Management of Bleeding in Early Pregnancy

JHPIEGO in partnership withJHPIEGO in partnership withSave the Children, The Futures Group,Save the Children, The Futures Group,

The Academy for Educational Development,The Academy for Educational Development,The American College of Nurse-Midwives and The American College of Nurse-Midwives and

Interchurch Medical AssistanceInterchurch Medical Assistance

JHPIEGO in partnership withJHPIEGO in partnership withSave the Children, The Futures Group,Save the Children, The Futures Group,

The Academy for Educational Development,The Academy for Educational Development,The American College of Nurse-Midwives and The American College of Nurse-Midwives and

Interchurch Medical AssistanceInterchurch Medical Assistance

Management of Bleeding in Early Management of Bleeding in Early PregnancyPregnancyManagement of Bleeding in Early Management of Bleeding in Early PregnancyPregnancy

Best Practices in Maternal and Newborn Care

2Vaginal Bleeding in Early Pregnancy

Session ObjectivesSession ObjectivesSession ObjectivesSession Objectives

•To describe best practices for diagnosis of vaginal bleeding in early pregnancy

•To describe best practices for management of vaginal bleeding during early pregnancy

•To list post-abortion family planning options


Case StudyCase StudyCase StudyCase Study

•Let everyone read Case Study 1 and discuss in group.


Definition and IncidenceDefinition and IncidenceDefinition and IncidenceDefinition and Incidence

•Bleeding in Early Pregnancy is:–Vaginal bleeding that occurs during the first 22 weeks of pregnancy

–May occur in up to 25% of all pregnancies


What may cause bleeding . . .What may cause bleeding . . .What may cause bleeding . . .What may cause bleeding . . .

. . . in early pregnancy?


Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: Diagnosis of AbortionDiagnosis of Abortion

Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: Diagnosis of AbortionDiagnosis of Abortion

•Threatened abortion•Inevitable abortion•Incomplete abortion•Complete abortion•Septic abortion•Missed abortion•Ectopic pregnancy•Molar pregnancy


Types of abortions (1)Types of abortions (1)Types of abortions (1)Types of abortions (1)

• Threatened Abortion – Uterine

bleeding – Cervix closed – Risk of

Complete Abortion: 50%

• Inevitable Abortion – Bleeding and/or

rupture of gestational sac <20 weeks

– Cervix dilated – Menstrual-type

cramping – No products of

conception expelled yet



•Incomplete Abortion

–Incomplete evacuation of products of conception

• Complete Abortion – Complete evacuation

of products of conception

– Difficult to differentiate from Incomplete Abortion • May require dilatation

and curettage for diagnosis



• Missed Abortion (fetal demise) – Retained non-

viable products of conception, up to 4 weeks

– May cause coagulopathy

• Septic abortion– Abortion

complicated by infection



• Spontaneous Abortion – Gestational

age <20 weeks – Weight <500

grams

•Induced Abortion

–Elective Abortion or

–Therapeutic Abortion


Ectopic pregnancyEctopic pregnancyEctopic pregnancyEctopic pregnancy

•The result of an abnormality in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in the death of the fetus.

Ectopic pregnancy sitesSource: Vicken Sepillan, MD. Dept. of

OB/GYN, Univ. of Texas


Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: General ManagementGeneral Management

Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: General ManagementGeneral Management

•Rapid evaluation of woman’s general condition including vital signs (pulse, blood pressure, respiration, temperature)

•If shock suspected, immediately begin treatment.

•If woman is in shock, consider ruptured ectopic pregnancy.

•Start an IV infusion and infuse IV fluids.


Management of Management of Threatened Threatened AbortionAbortion

•Medical treatment usually not necessary.•Advise woman to avoid strenuous activity and

sexual intercourse; bed rest not necessary.

•If bleeding stops, followup in antenatal clinic. Reassess if bleeding recurs.

•If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound). Persistent bleeding, esp. in the presence of uterus larger than expected may indicate twins or molar pregnancy.

Do not give medications such as hormones (e.g. estrogens or progestins) or tocolytic agents (e.g. salbutamol or indomethacin) as they will not prevent miscarriage.


Management of Inevitable Inevitable AbortionAbortion

•If pregnancy is less than 16 weeks, plan for evacuation of uterine contents. If evacuation not immediately possible:

– Give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary);

– Arrange for evacuation as soon as possible.

•Ensure follow-up after treatment.


Inevitable abortion Inevitable abortion contdcontd..Inevitable abortion Inevitable abortion contdcontd..

•If pregnancy is greater than 16 weeks:

– Await spontaneous expulsion of products of conception and then evacuate uterus to remove any remaining products of conception

– If necessary, infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min to help expulsion of products of conception


Management of Incomplete Incomplete Abortion:Abortion: Less than 16 Weeks

•If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix.

•If bleeding heavy, evacuate uterus:– Manual vacuum aspiration (MVA) is preferred method.

Sharp curettage should only be done if MVA not available

– If evacuation not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 min. if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours if necessary).

– Ensure followup of the woman after treatment.


Manual Vacuum Aspiration Manual Vacuum Aspiration (MVA) of uterus(MVA) of uterus

Manual Vacuum Aspiration Manual Vacuum Aspiration (MVA) of uterus(MVA) of uterus


Management of Incomplete Management of Incomplete Abortion: Greater than 16 Abortion: Greater than 16

WeeksWeeks

Management of Incomplete Management of Incomplete Abortion: Greater than 16 Abortion: Greater than 16

WeeksWeeks

•Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of POC occurs

•Evacuate any remaining products of conception from uterus by dilatation and curettage

•If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg.

•Ensure followup of the woman after treatment.


Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: Management of Complete Management of Complete

AbortionAbortion

•Evacuation of the uterus usually not necessary

•Observe for heavy bleeding

•Ensure followup of woman after treatment


Bleeding in Early Pregnancy: Bleeding in Early Pregnancy: Followup after AbortionFollowup after Abortion

•Tell woman that spontaneous abortion is common.

•Reassure woman that chances for subsequent successful pregnancy are good unless there has been sepsis or unless cause of abortion is identified that may have an adverse effect on future pregnancies (rare).


Follow-up after spontaneous Follow-up after spontaneous abortionabortion

Follow-up after spontaneous Follow-up after spontaneous abortionabortion

•Encourage her to delay next pregnancy until completely recovered.

•Provide counseling for women who have had unsafe abortion. If pregnancy not desired, certain FP methods can be started immediately (within 7 days) if:

– There are no severe complications requiring further treatment

– Woman receives adequate counseling and help in selecting most appropriate FP method.


Family Planning Methods after Family Planning Methods after Post-abortion CarePost-abortion Care

Family Planning Methods after Family Planning Methods after Post-abortion CarePost-abortion Care

Type of FP Method

Advise to Start

Hormonal Immediately

Condoms Immediately

IUDOr Voluntary Tubal Ligation

ImmediatelyIf infection present or suspected, delay insertion/surgery until clearedIf Hb < 7 g/dL, delay until anemia improves Provide interim method (e.g. condom)


ECTOPIC ECTOPIC PREGNANCYPREGNANCY

ECTOPIC ECTOPIC PREGNANCYPREGNANCY

•Pregnancy which is outside the uterine cavity– Can be in the tube,

ovary, abdomen or other locations

– If it ruptures, can lead to hemorrhage and death


Ectopic Pregnancy:Ectopic Pregnancy:Clinical DiagnosisClinical Diagnosis

Ectopic Pregnancy:Ectopic Pregnancy:Clinical DiagnosisClinical Diagnosis

•Symptoms:–Pain: 90-100% of patients–Amenorrhea/abnormal menses: 75-95%

–Irregular bleeding: 50-80%–Pregnancy symptoms: 10-25%

Weckstein 1987.


Ectopic pregnancy: Ectopic pregnancy: Clinical Diagnosis Clinical Diagnosis (cont’d)(cont’d)

Ectopic pregnancy: Ectopic pregnancy: Clinical Diagnosis Clinical Diagnosis (cont’d)(cont’d)

•Signs:–Afebrile–Abdominal tenderness: 80-95%–Rebound tenderness: 45%–Palpable mass: 50% (often opposite side)

–Normal sized uterus: 71%

•Use combination testing to increase sensitivity and specificity


Signs and Symptoms of Signs and Symptoms of Unruptured Ectopic PregnancyUnruptured Ectopic Pregnancy

Signs and Symptoms of Signs and Symptoms of Unruptured Ectopic PregnancyUnruptured Ectopic Pregnancy

•Symptoms of early pregnancy – Irregular spotting or bleeding– Nausea– Swelling of breasts– Bluish discoloration of vagina and

cervix– Softening of cervix– Slight uterine enlargement– Increased urinary frequency

•Abdominal and pelvic pain


Signs and Symptoms of Signs and Symptoms of Ruptured Ectopic PregnancyRuptured Ectopic Pregnancy

Signs and Symptoms of Signs and Symptoms of Ruptured Ectopic PregnancyRuptured Ectopic Pregnancy

•Collapse and weakness•Fast, weak pulse

(≥110/minute)•Hypotension•Hypovolemia•Acute abdominal and pelvic

pain•Abdominal distension•Rebound tenderness•Pallor

Ruptured ectopic pregnancy seen through a laparoscope Source: Vicken Sepillan, MDDept. of OB/GYN, Univ. of

Texas


•Threatened abortion•Acute or chronic PID•Ovarian cysts (torsion or rupture)

•Acute appendicitis

•Remember: A ruptured ectopic pregnancy could be life-threatening!

Differential Diagnosis for Differential Diagnosis for Ectopic PregnancyEctopic Pregnancy

Differential Diagnosis for Differential Diagnosis for Ectopic PregnancyEctopic Pregnancy


Treatment of Ectopic PregnancyTreatment of Ectopic PregnancyTreatment of Ectopic PregnancyTreatment of Ectopic Pregnancy

•Surgical-Salpingectomy (removal of the pregnancy or tube)

•Also treated medically, although not available in developing countries


Molar pregnancyMolar pregnancyMolar pregnancyMolar pregnancy

•Symptoms and signs:

– Heavy bleeding– Dilated cervix– Uterus larger than

dates– Uterus softer than

normal– Partial expulsion of

products of conception which resemble grapes


Molar pregnancy Molar pregnancy contd.contd.Molar pregnancy Molar pregnancy contd.contd.

Gross and histology


Molar Pregnancy Molar Pregnancy contd.contd.Molar Pregnancy Molar Pregnancy contd.contd.

•If diagnosis of molar pregnancy is certain, evacuate the uterus:

–Use vacuum aspiration•Risk of perforation using a metal curette is

high•Have three syringes cocked and ready for

use as uterine contents are copious and must be evacuated rapidly

–Infuse oxytocin 20 units in 1 L IV (NS or RL) at 60 drops/minute to prevent hemorrhage once evacuation is under way


Molar pregnancy Molar pregnancy contd.contd.Molar pregnancy Molar pregnancy contd.contd.

•Subsequent management–Use contraception for at least one year

–Follow up every 8 weeks for at least one year to monitor for trophoblastic disease or choriocarcinoma


SummarySummarySummarySummary•Vaginal bleeding in early pregnancy could be caused by:

– Threatened abortion– Incomplete abortion– Complete abortion– Ectopic pregnancy– Molar pregnancy

•Diagnosis can often be made clinically, saving time and expense

•Treatment should be directed at the aetiology


ReferencesReferencesReferencesReferences

•Ganges F. Bleeding in Early Pregnancy, a presentation in Accra, Ghana, Basic Maternal and Newborn Care Technical Update. April, 2006.

•Jongen V. 1996. Ectopic pregnancy and culdo-abdominocentesis. Int J Gynecol Obstet 55: 75-76.

•Musnick RA. 1982. Clinical test for placenta in 300 consecutive menstrual aspirations. Obstet Gynecol 60:738-741.

•Weckstein LN. 1987. Clinical diagnosis of ectopic pregnancy. Clin Obstet and Gynecol 30(1):236-244.

•WHO. Managing Complications in Pregnancy and Childbirth. WHO. Geneva. 2000

Management of Bleeding in Early Pregnancy

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