VAGINAL BLEEDING DURING PREGNANCY

-FIRST before 22 WEEKS= early pregnancy

-SECOND after 22 WEEKS= late pregnancy (APH)

Bleeding in Early Pregnancy(22weeks)

 Three primary causes:
 ABORTION
 ECTOPIC PREGNANCY (EP)
 TROPHOBLASTIC DISORDERS(vesicular mole)
Local causes – Erosion, Polyp, Varicose veins rupture, Cervical malignancy.
ABORTION
DEFINITION: Termination of pregnancy before 20 weeks gestation calculated
from date of onset of last menses. or Delivery of a fetus of weight less than 500
grams. Early Abortion: before 12 weeks,,. Late Abortion: from 12-20 weeks

Period of viability: Developing countries – 28 weeks.

UK, USA – Less than 22 to 24 weeks

Etiology-
 Maternal factors
 Infectious-Mycoplasma, Toxoplasmosis,Listeria
 Environmental-Alcohol abuse, Smoking
 Uterine - Septum, Fibroids, Cervical Incompetence
 Systemic Disease-Thyroid, Diabetes
 Paternal factors-Chromosomal translocation
 Fetal Factors- Chromosomal 50% of 1st trimester abortions caused by
chromosomal anomalies.
1-SPONTANEOUS ABORTION
DEFINITION: It is defined as the involuntary loss of the products of
conception prior to 20 weeks of gestation.

2-THREATENED ABORTION:
It is a clinical entity where the process of miscarriage has started and not
progressed to a state from which recovery is impossible
Clinical features:
1-Vaginal bleeding(Slight ,Brownish or bright red in color)
2- Mild lower abdominal pain 3-Vitals stable
Vaginal examination – Cervix is closed and uterus size will correspond to
pregnancy
Diagnosis – CBC, Ultrasound, Serum Progesterone and Serum HCG levels
Treatment – Rest, sedation and synthetic progesterone and HCG injections?

Advice (Limit her activities for two week ,,, Avoid heavy work, strenuous
exercise and excitement ,,, Coitus is contraindicated)
3-INEVITABLE ABORTION:
It is the clinical type of abortion where the changes have progressed to
the state where continuation of pregnancy is impossible.
Clinical features:
1-Vaginal Bleeding (Increased) 2- Pain lower abdomen (Aggravation)
Vitals - disturbed according to the blood loss
Vaginal examination: Cervix is dilated with felting of fetal products
and uterus size will correspond to amenorrhea
Diagnosis – Ultrasound Treatment– Stabilize vitals and Suction
evacuation / curettage . After 12 weeks – IV oxytocin drip
4-COMPLETE ABORTION:
When the products of conception are expelled in mass,it is called
complete miscarriage
Clinical features:
1-Vaginal Bleeding with passage of products of gestation
2-Pain may be less or absent
Vitals - disturbed according to the blood loss
Vaginal examination: Cervix is closed and uterus size is lesser than
amenorrhea
Diagnosis – Ultrasound Treatment – No active intervention.
5-INCOMPLETE ABORTION:
When the entire products of conception are not expelled, instead a part
of it is left inside the uterine cavity, it is called as incomplete
miscarriage.
Clinical features:
1-Vaginal Bleeding with passage of products of gestation(Persistence)
2-Pain lower abdomen (Continuation)
Vitals - disturbed according to the blood loss
Vaginal examination: Cervix is dilated with hanging of fetal products
and uterus size will be lesser than amenorrhea
Diagnosis – Ultrasound(present of products )
Treatment – Stabilize vitals and Suction evacuation / curettage
After 12 weeks – Under GA and IV oxytocin drip products are removed
by ovum forceps / Curettage
COMPLICATIONS:1-Profuse bleeding 2- Sepsis 3-Placental polyp
6-MISSED MISCARRIAGE:
When the fetus is dead and retained inside the uterus for a variable
period it is called missed miscarriage or early fetal demise.
Fetus is dead and retained for variable period [ 4 – 6 weeks ]
Clinical Features: 1-Brownish vaginal discharge 2-Subsidence of
pregnancy symptoms 3-Retrogression of breast changes
Vaginal examination: Uterus will be less than amenorrhea and cervix
is closed Diagnosis – Ultrasound
COMPLICATION: 1-Psychological upset 2-Infection
3-Blood coagulation disorders(DIC)
4-During labor( Uterine inertia,, Retained Placenta,, PPH)
Treatment:1-Dialatation and Curettage – less than 12 weeks
2-After 12 weeks – IV Oxytocin drip / Prostaglandin vaginal pessaries .
7-SEPTIC MISCARRIAGE:
Any abortion which is associated with clinical evidences of infection of
the uterus and its contents is called septic abortion.
Clinical features: 1-High Temperature –for 24 hrs. or more
2-Offensive or purulent vaginal discharge
3-Lower abdominal pain and tenderness
This is mostly due to incomplete and illegal abortions or also following
spontaneous abortion.
4-Peritonitis features may be present
Vaginal examination – 1-cervix may be closed or dilated , pus like
offensive discharge
2-Tender uterus and size of uterus will be lesser than amenorrhea
Complications - End-toxemic shock, acute renal failure, DIC,
Peritonitis and Gas gangrene)) - Investigations:
Treatment:1- IV Antibiotics 2-Evacuation of uterus
8-RECURRENT MISCARRIAGE
Recurrent miscarriage is defined as three or more consecutive
spontaneous miscarriage
9-Induced Abortion
1-Therapeutic Abortion :Medical Termination of Pregnancy
Indications:1-Failure of contraception 2-Congenital anomalies
2-Medical diseases that may deteriorate mother’s health
2-Criminal Abortion : Illegal abortion induced for a non-medical
indication.
 ECTOPIC PREGNANCY
Ectopic means "out of place." In an ectopic pregnancy, a fertilized egg
has implanted outside the uterus. The egg settles in the fallopian tubes
in more than 95% of ectopic pregnancies. This is why commonly called
"tubal pregnancies. Mean gestational age of rupture is (7.2 )weeks.

GREATEST RISK :
1-PREVIOUS EP 2-PREVIOUS TUBAL SURGERY 3- PID
4-DIETHYSTILBESTROL EXPOSURE 5- IUD USE
6- DOCUMENTED TUBAL SCARRING 7-AIDS & STD.
Signs and Symptoms
1-These can include missed periods, breast tenderness, nausea,
vomiting, or frequent urination.
2-The first warning signs of an ectopic pregnancy are often pain or
vaginal bleeding.
Investigations: Treatment: medical or surgical.
Fate of ectopic pregnancy : (Tubal abortion ,Tubal rupture)
 Hydatidiform pregnancy ( vesicular mole )
It is a benign neoplasm of the chorionic villi

Symptoms and Signs

1-Bleeding. 2-pain. 3-toxemia (25% ). 4-hyperemesis (25%) .
5-absent fetus 6-hyperthyroidism (7%).
7-passage of tissue with vesicles. 8-bilateral theca lutein cysts (30%).

Treatment : Evacuation of Molar Pregnancies

Bleeding in late pregnancy APH

Bleeding from the genital tract in pregnancy between 20 to 24 week’s
gestation and the onset of labour. It is associated with increased risks
of fetal and maternal morbidity and mortality.

Causes
Placental: 1-Abruptio placenta. 2- Placenta previa.
Non-placental: 1-Vasa previa. 2-Bloody show. 3-Trauma.
4-Uterine rupture. 5-Cervicitis. 6-Carcinoma. 7-Idiopathic.
 ABRUPTIO PLACENTA
It is the separation of the placenta from its site of implantation before
delivery of the fetus.
Types of Placental Abruption
 Revealed placental abruption: causes vaginal bleeding.
 Concealed placental abruption: internal bleeding

Risk Factors: 1-Increased age & parity. 2-Hypertensive disorders.

3-Preterm ruptured membranes. 4-Multiple gestation.
5-Polyhydramnios. 5- Smoking. 6-Cocaine use.
7-Uterine fibroid. 8-Trauma

Clinical Presentation: 1-Vaginal bleeding. 2-Uterine tenderness or

back pain. 3-Fetal distress. 4-High frequency contractions.
5-Uterine hyper tonus. 6-IUFD. 7-Nausea and vomiting
Classification: Grade 0== Asymptomatic,
Grade 1== .External vaginal bleeding
.Uterine tetany and tenderness may be present
.No signs of maternal shock .No evidence of fetal distress
Grade 2== External vaginal bleeding may or may not be present
.Uterine tender and tentany .No signs of maternal shock
.Signs of fetal distress present
Grade 3== External bleeding may or may not be present.
Marked uterine tetany .Maternal shock
.Fetal death or distress .Coagulopathy in 30% of the cases
Prevention: 1-Do not drink alcohol . 2-Do not smoke or use drugs
3-Get early and regular prenatal care
4- Early recognizing and managing conditions in the mother such as
diabetes and high blood pressure also decrease the risk of placental
abruption
Complications:
Maternal: Hypovolemic shock, DIC, Renal failure , .Death
.Uterine rupture
Fetal: Hypoxia. , Brain Damage , IUGR. , stillbirth , Anemia .

PLACENTA PREVIA
The presence of placental tissue overlying or proximate to the internal
cervical os after viability.
  Predisposing factors: 1-Multiparty 2-Increased maternal age
3-Previous placenta previa 4-Multiple gestation
5-Previous cesarean section 6- Uterine anomalies 7-Maternal smoking.

Grades:
Grade 1: the placental edge is in the lower uterine segment but does not
reach the internal os (low implantation).
Grade 2: the placental edge reaches the internal os but does not cover it.
Grade 3: the placenta covers the internal os when it is close and is
asymmetrically situated (partial).
Grade 4: the placenta covers the internal os and is centrally situated
(complete)

Clinical presentation: 1-Bright red vaginal bleeding without pain.

2-Premature contractions. 3-Baby is breech in transverse position.
Complications of Placenta praevia:
Maternal: APH , PPH , Increase risk of puerperal sepsis
Malpresentation ; breech, oblique, transverse.
Fetal: IUGR Premature delivery Death