Bleeding During Pregnancy

• Vaginal bleeding can occur frequently in THE FIRST TRIMESTER of pregnancy and may not be a sign of problems.

• But bleeding that occurs in the SECOND AND THIRD TRIMESTER of pregnancy can often be a sign of a possible complication.

• Bleeding can be caused by a number of reasons.

Bleeding in

First Half of Pregnancy

• Miscarriage• Ectopic Pregnancies• Molar Pregnancies

Miscarriage

• ~ spontaneous abortion• Spontaneous abortion (SAB), or miscarriage, is

the term used for a pregnancy that ends on its own, within the first 20 weeks of gestation.

• The medical name spontaneous abortion (SAB) gives many women a negative feeling, so we will refer to any type of spontaneous abortion or pregnancy loss under 20 weeks as miscarriage.

• 10-25% of all clinically recognized pregnancies will end in miscarriage.

• Chemical pregnancies may account for 50-75% of all miscarriages ; a pregnancy is lost shortly after implantation, resulting in bleeding that occurs around the time of her expected period.

• Most miscarriages occur during the first 13 weeks of pregnancy.

WHY DO MISCARRIAGES OCCUR?

• Is varied, and most often cannot be identified. • During the First Trimester , the most common

cause of miscarriage is CHROMOSOMAL ABNORMALITY – (meaning that something is not correct with the baby's chromosomes).

• Most chromosomal abnormalities are the cause of a DAMAGED EGG or SPERM CELL, or are due to a problem at the time that the zygote went through the DIVISION PROCESS.

OTHER CAUSES FOR MISCARRIAGE (but are not limited to):

1. Hormonal problems - infections or maternal health problems

2. Lifestyle (i.e. smoking, drug use, malnutrition, excessive caffeine and exposure to radiation or toxic substances)

3. Implantation of the egg into the uterine lining does not occur properly

4. Maternal age5. Maternal trauma

What are the chances of having a Miscarriage?

An increase in maternal age affects the chances of miscarriage• under the age of 35 yrs old have about a 15% chance of

miscarriage• 35-45 yrs old have a 20-35% chance of miscarriage• over the age of 45 can have up to a 50% chance of

miscarriage• has had a previous miscarriage has a 25% chance of having

another (only a slightly elevated risk than for someone who has not had a previous miscarriage)

Warning signs of Miscarriage

• Mild to severe back pain Weight loss• White-pink mucus • True contractions (very painful happening every 5-

20 minutes)• Brown or bright red bleeding with or without

cramps (about 50% of those resulting in normal pregnancies)

• Tissue with clot passing from the vagina• Sudden decrease in signs of pregnancy

The different types of Miscarriage

1. Threatened Miscarriage 2. Inevitable Miscarriage3. Incomplete Miscarriage4. Complete Miscarriage 5. Missed Miscarriage6. Recurrent Miscarriage (RM) 7. Blighted Ovum

Threatened Miscarriage

• ~ Abortus Iminen• Some degree of early pregnancy

uterine bleeding accompanied by cramping or lower backache.

• The cervix remains closed. This bleeding is often the result of implantation.

Inevitable Miscarriage

• Abortus Insipien• Abdominal or back pain accompanied by

bleeding with an open cervix. • There is a dilation or effacement of the cervix

and/or there is rupture of the membranes. Bleeding and cramps may persist if the miscarriage is not complete.

Complete Miscarriage

• A completed miscarriage is when the embryo or products of conception have emptied out of the uterus.

• Bleeding should subside quickly, as should any pain or cramping.

• Can be confirmed by an ultrasound or by having a surgical curettage (D&C) performed.

Missed Miscarriage

• Missed Abortion• A missed miscarriage is when embryonic

death has occurred but there is not any expulsion of the embryo.

• Signs of this would be a loss of pregnancy symptoms and the absence of fetal heart tones found on an ultrasound.

Recurrent Miscarriage

• Habitual Abortion• Defined as 3 or more consecutive first

trimester miscarriages. • This can affect 1% of couples trying to

conceive.

BLIGHTED OVUM

• an anembryonic pregnancy. • A fertilized egg implants into the uterine wall, but fetal

development never begins. • Often there is a gestational sac with or without a yolk sac,

but there is an absence of fetal growth.• Is the cause of about 50% of first trimester miscarriages

and is usually the result of chromosomal problems. • This can be caused by :

– abnormal cell division, or – poor quality sperm or egg.

ECTOPIC PREGNANCY

• Ectopic Pregnancy : the fertilized egg attaches itself in a place other than inside the uterus.

• Almost all ectopic pregnancies occur in a fallopian tube (tubal pregnancies )

• The fertilized egg in a tubal pregnancy cannot develop normally and must be treated.

• An ectopic pregnancy happens in 1 out of 50 pregnancies.

WHAT CAUSES AN ECTOPIC PREGNANCY?

• An infection or inflammation of the fallopian tube can cause it to become partially or entirely blocked.

• Scar tissue left behind from a previous infection or an operation on the tube may also impede the egg's movement.

• Previous surgery in the pelvic area or on the tubes can cause adhesions.

• An abnormality in the tube's shape can be caused by abnormal growths or a birth defect.

SITES OF ECTOPIC PREGNANCY

WHO IS AT RISK FOR HAVING AN ECTOPIC PREGNANCY?

1. Are 35-44 years of age2. Have had a previous ectopic pregnancy3. Have had pelvic or abdominal surgery4. Have Pelvic Inflammatory Disease (PID) 5. Have had several induced abortions6. Women who get pregnant after having a tubal ligation or while

an IUD is in place7. Women who smoke8. Have endometriosis9. Have undergone fertility treatments or are using fertility

medications

WHAT ARE THE SYMPTOMS OF AN ECTOPIC PREGNANCY?

• Sharp or stabbing pain that may come and go and vary in intensity.

• The pain may be in the pelvis, abdomen or even the shoulder and neck (due to blood from a ruptured ectopic pregnancy gathering up under the diaphragm).

• Vaginal bleeding, heavier or lighter than your normal period

• Gastrointestinal symptoms• Weakness, dizziness, or fainting

HOW IS AN ECTOPIC PREGNANCY DIAGNOSED?

• PELVIC & ABDOMINAL EXAMINATION • an ULTRASOUND to determine whether the uterus

contains a developing fetus.• The measurement of hCG levels. – An hCG level that is lower than what would be expected is

one reason to suspect an ectopic pregnancy. – Low levels of progesterone may also indicate that a

pregnancy is abnormal.• a CULDOCENTESIS :– The presence of blood in this area may indicate bleeding

from a ruptured fallopian tube.

HOW IS AN ECTOPIC PREGNANCY TREATED?

• METHOTREXATE (depending on how far the pregnancy has developed.

• If the tube has become stretched or it has ruptured and started bleeding, all or part of the fallopian tube may have to be removed.

• Laparoscopic OR laparotomy surgery under general anesthesia may be performed. – This procedure involves a surgeon using a laparoscope to remove the

ectopic pregnancy and repair or remove the affected fallopian tube. – If the ectopic pregnancy cannot be removed by a laparoscope

procedure, then another surgical procedure called a laparotomy may be done.

WHAT ABOUT THE FUTURE?

• The hCG level will need to be rechecked on a regular basis until it reaches zero if you did not have your entire fallopian tube removed. – An hCG level that remains high could indicate that the ectopic

tissue was not entirely removed, which would require surgery or medical management with methotrexate.

• The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal– If the fallopian tubes have been left in place, there are

approximately a 60% chance of having a successful pregnancy in the future.

MOLAR PREGNANCY

MOLAR PREGNANCY

• A molar pregnancy : an abnormality of the placenta, caused by a problem when the egg and sperm join together at fertilization.

• Molar pregnancies are rare, occurring in 1 out of every 1,000 pregnancies.

• Molar pregnancies are also called :– gestational trophoblastic disease (GTD), – hydatidiform mole or simply referred to as a – “mole.”

What is a molar pregnancy?• A molar pregnancy is the result of a genetic error during the

fertilization process that leads to growth of abnormal tissue within the uterus.

• Molar pregnancies rarely involve a developing embryo, and the growth of this material is rapid compared to normal fetal growth.

• It has the appearance of a large and random collection of grape-like cell clusters.

• There are two types of molar pregnancies, – “complete,” and – “partial.”

WHAT IS A PARTIAL MOLAR PREGNANCY?

• PARTIAL MOLE occurs when the mass contains both the abnormal cells and an embryo that has severe defects. – In this case the fetus will be overcome by the growing

abnormal mass rather quickly.• An extremely rare version of a partial mole is when

twins are conceived but one embryo begins to develop normally while the other is a mole. – In these cases, the healthy embryo will very quickly be

consumed by the abnormal growth.

WHO IS AT RISK FOR A MOLAR PREGNANCY?

1. In the US, approximately 1 out of 1,000 pregnancies is a molar pregnancy

2. Mexico, Southeast Asia, and the Philippines have higher rates than the US for molar pregnancies in women– White women in the US are at higher risk than black

women3. Women over the age of 404. Women who have had a prior molar pregnancy5. Women with a history of miscarriage

What are the symptoms of a molar pregnancy?

• Vaginal spotting or bleeding • Nausea and vomiting• Develop rare complications like thyroid

disease • Early preeclampsia (high blood pressure)• Increased hCG levels • No fetal movement or heart tone detected

HOW TO DIAGNOSED

• A PELVIC EXAM may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high amounts of the pregnancy hormone hCG.

• A ULTRASOUND will often show a “cluster of grapes” appearance, signifying an abnormal placenta.

How is a molar pregnancy treated?

1. Most molar pregnancies will spontaneously end and the expelled tissue will appear grape-like.

2. Molar pregnancies are removed by – suction curettage, – dilation and evacuation (D & C), or sometimes through – medication.

3. Approximately 90% of women who have a mole removed require no further treatment.

4. Follow-up procedures that monitor the hCG levels can occur monthly for six months or as your physician prescribes.

5. Follow-up is done to ensure that the mole has been removed completely.– Traces of the mole can begin to grow again and may possess a cancerous-type threat to

other parts of the body.6. Pregnancy should be avoided for one year after a molar pregnancy.7. Any birth control method is acceptable with the exception of an intrauterine

device.

THANK YOU

dr.Bambang Widjanarko, SpOGHead of Departement Obstetric and GynaecologyFKK – UMJJakarta