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Bleeding in first trimester - miscarriage, non-obstetrical reasons…
Bleeding in first trimester - miscarriage, non-obstetrical reasons
I trimester
Since conception To the end of 14th week of gestation (calculated from the first day of LMP)
Bleeding diagnosis
History
LMP, Time of bleeding, Intensity and character of bleeding, Abdomen and back pain, Other symptoms (nausea and vomiting, headache, heart palpitation, muscular tremor, weakness, fainting)
Physical examination
Overall condition (blood pressure, heart rate)
Skin colour (pale, yellow)
Examination with speculum (bleeding assessment, tissue pieces)
Gynecological examination (size of the uterus, uterine tension, ovaries)
Additional tests
Progesteron level
Choriogonadotropin level (checking level of hcg every 2-3 days)
Thyroid hormones
Ultrasound
Speculum (blood, place of bleeding, local status)
Pap-smear, pathology (tissue sampling)
Laboratory tests of coagulation, thrombophilia
Non-obstetrical reasons
Trauma (vulva, vagina)
Neoplasms (uterine cervix, vagina, vulva)
Cervical ectopia
Polyps (decidual)
Infections
Coagulation disorders
Intensity of bleeding
Spotting (minimal amount of blood, spots on the underwear)
Bleeding (average amount of blood)
Hemorrhage (life-threatening condition – above 1500 ml or 25-35% of total blood volume; more than 150 ml/min)
Treatment
Trauma - sutures
Antiinflammatory treatment
We do not remove polyps except extremal situations – risk of miscarriage
We do not treat surgically cervical ectopias (antiinflammatory treatment)
Genital herpes – acyclovir per os, local antiviral treatment
Genital warts – kryotherapy, curetage
Obstetrical reasons
Miscarriage (25% of preganancies)
Ectopic pregnancy
Hydatiform Mole
Miscarriage (spontaneous aborion)
spontaneous loss of the fetus before 22 weeks of gestation and before the fetus is able to exist by itself (independently of weght).
Reasons – chromosomal abnormalities, hormonal insufficiency (progesteron, thyroxin), uterine malformations, homeostatic disturbancies, maternal diseases (hypertension, autoimmunologic diseases, diabetes), infections, coagulopathic disordres- thrombophilia, antiphospholipid syndrome, environmental factors- ionizing radiation, drugs, injuries
Types of miscarriages
Spontaneous, induced (indications)
Complete, incomplete
In tractu
Threatening
Missed (fetal demise)
Ovum caecum
Recurrent
Septic
diagnosis
Bleeding or spotting, abdominal pain.
Gynecological examination:
Uterus of the size corresponding to the LMP, increased tonus of the uterus (threatening abortion, abortion in tractu);
Uterus smaller than expected (complete or incomplete abortion)
External os closed (threatening abortion, complete abortion, incomplete abortion when bleeding finished);
Cervix open for 1-2 fingers (abortion in tractu, complete or incomplete)
Septic miscarriage: fever, chills, bloody purulent vaginal discharge, tenderness in the uterus and ovaries, shock symptoms
US
Gestational sac with live fetus in uterine cavity (threatening abortion)
Gestational sac with dead fetus in uterine cavity (missed abortion)
Gestational sac without fetus in uterine cavity (ovum caecum)
Gestational sac in the uterine cervix (abortion in tractu, ectopic pregnancy)
No gestational sac at all (complete or incomplete abortion)
Gestational sac out of uterus (ectopic pregnancy)
treatment
In threatening abortion – hormone supplementation and minimal physical activity.
In missed abortion, abortion in tractu and incomplete abortion:
Conservative treatment – observation (60-85% abortion without medical intervention)
Farmacological treatment (prostaglandins – Mizoprostol)
Instrumental uterine cavity content evacuation (curretage, vaccum) – if requires cervical dilatation may cause cervical insufficiency in consecutive pregnancies
Ectopic pregnancy
Implantation of the pregnancy out of the uterine cavity (95% in Fallopian tube, uterine cervix, ovary, visceral peritoneum)
None of the listed surfaces is covered with decidua, which limits lytic abilities of the trophoblast. In the consequence the tissues are destroyed, hemorrhage starts and may cause life-treatening situation.
1-2% of all gestations are ectopic
Hydatiform mole
Abnormal development of trophoblastic cells being a result of abnormal conception (triploid) and having an occurence 1 per 1000 pregnancies.
Risk factors
previous molar pregnancy,
mother's age <20 years /> 40 years,
previous spontaneous abortion,
smoking,
increased content of vit. A in the diet,
parity> 1, without miscarriage
Symptoms
hyperemesis, spotting, quickly growing uterus, high HCG level, hypertension.
hyperthyroidism (thyrotoxicosis)
pathognomonic US image („snowstorm” or „honeycomb”)
multiple ovarian cysts like in hyperstimulation syndrome
numerous ovarian tecalutein cysts as in hyperstimulation syndrome
no embryonic or fetal tissue
Types
Hydatiform mole (complete and incomplete),
Invasive mole (limited to the uterus or with metastases)
Chorioncarcinoma (limited to the uterus or with metastases) – the highest risk of choriocarcinoma occurs in women who have had mole)
Persistent trophoblastic disease (prolonged uterine bleeding, incomplete uterus involution, persistent elevated Beta hCG level).
FIGO classification
I – limited to the uterine cavity
II – limited to the genital organs
III – metastases to the lungs
IV – metastases to other organs
treatment
Evacuation of the uterine cavity content (curettage)
Beta-hCG control
In cases of suspition of chorioncarcinoma:
X-ray of the chest
Bones scintigraphy
MRI of the head
After confirmation of the diagnosis – Methotrexat therapy
Chorioncarcinoma
The most malignant neoplasm in humans.
It may develope after:
hydatiform mole (50%), miscarriage (25%)
delivery (20%), ectopic pregnancy
Metastases to:
Lungs (80%), vagina (30%)
pelvis (20%), liver (10%)
brain (10%)
Differential diagnosis
