Bleeding (2)

Approach to vaginal Approach to vaginal bleeding during bleeding during

pregnancypregnancy Basma mohamed abdel

azizAssistant lecture of

Family medicine ,Suez Canal University

Dr.Basma ,FM,SCU,2012-2013

Approach to vaginal bleeding Approach to vaginal bleeding

In early pregnancyIn early pregnancy


Causes of early bleeding in pregnancy

AbortionAbortionEctopic pregnancyEctopic pregnancy

Hydatidiform moleHydatidiform mole


Abortion

pregnancy loss at less than 20 weeks' gestation


Types of abortion Threatened abortion. Inevitable abortion. Incomplete abortion.

Complete abortion. Missed abortion Septic abortion: Any type of

abortion, which is complicated by infection

Recurrent abortion: 3 or more successive spontaneous abortions



Hydatidform mole


Lab Studies: Suspect gestational trophoblastic neoplasia when a positive

pregnancy test result occurs in the absence of a fetus. A serum HCG greater than 100,000 mIU/mL should raise the

concern of gestational trophoblastic disease (GTD). A CBC count may help detect anemia secondary to vaginal

bleeding. Liver enzymes may become elevated in the presence of

metastasis to the liver.

Assessment-:


Snowstorm appearance


Ectopic pregnancyEctopic pregnancy The classic clinical triad of ectopic pregnancy is pain,

amenorrhea, and vaginal bleeding; only about 50% of patients present with all 3 symptoms.

clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness.

Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture.


Case one 27 years old , married from 6 month ,her menses

is regular , presented with vaginal bleeding from one day , she had a history of amenorrhea one week after the missed period

What is your approach to mange such case?What is your approach to mange such case?



Ask your selfAsk your self

Is she pregnant ? Intra uterine or ectopic pregnancy ? Viable or not viable fetus ? How to mange?


Is she pregnantIs she pregnant? ? History of amenorrhea History of amenorrhea

Lab Lab B hCG test S.Progesterone

Ultrasound Ultrasound


Beta HCG

hCG is detectable in the serum of approximately :

5% of patients 8 days after conception in more than 98% of patients by day 11.


according to the American Pregnancy Association. Most urine tests have a detection level of 25 mIU/mL to indicate pregnancy

According to the National Women's Health Information Center, 90 percent of women who were pregnant got a positive urine test on the

first day of a missed pregnancy.

This goes up to 97 percent one weekone week after the first missed period.



Is she pregnant ? Intra uterine or ectopic pregnancy ? Viable or not viable fetus ? If not vaible ……..which type?


Intra uterine or ectopic pregnancy ?5 week embryo and yolk sac


When you find gestational sac??



True gestational sac True gestational sac must bemust be differentiated from differentiated from pseudo sacpseudo sac

Embryonic Vesicle (Primary yolk sac Round or oval. Double ring )Ring of decidualized

endometrium. Fundal or mid-portion of the uterus. May occasionally implant low down in the

uterine cavity.


Double-decidual sign (5 weeks menstrual age). The decidua vera (dv) can be discerned from the decidua capsularis (dc) and chorion laeve surrounding the gestational sac. A small subchorionic hemorrhage(*) is present between the unapposed layers of

deciduvera .


The "Double Decidual Sign"consists of two echogenic rings surrounding the hypoechoic gestational sac.

The inner ring represents the chorion, embryonic disc and decidua capsularis (*). The outer ring represents the decidua parietalis (**).





Blighted ovum


Single decidul ring ( pseudo sac)This may be due to a decidual cast and fluid in the endometrial cavity. This appearance can be found in the presence of an ectopic pregnancy


Double ring appearance







US at 5 wks, intrauterine


US at 6 weeks shows intrauterine pregnancy


Gestational Sac 7wk Embryo and Yolk Sac


ExtrautrineExtrautrine


If early pregnancy problems…. Urine B-hCG + AScan

Intra-uterine pregnancy …….GOOD No Intra-uterine gestation Seen…… serum B-

hCG + TVS. with serum B-hCG of 1500-2000 ml I.U/ml Intra

uterine gestation should be seen using TVS…… otherwise suspect Ectopic pregnancy


Serum Human Chorionic Gonadotropin Discriminatory zone: B-hCG level at which

Gestational sac of IU pregnancy should be seen with U/S confirming IU pregnancy and essentially R/O EP.

Intrauterine sac should be visulized:TVUS B-hCG level >= 1,000-2,000 IU/LTAUS B-hCG level >= 6,500 IU/L

In Singleton pregnancy


Serum Human Chorionic Gonadotropin Rise in B-hCG levels of at least 66% in 2 days or 100% in 3

days is consistent with normal pregnancy.

Minimum increase is 53%

A rise less than this(<53%) is inconclusive because it seen in:1. 15 % of normal pregnancy2. EP3. Nonviable IU pregnancy

– Falling hCG level suggest non viable IU pregnancy.

< 7 week GA


ultrasonographic diagnosis Definitive ultrasonographic diagnosis of an ectopic pregnancy is made in

only about 20% of cases, when an extrauterine pregnancy is clearly identified (ie, an extrauterine gestational sac with a yolk sac or fetal pole is visualized).

numerous findings that are highly suggestive of ectopic pregnancy, including

1. an empty uterus in a patient with a β-hCG level above the discriminatory zone,

2. an adnexal mass other than a simple cyst .3. echogenic fluid in the cul-de-sac, or anything more than a small amount

of fluid in the cul-de-sac.



Ultrasound sign A tubal ring is a thick-walled cystic structure in the adnexa, independent of the ovary and uterus, and is highly predictive

of ectopic pregnancy It can sometimes be confused with a corpus luteum cyst when

the ovary is not well visualized. The corpus luteum cyst wall tends to be thinner and less

echogenic than the endometrium, and the cyst tends to contain clear fluid

When surrounded by free fluid, it can sometimes be confused with a hemorrhagic ovarian cyst.[17]



Uterus outlined red, uterine lining greenTubal ectopic pregnancy yellow

Fluid in uterus at blue circle is a "pseudosac"Looks like early pregnancy sac, but is not


The most definitive sonographic sign of ectopic pregnancy is the visualization of an extrauterine gestational sac containing a yolk sac, embryo or fetal heart beat

ectopicUterus


balder

EctopicEctopic

uterusuterus



Normal US Findings

Embryo (black arrow); amnion (small arrow) does not fuse with chorion (large arrow) until 12-16wks gestation.


Picture of uterus without a fetal pole and a complex

adnexal mass consistent with ectopic pregnancy



Is she pregnant ? Intra uterine or ectopic pregnancy ? Viable or not viable fetus ? If not vaible ……..which type?


Viable or notViable or not


Viable or not


Signs suggestive of abnormal embryonic developmentSigns suggestive of abnormal embryonic development include a gestational sac greater than 10 mm10 mm in diameter without a visible

yolk sac

gestational sac greater than 18 mm18 mm in diameter without a fetal pole a collapsed gestational sac

Additionally, when the difference between the mean sac diameter and crown rump length (CRL) is less than 5mm5mm, there is a significant risk of spontaneous abortion.

Other signs associated with a poor prognosis include the absence of a fetal heart beat in an embryo with a CRL of at least 5 mm5 mm

a fetal heart beat less than 90 beats90 beats per minute.


Serum Human Chorionic Gonadotropin Rise in B-hCG levels of at least 66% in 2 days or 100% in 3

days is consistent with normal pregnancy.

Minimum increase is 53%

A rise less than this(<53%) is inconclusive because it seen in:1. 15 % of normal pregnancy2. EP3. Nonviable IU pregnancy

– Falling hCG level suggest non viable IU pregnancy.

< 7 week GA


Serum Progesterone


Transvaginal ultrasound in a longitudinal plane showing a gestational sac greater than 8 mm in diameter without a yolk


A gestational sac greater than 18 mm without a fetal pole


Transvaginal ultrasound in a longitudinal plane showing a collapsed gestational sac


MangementMangement



Is she pregnant ? Intra uterine or ectopic pregnancy ? Viable or not viable fetus ? Management ?




No ectopic or pregnancy sac seen??

Abortion Early preganancy ectopic




Management Expectant management (wait and see) is highly effective for

the treatment of incomplete abortion, follow up by b hcg incomplete abortion, follow up by b hcg 80 80 percent drop in the β-hCG level one week following the passage of tissue confirms completion.

misoprostol and uterine aspiration are more effective for the management of anembryonic gestationanembryonic gestation and embryonic embryonic demise.demise.


Misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated.

Cramping and bleeding typically occur within two to six hours of misoprostol insertion, with the most sever symptoms resolving in about three to five hours.

Pretreatment with a nonsteroidal anti-infammatory drug

before administering is helpful adverse effects of fever, chills, and severe cramping


Ultrasound findings post-abortion

“thin stripe” “thick strip”


SummarySummary



Affp, 2011



THANK YOUTHANK YOU

Bleeding (2)

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