal bleeding, mild period-type pelvic pain, volume less than usual menstrual blood loss. Cervical os closed, uterine size corresponds to gestational period, USS confirms viable pregnancy

Question 16

What are features of a Inevitable miscarriage?

Answer 16

Open cervical os, vaginal bleeding associated with mild-severe crampy pelvic pain. USS confirms non-viable pregnancy, and reveals products of conception in utero

Question 17

What are features of an Incomplete miscarriage?

Answer 17

Vaginal bleeding, pelvic pain. Cervical os open, remains open until miscarriage is completed: medically, surgically or spontaneously. Some products of conception possibly visible on vaginal examination- may be passed and stuck in cervical os/uterus.

Question 18

What are some features of a Complete miscarriage?

Answer 18

Vaginal bleeding, pelvic pain resolve spontaneously. Cervical os open, closes spontaneously. USS shows empty uterus: no products of conception remain, no ectopic pregnancy

Question 19

What are features of an ectopic pregnancy?

Answer 19

Massive haemorrhage, pale, sweaty, unwell, possible collapse.
After rupture, entire abdomen tense and tender, guarding, rebound.
Prior to rupture uterus non-palpable, affected side tender with possible guarding and rebound.
NB: Young fit healthy women can bleed a huge amount into their abdomen with normal vital signs. Beware!

Question 20

What are features of cervical shock?

Answer 20

Cervical shock occurs when a miscarriage is occurring and a clot or pregnancy tissue gets stuck in transit in the cervix, causing a profound vagal response of hypotension and bradycardia.

(rare) low BP and HR, ruptured ectopic pregnancy-massive haemorrhage with weak pulse and tachycardia.

Treatment is required immediately by doing a speculum and removing the POC from the cervical os

Question 21

What is the Management/Resuscitation of an acutely unwell woman presenting with pain and/or bleeding in early pregnancy?

Answer 21

1. Perform ABC’s with a few modifications for pregnancy

2. Obtain IV access
3. Give O2
4. Continuous monitoring
5. Give IV fluids.
6. Request urgent bloods including group and hold. Transfuse blood while finding cause of bleeding and treating it.

Question 22

What is the role of BHCG to make a diagnosis of early pregnancy viability and location ?

Answer 22

Serum β-hCG - presence thereof confirms pregnancy, but cannot be used to diagnose ectopic pregnancy. Quantitative hCG tests can indicate viability of pregnancy, using serial hCG’s taken over time. β-hCG level is supposed to double roughly every two to three days in early pregnancy.

1. Slower doubl-ing time can indicate an ectopic
2. Decrease over time can indicate miscarriage.

Question 23

What is the role of USS to make a diagnosis of early pregnancy viability and location ?

Answer 23

Transvaginal scan provides the best view in early pregnancy.

1. Examine uterus for gestation sac, fetal pole and fetal heartbeat.
2. If uterus is empty, examine adnexae looking for mass (ectopic pregnancy).
3. Examine for free fluid and retained POC products of conception.

One would expect to see products of conception in the uterus via USS when βhCG levels reach 1500 mIU/mL. Before this time, one could look for pelvic free fluid in to justify scan (don’t miss ectopic!)

Question 24

What is the management of a missed miscarriage?

Answer 24

1. Conservative - no treatment; 65-80% will pass within 2-6 weeks. Advantages: considered “natural” – no complications of medical and surgical management. Disadvantages: woman goes home, is not monitored for bleed or infection.

2. Medical – give misprostol, 95% of missed miscarriages will complete within a few days.
3. Surgical – vacuum aspiration – instant, woman doesn’t go home unmonitored, provides rapid closure.

Risks of vaccum aspiration (future problems getting pregnant):

1. Damage to cervix causing cervical incompetence.
2. Rupture of uterus.
3. Scarring of uterus.

Question 25

What are some of the important points which should be discussed with every woman who has an early pregnancy loss?

Answer 25

Grief and loss after miscarriage is often more extensive and intense than one may expect. Research indicates that many couples who have had a miscarriage experience grief responses similar in duration and intensity to those parents who have lost a new baby. Common emotions couples experience may include **fear** (particularly as the miscarriage begins), **anger** and a sense of unfairness, **disappointment**, **guilt** and then sadness and grief. Mothers commonly blame themselves and feel guilty about the loss of their baby, even though most miscarriages are not preventable. For these reasons, following a miscarriage all women should have access to support, follow-up and formal counselling when necessary. Grief Counselling and Support Services  Miscarriage Support Auckland Inc.  Sands New Zealand  SIDS New Zealand 24 hour support line 0800 164 455  SIDS New Zealand  Patients should also be advised that there is no evidence to support a couple delaying attempts to conceive following a miscarriage. They should be advised of lifestyle risk factors, such as alcohol consumption, smoking and elicit drug use.

Question 26

What is an ectopic pregnancy?

Answer 26

A complication of pregnancy in which the embryo implants at a site other than the endometrium of the uterine cavity. Generally **non-viable**, with rare exceptions. Most occur in the **Fallopian tubes (95%)** but can also occur in the cervix, ovaries, caesarean scar and abdomen. A potential medical emergency, they can cause massive haemorrhage and if not adequately managed, death.

Question 27

What are the rates of ectopic pregnancy?

Answer 27

More common than one would expect, at a rate of **1/50 pregnancies or 2%**. **7%** of maternal deaths are due to ectopic pregnancies.

Question 28

What are risk factors for Ectopic Pregnancy?

Answer 28

1. Factors that **slow** the passage of the ovum to the uterus, i.e. **damage to the fallopian tubes** a. salping**itis**, b. previous **surgery**, c. previous **ectopic** pregnancies, d. tubal **ligation** 2. **Uterine** pathology, e.g. Endometriosis 3. **Contraception** (IUD, POP)

Question 29

What is the management for ectopic pregnancies?

Answer 29

Medical: **IM Methotrexate** (women with ectopics who are haemodynamically stable, asymptomatic and whose BHC level (\<5000) and USS findings are within specific limits. **ANTI D** for all Rhnegative women. ## Footnote Surgical: a. usually **Laparoscopic**, indicated for women who are haemodynamically stable but do not meet the criteria for medical management. b. **Laparotomy** indicated if patient is in shock, or laparascopy likely to be difficult (increased BMI, previous surgery).

Question 30

What advice should you give to someone following an ectopic pregnancy?

Answer 30

1. In most cases it is recommended that women wait for **at least two full menstrual cycles** before trying for another pregnancy, to allow time for fallopian tube to recovery. 2. If treated with _methotrexate_, recommended to wait at least **three months**. Chances of having a successful pregnancy will depend on the underlying health of your fallopian tubes. In general, 65% of women achieve a successful pregnancy 18 months after having an ectopic pregnancy. IVF can be an option if unable to conceive naturally

Question 31

What is a molar pregnancy?

Answer 31

An abnormal form of pregnancy in which a **non-viable fertilized egg** **implants** in the uterus . The pregnancy will **always fail** to come to term. The cell mass grows and develops **swollen chorionic villi** which resemble a _bunch of grapes_. It may occupy the entire uterus.

Question 32

What are the two types of molar pregnancies?

Answer 32

1. Complete molar pregnancy. An egg with no DNA is fertilized by a sperm. The sperm grows on its own, cannot become a fetus. 2. Partial molar pregnancy. An egg is fertilized by two sperm. The placenta becomes the molar growth. Any fetal tissue that forms is likely to have severe defects. Very rarely, a pregnancy that seems to be twins is found to be one fetus and one molar pregnancy

Question 33

What are risk factors for having a molar pregnancy?

Answer 33

1. **Age** (risk for complete molar pregnancy steadily increases after age 35), ## Footnote 2. History of molar pregnancy, especially two or more, 3. History of miscarriage, 4. Diet **low in carotene**.

Question 34

What are risks associated with having a molar pregnancy?

Answer 34

Heavy bleeding ## Footnote On-going gestational trophoblastic disease and rarely choriocarcinoma. Patients are advised not to conceive for **one year after a molar pregnancy**. The chances of having another molar pregnancy are approximately 1%.

Question 35

What is the management of a molar pregnancy?

Answer 35

Evacuation of uterus by suction curettage (risk of heavy bleeding). ## Footnote Follow up required, preferably at specialist clinic, with serum **BhCG measured every 1-2 weeks** until **non-detectable**, then **monthly** for 6 months. ANTI D for all Rh-negative women.

Question 36

What advice is given following a molar pregnancy?

Answer 36

Outlook for future pregnancy is good, with repeated molar pregnancy only 1-2%. ## Footnote Avoid pregnancy for full duration of follow up and up to 1 year, **contraception should be used**. Persistant disease/evidence of cancer- consider chemotherapy

Question 37

What is the definition of a recurrent miscarriage?

Answer 37

Definition: loss of three or more consecutive pregnancies. ## Footnote Affects 1% of women.

Question 38

What are recurrent miscarriages associated with?

Answer 38

a. **chromosomal** abnormality, b. congenital uterine abnormality, c. **cervical incompetence**, d. **infection**, e. **inadequate progesterone** secretion in luteal phase, f. **PCOS**, g. **auto-immune** disease (anti phospholipid syndrome)