Bleeding in first trimester

BLEEDING IN FIRST
TRIMESTER

Prof. M.C.Bansal.
MBBS; MS,. MICIOG; FICOG.
Fonder Principal & Controller ,
Jhalawar Medical College & Hospital Jhalwar.
Ex Principal & controller Mahatma Gandhi Medical
College & Hospital . Sitapura, Jaipur.

Bleeding in First Trimester
 20-25 % pregnant women present with the
complain of bleeding per vagina in first
trimester.
 50% 0f them Miss carry .
 Incidence of spontaneous abortion varies from
15 – 25 %.
 This symptom maybe due to ----
Obstetrical cause ---more common.
Non obstetrical cause.

Obstetrical causes of bleeding in
First Trimester
 Bleeding with viable embryo –ascertained by USG.
1. Bleeding from un fused membranes ,shading of decidual parietilis as in
accessory horn /no pregnant side of didelphus uterus, exposed blood vessels of
decidua basalis by the in growing blastocoele ( rodent like activity of syncitial
trophoblast at the site of implantation).
2. Embryos with karyotypical like triosomy ,monosomi , Robertsonian Traslocation
may present as threatened abortion and continues to grow as IUGR foetus /
hydrops fetalis or IUFD.
3. Low implantation of gestational sac.
4. Retrochorionic bleeding.
5. Multi fetal gestation .
6. Complete mole .
Ectopic Pregnancy ---USG may show Fetal heart activity To be present in few
cases of intact ectopic pregnancy as in cornual / accessory horn and cervical
pregnancy .

Obstetrical causes Of Bleeding in
First Trimester
 Bleeding with a non viable embryo ---USG
scan needed---
1. Blighted ovum .
2, Missed Abortion.
3. Ectopic Pregnancy .
4. compete mole.
5. Vanishing Twin syndrome.
6. Vase prevail.

Non Obstetrical causes of bleeding
in First Trimester
 A. Cervical— Fibroid Polyps , Erosion ,
Ectropion , cervical carcinoma , Mucous polyp.
 B. Vaginal – Trichomonas vaginitis , Bacterial
vaginosis , Foreign body in vagina , vaginal
tumors , trauma , varicose veins .
 C. Bleeding Disorders –Thrombocytopenia ,
haemophilia , Von Wlebrand’s disease.
 D. drug induced –Heparin , Asprin ., warfein .

Note bleeding from other sites like rectal /
urethral or bleeding from haemangioma of
vulva etc.

Diagnosis and Investigations---
 Care full history taking local examination in good light
will help a lot .in excluding most common non obstetrical
causes of bleeding.
 TVS is gold standard to know the viability status of
embryo . It help in diagnosis of all possible obstetrical
causes , except due to karyotypic defects in embryo. It
may give snapshot and may have limited value.
 If no local cause is found case needs to be investigated
for bleeding disorders-- by tests such as BT, CT ,Clot
retraction , platelet count, PBF and prothrombin Time
(PT).
 Note all women should have their ABORh
grouping done , if RH negative ; Anti D therapy in
low dose 100mg is tube given with in 24 hours of her
first bleeding episode.

Terminology of Abortion
 Threatened Abortion—Amenorrhea, small
bleeding usually < then MC loss , little / no pain .
Uterus soft, uterine size & shape corresponds to
period of amenorrhea, so is closed. TVS ---FHA
present., if absent ---early missed abortion .in
early 6-8 weeks if only gestational sac present
and no embryonic pole is identified ----it is
Blighted ovum. Assurance bed rest,
progesterone, HCG , anxiolytic drugs and wait
and watch policy that is all needed --With hope
that pregnancy will continue. Absent FHA / no
embryonic pole– present evacuation of RPOC is
needed.

Inevitable Abortion---
 Pregnant woman presents with more bleeding and pain
in lower abdomen . Bleeding is more then MC loss /
leaking from ruptured amniotic sac ,Pain is more
than dysmenorrheal as described by the woman.
Uterine size corresponds with period of amenorrhea but
its shape is changed uterus is flattened anterio-
poseriorly and no more globular or spherical. It is
contracting and irritable ,cervical canal is ballooned up
as the separated sac descents down and is not
expelled due to closed external so. The pregnancy will
be aborted spontaneously , but often need to accelerate
the process with the help of syntocinon drip so as to
minimize the duration , blood loss and chances of
infection.

Incomplete Abortion--
 Pregnant women present with more pain like mini
delivery , more bleeding ., passage of clots and
few pieces of placental tissue or foetus. There is
partial retention of RPOC .Uterus is smaller, os is
open and RPOC is felt in uterine cavity with
examining finger.
 Depending upon amount and rate of blood loss
patient may develope hemorrhagic, hypo volumic
shock . Immediate evacuation of RPOC under
oxytocin , fluid replacement ( ringer / blood )
Prophylactic antibiotic therapy , tetanus toxoid are
the basic requirements to treat such woman.

Spontaneous complete Abortion --

 Complete expulsion of products of conception
from the uterine cavity , reduction in size of
uterus by contraction and retraction of
myometrium , closure of cervical os , bleeding
is stopped and pain subsides by it self.
Prescribing T,Toxoid , prophylactic antibiotics,
haematinics and contraceptive advice for
spacing purpose must always be given .

Induced Medical Abortion --
 When growth of embryo is disturbed as in
blighted ovum , after expected treatment of
threatened abortion , self medication or
prescription for medical termination in early
gestation period > 49 days. The conceptus is
to be expelled out with medical method
(Mifepriston and prostaglandin tabs ) or by—
 Surgical method ---Dilatation curettage /
suction evacuation.

Septic Abortion--
 Often induced / illegal incomplete abortion
complicated by frank sepsis due to mixed (
aerobic gram +vet and -vet , anaerobic and
sometime tetanus ) infection . Peritonitis,
septicemia septic shock and DIC ----high % of
maternal mortality and morbidity.
 Thanks to MTP law and wide availability of
MTP facilities , the incidence of septic abortion
has decrease significantly over last 3 decades
in our country .

Abortions

Threatened Abortion
Viable embryo Missed abortion
(Continue Pregnancy)
Inevitable abortion
(Ballooned cervical canal)

Complete abortion Incomplete abortion

Septic Abortion

Light Bleeding
Vaginal Bleeding expulsion of Severe pain , uterine size
Mild pain H/O ( before 20
Mild pain , No H/O
Expulsion of products of
products of conception, normal size ? Bulky , tender
weeks)
conception, Uterine size
uterine size decreased , os cervical movements ,
correspond to period of
closed tender mass in fornix
Gestation, Os closed
Threatened Abortion Complete Abortion Ectopic Pregnancy confirm
by UPT and TVS
USG Observe and Follow up Mange as Ectopic
Pregnancy.

Fetus viable Vaginal Bleeding Persists Fetus not viable
Repeat USG for fetal
viability after 1week
Threatened Abortion Missed Abortion
reassure , rest and UT < 12 weeks Ut < 12 weeks
abstinence
Bleeding stops –routine Evacuation Misoprost 400mcg orally 4
ANC hourly maximum 5 doses
Check for completeness. If
still bleeding -Evacuation

Heavy Bleeding
 h/o Expulsion of POC , Uterine size < period of
gestation , Os may be open
 Diagnosis --- Incomplete Abortion
 Management---Immediate Resuscitation and BT if
needed , start 10-20 Sintocinon drip in 500ml of
RL /NS @ 40-60 drops / min.
 Evacuation & curettage. , injection syntomethergin
1 amp. / carboprost IM .
 Suitable antibiotics ( against anaerobic, graham –
ve & +ve organism for a week and T. Toxoid .

Any bleeding with----
H/o passage of vesicles Pain , fever , abdominal distension , H/o
interference by quack / nurse or doctor

Vesicular Mole Septic Abortion
Serum - HCG USG And flat plate abdomen in standing
Chest X-ray. position , Hb , CBC, Blood grouping cross
TVs for Theca Lutein cysts matching , arrange 2 units of blood , Start
brad spectrum antibiotics and metronidazole
IV. T.Toxoid. Ryles tube suction , Iv fluid
therapy, CVS monitoring and fluid electrolyte
balance.

Suction Evacuation --- send Tissue for Evacuate uterus
HPR. Laparotomy if perforation of uterus / intestinal
injury or Pyoperitoneum.
Follow up of mole Medico legal reporting

Note --- council all cases to avoid Too Advise Contraception
early pregnancy At least 6—12 months

Further Reading --

 Coulam CB , Goodman C, Dorffmann A.
Coparison of ultrasonic findings in
spontaneous abortion with normal and
abnormal karyotypes. Hum Reprod 1997 ;12 :
823-6

Bleeding in first trimester

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