Bleeding in early pregnancy

Definition

• vaginal bleeding in first half pregnancy

• before age viability

• at less than 24 weeks gestation (or 500g)

Incidence

• 15-20% pregnancies

• 80% within 12 weeks

• 50% continue to viability

Aetiology

• foetal factors

  • commonest cause of miscarriage

  • occurs early (<8 weeks)

  • usually chromosomal abnormalities (up to 50%)

  • autosomal trisomies - 50%

• paternal factors

  • balanced translocation

  • carrier state

  • ? increased abnormalities with ageing sperm

• idiopathic

• maternal factors

  • endocrine disorders

    • polycystic ovary disease

    • Hyperthyroidism

    • uncontrolled Diabetes Mellitus

    • luteal phase deficiency

  • anti-phospholipid syndrome

  • chronic renal disease

  • chronic cardiovascular disease

  • anatomical abnormalities

    • submucous fibroids

    • congenital uterine abnormalities

      • septate / bicournate / unicournate uterus

    • cervical incompetence

    • intra-uterine adhesions (Asherman's syndrome)

  • infections

    • listeria

    • toxoplasmosis

    • Mycoplasma

    • Syphilis

  • environmental

    • toxins

    • radiation

    • drugs

    • smoking

    • alcohol

Management

• supportive

• treatment of known causes between pregnancies

• non-viable pregnancies

  • RU486 / mifepristone

  • conservative management

  • salpingostomy

  • salpingectomy

  • methotrexate

Differential diagnosis

• threatened abortion

  • painless vaginal bleeding

  • closed cervix

• inevitable abortion

  • vaginal bleeding

  • cervical dilatation

  • +/- rupture of membranes

• incomplete abortion

  • bleeding

  • pain

  • open cervical os

  • some foetal tissue expelled

• complete abortion

• blighted ovum

  • anembryonic pregnancy

• missed abortion

  • retention of dead foetal tissue

  • pregnancy symptoms absent

  • may lead to DIC

• septic abortion

  • fever

  • pain

  • tenderness

  • often retained products

  • predisposing factor

    • IUCD

    • TOP

  • complications

    • renal failure

  • Treatment

    • antibiotics

    • evacuation

    • fluids

  • Sequelae

    • infertility

    • chronic PID

    • pain

• hydatidiform mole

  • hydropic placental villi

  • complete or partial

• recurrent abortion

• ectopic pregnancy

• local genital factors

  • cervical polyps

  • chronic cervicitis

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