Post on 30-Sep-2020
Bleeding in Pregnancy
By Clare Di Bona
Early Pregnancy Loss
Defined as pregnancy loss before 20 weeks gestation
Approximately 20% of pregnancies miscarry Approximately 1 in 200-500 pregnancies are
ectopic Miscarriages and ectopic pregnancy can
cause considerable distress Women should have the opportunity to make
informed decisions about their care and treatment
Objectives
How to take an obstetric/gynaecological history, investigations, examination in pregnancy
Understand the principles of diagnosis and management of miscarriage
Understand the principle of diagnosis and management of ectopic pregnancy
Understand the distress caused by miscarriage and ectopic and how you can support women that present to the ED
O&G History Taking
Investigations
Examination
Miscarriage
Definition Early pregnancy loss is defined as a loss before 20
weeks of pregnancy US criteria
Gestational sac ≥25mm diameter does not contain a yolk sac or embryo
Embryo with CRL >7mm that does not have cardiac activity
Risk Factors: Advanced maternal age, previous miscarriage and
maternal smoking
Normal Fetal Development
During normal fetal development the gestational sac develops, followed by the yold sac then the embryo
Gestational sac >25mm without a yolk sac or embryo criteria for failed pregnancy
CRL >7mm with no cardiac activity meets criteria for a failed pregnancy
Miscarriages
Causes: Most commonly caused by structural or chromosomal
abnormalities of the embryo Accounts for 50% miscarriages Most common chromosomal abnormality aneuploidy (missing
or additional chromosome) Extrinsic factors: amniotic band, chorionic villus sampling,
amniocentesis, trauma Uterine issues: uterine septum, submucosal leiomyoma,
intrauterine adhesions Exposure to teratogens: thalidomide Maternal Disease: infection (Listeria, parvovirus B19, rubella..)
poorly controlled diabetes, endocrinopathies (thyroid, Cushing’s syndrome, PCOS), thrombophilias (SLE, antiphospholipid)
Miscarriages
Classification Threatened
Vaginal bleeding +/- abdo pain, closed cervix and presence FHR. Often attributed to marginal separation of the placenta
Managed expectantly, weekly US if bleeding stops go back to routine care. Missed
Non-viable pregnancy (embryo >7mm no cardiac acitvity) that has not passed. Cervix is closed. Or can an anembryonic pregnancy (gestation sac >25mm without embryonic tissue (yolk sac or embryo)).
Complete/incomplete Incomplete; some products have passed but placental/fetal tissue remains in uterus Complete: all tissues and placenta have passed from uterus
Inevitable Vaginal bleeding +/- pelvic pain with a dilated cervix +/- products at the os
Septic Miscarriage associated with intrauterine infection
Miscarriage-ED treatment
In unstable patient 2 large IV lines (BHCG, G&H, FBP, U&E, VBG(Hb)) In patients with heavy bleeding need urgent
speculum exam and possible removal of tissue from cervix
If active heavy bleeding from os +/- unstable patient urgently discuss with O&G reg directly
IVH and possible blood products may be needed for BP
Arrange theatre promptly via O&G reg is necessary DO NOT CONSIDER A PRIVATE ADMISSION
FOR UNSTABLE O&G PATIENTS AS THIS LEADS TO DELAYS IN TREATMENT
Miscarriages
Treatment Options: 1) Expectant 2) Medical 3) Surgical
Good success rates with expectant and medical treatment success rates incomplete miscarriage 74-94% expectant vs
96-100% medical For missed miscarriage lower success rates expectant 14-50% vs
medical 80-90% More outpatient visits expectant>medical>surgical More bleeding medical treatment vs surgical but less pain Misoprostol is the medication of choice and is prescribed only by
the O&G team.
Miscarriage
Expectant Management Means waiting for the natural loss of the
pregnancy-this occurs in about 50% of miscarriages
It take some time before the bleeding starts and can take up 3-4 weeks
If bleeding doesn’t start or miscarriage isn’t completed, offered medical or surgical treatment
Miscarriage
Medical Management Misoprostol tablets are placed into vagina and help
open the cervix and pass the pregnancy Takes a few hrs to start and can cause pain,
bleeding or clotting May continue to bleed for up to 3 weeks Sometimes more than 1 dose is needed 1 week
apart 80-90% success rate If treatment doesn’t work need surgical
management
Medical Treatment Miscarriage
Medical Management Miscarriage
Surgical Management of Miscarriage
Dilatation and curretage Success rate 95-100% Necessary in cases of heavy ongoing bleeding,
infection or used in women who don’t want to wait for products to pass or sick of bleeding
Risks Endometritis Cervical trauma Small risk of perforation of uterus Retained products Adhesions
Support and Information Giving
Throughout the woman’s care give her and her partner appropriate support and information including: When and how to seek help is symptoms worsen What to expect in the time she is waiting for
treatment ie length and extent of pain/or bleeding and possible side effects
What to expect in recover-when to resume sexual activity and/or try to conceive again
Information on impact of her treatment on future fertility
Where to access support and counselling services including leaflets, web addresses, help lines
Post Management Counselling
When to start trying again? After next normal period BUT no absolute right or wrong
answer. Recommended have at least 2 weeks rest (no sex, tampons,
heavy lifting Why did this happen to me?
50% time chromosomal abnormality A lot of the time we can’t give an answer
What are the risks of miscarriage in future pregnancies? FUTURE REPRODUCTIVE OUTCOMES — The predicted
risk of miscarriage in future pregnancy is approximately 14 percent after one miscarriage, 26 percent after two miscarriages, and 28 percent after three miscarriages [66].
Ectopic
Occurs when the developing blastocyst implants in a site other than the endometrium of the uterine cavity
Diagnostic Criteria: Positive pregnancy test Empty intrauterine cavity Complex adnexal mass +/- extrauterine
gestational sac
Ectopic
Symptoms of ectopic Common: abdo/pelvic pain, amenorrhoea or
missed period, vaginal bleeding with or without clots
Other: breast tenderness, GIT symptoms, dizziness/fainting or syncope, shoulder tip pain, urinary symptoms, passage of tissue, rectal pressure or pain on defecation
Ectopic
Signs: Pelvic/adnexal tenderness Cervical motion tenderness Rebound tenderness or peritoneal signs Pallor Abdominal distention Enlarged uterus Tachycardia (>100bpm) or hypotension (<100/60) Shock or collapse Orthostatic hypotension
Ectopic
Most common site of ectopic is the fallopian tube (98%) Other: ovarian, cornual (junction uterus and
fallopian tube), C-section scar, abdominal, cervical, heterotopic (multiple pregnancy intra and extrauterine).
Ectopic
Diagnostic Algorithm BHCG >1500 perform TV Ultrasound
no intrauterine gestational sac strongly suggests ectopic
BHCG <1500 repeat BHCG in 72hrs
Ectopic ED Management
2 large bore IV lines (G&H, FBP, U&E, BHCG) Immediately discuss with O&G reg possible
ectopic in unstable patients IVH to maintain BP if required (low Hb and
unstable may need blood product) Urgently arrange US (transvaginal) Urgently arrange for theatre in unstable
patients
Ectopic
Management Expectant BHCG days 3,7 and follow up US day 7 looking
for looking for drop 50% in BHCG and reduction in size of ectopic mass
BHCG performed weekly until <15 Only can be offered if the following criteria can be met: 1) No sign of rupture 2) Pelvic free fluid <100ml 3) Tubal mass <2cm 4) No yolk sac or fetal pole seen on ultrasound 5) BHCG <1000 IU/L
Ectopic
Management Medical: Methotrexate Folic acid antagonist (anti-metabolite) prevents
growth of rapidly dividing cells including trophoblastic and fetal cells by interfering with DNA synthesis
Inclusion Criteria Haemodynamically stable Unruptured BHCG <5000IU/L Size <3.5cm Normal LFT, U&E, FBP Patient compliant with regular follow-up
Ectopic
Medical Management Given as an IM injection Cytotoxic precautions needed
Ectopic Medical Management
Ectopic Medical Management
Side effects Commonly: stomatitis, conjunctivitis Rarely: gastritis, enteritis, dermatitis,
pneumonitis, alopecia, elevated liver enzymes, bone marrow suppression
Separation pain 2-7 days after the injection No negative effect on future fertility medical
management vs other treatments.
Ectopic
Surgical Management First line treatment when the patient is unstable With health tubes no evidence that salphingostomy
should be used vs salphingectomy Risk salpingostomy is persisting trophoblast and
small increase risk of bleeding Fertility rates are similar providing the contralateral
tube is normal Pregnancy rates not significantly different surgery
vs medical treatment
Ectopic
Salpingectomy vs salpingotomy Offer salpingectomy for women undergoing
surgery for ectopic pregnancy unless have issues infertility (contralateral tube damage)
Inform women that having a salpingotomy up to 1 in 5 women may need further treatment. This may include methotrexate and or salpingectomy
Women have salpingotomy need weekly BHCGs
Ectopic
Indications for surgery Haemodynamically unstable Ruptured Co-existing intrauterine pregnancy Contraindication of medical treatment
Ectopic
Follow-up All women should be counselled re the risk
of recurrence Anti-D needs to given to all Rhesus negative
women If histology shows no fetal tissue the case
must reviewed by a consultant BHCG needs to monitored weekly post
surgery (may take up to 10 weeks to normalise)
References
KEMH guidelines (via JEDO) Early pregnancy complications-Assessment and diagnosis Early Pregnancy Failure-Management of Miscarriage Diagnosis of Ectopic Pregnancy Medical Management using Methotrexate Surgical Expectant Management Pregnancy Loss in the First 13 Weeks of Pregnancy (patient pamphlet)
NICE Guidelines Ectopic pregnancy and miscarriage: Diagnosis and initial management in early
pregnancy of ectopic pregnancy and miscarriage Uptodate
Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation
Spontaneous abortion: Management Ectopic pregnancy: clinical manifestations and diagnosis Ectopic pregnancy: Choosing a treatment and methotrexate therapy Ectopic pregnancy: Incidence, risk factors, and pathology Ectopic pregnancy: Surgical treatment