VAGINAL BLEEDING DURING PREGNANCY

Course: Introductions to Clinical Medicine

Prepared/Modified by Dr. Alisa
Chebotarova, MD, PhD
Summer 2018
 Learning objectives
• Define normal menstrual and ovarian cycle, mark hormones controlling normal menstrual cycle
• List conditions which can lead to abnormal vaginal bleeding
• List pathology of pregnancy, accosted with vaginal bleeding
• Develop a differential diagnosis for first-trimester bleeding
• Distinguish the types of spontaneous abortion; Define the signs of the different types of abortion and
List complications of abortion
• List risk factors predisposing patients to ectopic pregnancy; Describe symptoms and physical findings
suggestive of ectopic pregnancy; Understand methods and test used to confirm the diagnosis of
ectopic pregnancy
• Describe the approach to the patient with third-trimester bleeding
• Compare symptoms, physical findings, and diagnostic methods that differentiate patients with
Placenta Previa and Abruptio Placenta
• Describe complications of Placenta Previa and Abruptio Placentae
• Describe best practices for diagnosis and management of vaginal bleeding in early and late pregnancy
• Outline best practices for management of vaginal bleeding during early and late pregnancy
 Clinical case
History

A 27-year-old woman attends the emergency department with irregular vaginal bleeding and
abdominal discomfort.
She noticed the bleeding 2 days previously and it is dark red, sufficient for her to need to wear a
sanitary towel, but not heavy. The abdominal discomfort is suprapubic and crampy, slightly more
on the right-hand side. She is systemically well with no fever, change in appetite, nausea or
vomiting. She says that her bowel and urinary habits are normal. Her last menstrual period
commenced 45 days previously and she usually has a slightly irregular cycle, bleeding for 3-5
days every 28-35 days. She has never been pregnant. She has been with her regular sexual
partner for 2 years and they generally use condoms but there are some occasions where they do
not. She had a sexual health screen 6 months ago at the genitourinary clinic where she was told
all her swabs were negative. She has no previous gynaecological history and no significant
previous medical problems.
 Clinical case
Examination
The blood pressure is 128/72 mmHg and heart rate is 82/min. The abdomen is soft and non-
distended. There is tenderness on deep palpation in the suprapubic and right iliac fossa regions,
but no rebound tenderness or guarding. Bimanual examination is not performed.

Investigations
Urinary pregnancy test: positive
Transvaginal ultrasound scan is shown in Fig.
 Clinical case
The woman is taken for laparoscopy after the
ultrasound scan and Fig. shows the findings.

Questions:

What is the diagnosis? Cyst, ectopic pregnancy.

Management to prevent rapture and peritoneal infection

What are the management options in this case?

Surgery, egectomy, resect it – older + has children. Abortion pills/injection.

How would you counsel the woman postoperatively?

Emotional loss, grief, birth control.
 Internal female genitalia
• Ovaries are ovum producing female gonads;
• - they are also endocrine glands that produce
reproductive hormones;
• - usually each ovary takes turns releasing an egg
every month.
• Uterine (fallopian) tubes conduct ovum
discharged monthly from the peritoneal cavity to
the uterine cavity;
• - they also provide the usual site of fertilization.
• Uterus is the organ where embryo and fetus
develop;
• - its muscular walls are adapted to the growth
of the fetus and the providing the power for its
expulsion during the childbirth.
• Implantation bleeding – spotting after pregnancy, early
pregnancy
 Ovary
• Its parenchyma is subdivided into outer layer –
cortex and inner – medulla
• Cortex consists of ovarian follicles and stroma
between them
• Medulla (or zona vasculosa) is a highly vascular
stroma in the center of the ovary;
• A follicle is a small spherical group of cells
containing a cavity in which some other structure
grows.
• - the primary role of the follicle
is oocyte support;
• - from birth up to puberty, the ovaries of the
human female contain a number of
immature, primordial follicles;
• - these follicles each contain a similarly
immature primary oocyte that is arrested in
prophase of meiosis I
 Uterus
• The wall of the uterus consists of three layers:
- endometrium, a thin internal mucous membrane;
- myometrium, a thick smooth muscles layer;
- perimetrium, a thin external layer of peritoneum.

• The endometrium is essential for the uterine cycle;

three layers can be distinguished microscopically:
• - compact layer, spongy layer, basal layer

• Functionally endometrium subdivides into two

parts: functional and basal
- the superficial layer is functional because it grows,
reforms and peels off during each menstrual cycle; it
becomes 7mm thick before menstruation and 1 - mm
after menstruation;
- the deep layer is basal; this does not slough during
menstruation and the new functional layer is formed
from basal after menstruation
 Menstrual cycle - ranging from 25 to 35 days, with 28 days designated
as the average length.
• Starting at puberty, females undergo monthly
reproductive cycles regulated by the hypothalamus,
pituitary gland and ovaries for the purpose of sexual
reproduction.
• It essentially occurs in the ovary - ovarian cycle for the
egg production, and in the uterus - uterine cycle - for
the preparation of the uterus for pregnancy.
• Gonadotropin-releasing hormone (hypothalamus)
stimulates release of two hormones by pituitary gland
that act on the ovaries : follicle-simulating hormone
(FSH) and luteinizing hormone (LH).
• Follicle-stimulating hormone (FSH) stimulates the
development of ovarian follicles and the production of
estrogen (Development of genitalia and breast, female
fat distribution, growth of follicle, endometrial
proliferation, ↑ myometrial excitability) by its follicular
cells
• Luteinizing hormone (LH) serves as the “trigger” for
ovulation (release of a secondary oocyte) and stimulates
the follicular cells and corpus luteum to produce
progesteron ( Stimulation of endometrial glandular
secretions and spiral artery development)
 Ovarian cycle
• cyclic changes in the ovaries under the influence of the FSH and LH that includes:
1) development of the ovarian follicles
2) ovulation
3) formation of the corpus luteum – released progesterone
• - During each cycle, FSH promotes growth of several primary follicles + estrogen increase;
however, only one of them usually develops into mature follicle and ruptures.
• Menopause reduction of estrogen increase of FSH (low estrogen)* and LH
 Ovarian cycle
• 1) development of the ovarian follicles
The process begins continuously, meaning that at any time the ovary contains follicles in all
stages of development (primordial follicle ➛ primary follicle ➛ secondary follicle ➛ at maturity,
the follicle, which may be 10mm or more in diameter, is known as the vesicular or graafian
follicle
In the days immediately preceding the ovulation, the graafian follicle (second miotic) *
increases rapidly in size under the influence of FSH and LH and expands to a diameter of 15 mm.
 Ovarian cycle
• 2) Ovulation occurs on day 14 of the ovarian cycle
• is a phase, in which a mature egg is released from
the ovary into the oviduct
• the follicle continues to enlarge and soon forms a
bulge on the surface of the ovary
• ↑ estrogen, ↑ GnRH receptors on anterior
pituitary. Estrogen surge then stimulates LH
release ➛ ovulation (rupture of follicle).
• ↑ temperature (progesterone induced)**.

• - the high concentration of LH increases

collagenase activity, resulting in digestion of
collagen surrounding the follicle
• - Prostaglandin levels rise in response to LH surge.
This causes local muscular contraction in the ovarian
wall. These contractions extrude the oocyte
• Ovulation can be accompanied by slight pain known
as middle pain because it occurs near the middle of
the menstrual cycle and is accompanied by a rise in
basal temperature
 Ovarian cycle
• 3) formation of the corpus luteum
• Shortly after ovulation, the ovarian follicle collapses and under the influence
of LH, the walls of the follicle develop into a glandular structure, the corpus
luteum, which secretes mainly progesterone and some estrogen.
• The corpus luteum (Latin for "yellow body") - is typically very large relative
to the size of the ovary; in humans, the size of the structure ranges from
under 2 cm to 5 cm in diameter. (very large takes over most of ovaries*

1. If the oocyte is fertilized, the corpus luteum enlarges to form a corpus

luteum of pregnancy and increases its hormone production.
• It secretes progesterone which is a steroid hormone responsible for
preparation of uterine endometrium for implantation of the embryo.
• Degeneration of the corpus luteum is prevented by human chorionic
honadotropin (hCG) (released from chorionic membrane)-, a hormone
produced by syncytiotrophoblast (the outermost layer of the early developing
embryo)
• The corpus luteum is functionally active in the first 20 wks of pregnancy ,
then the placenta assumes the production of estrogen and progesterone
required for the maintenance of pregnancy

2. If the ovum is not fertilized the corpus luteum degenerates in 10 to 12

days and is called corpus luteum of menstruation which is subsequently
transformed into white scarred tissue called corpus albicans  menstrual
cycle
 Uterine cycle
• The average of the cycle is 28 days, with day 1 that
corresponds to the day on which menstrual flow
begins
• The cyclic changes in the endometrium of the uterus
caused by estrogen and progesterone constitute the
menstrual cycle
• although the uterine cycle is a continuous process, it
can be divided into three phases:
✓ menstrual -Begins on the first day of
menstruation and lasts for 4-5 days, where
menstrual flow has blood and small pieces of
endometrial tissue, where the functional layer of
uterine wall is sloughed off.
✓ proliferative - Lasts for about 9 days with an
increase in estrogen secretion with the growth of
ovarian follicles. Thickness of the endometrium
increases*, endometrial glands increase in number
and length of spiral arteries elongate.
✓ secretory or luteal - It is initiated by the
formation of the corpus luteum after ovulation. This
phase lasts for about 13 days. The progesterone
produced by the corpus luteum stimulates the
glandular epithelium. Then sloughs off
Menstrual cycle - ovarian cycle and uterine cycle
 Abnormal vaginal bleeding
1. PREGNANCY*
• In a patient who has abnormal bleeding during the reproductive age group, pregnancy or a complication must first be
considered.
• Complications of early pregnancy that are associated with bleeding include incomplete abortion, threatened abortion, ectopic
pregnancy, and hydatidiform mole
• Diagnosis. Urine or serum b-hCG test is required to confirm pregnancy. If pregnancy is identified vaginal ultrasound will help
sort out which pregnancy complication is operative.
• Complications of late pregnancy include Abruptio Placentae, Placenta Previa, Uterine Rupture, Vasa Previa
2. ANATOMIC LESION
• If the pregnancy test is negative, then an anatomic cause of vaginal bleeding should be considered. The classic history is that
of unpredictable bleeding (without cramping) occurring between normal, predictable menstrual periods (with cramping).
• A variety of lower and upper reproductive tract factors can cause bleeding:
• Vaginal lesions: lacerations, varicosities or tumors*
• Cervical lesions: polyps, cervicitis or tumors (cervical cancer*), HPV*
• Endometrial lesions: submucous leiomyomas (fibroids)* - south east asian, polyps, hyperplasia or cancer, endometrial cancer
– hormones replacements/estrogen replacement*
• Myometrial lesions: adenomyosis
• Diagnosis. A number of tests can be used to for anatomic diagnosis.
 Abnormal vaginal bleeding
• 3. INHERITED COAGULOPATHY – does she have bleeding disorder.
• Up to 15% of patients with abnormal vaginal bleeding, especially in the adolescent age group, have
coagulopathies. Review of systems may be positive for other bleeding symptoms including epistaxis, gingival
bleeding and ecchyoses. Von Willebrand* disease is the most common hereditary coagulation abnormality. The 3
types can vary in severity.
• Diagnosis. Positive family history and review of systems are helpful for screening. Initial laboratory tests include
CBC with platelet count, PT and PTT. The best screening test for Von Willebrand disease if a vWF antigen.
• 4. DYSFUNCTIONAL UTERINE BLEEDING (DUB), combination of hormonal imbalances/stress* seen in premenaupausal
• If the pregnancy test is negative, there are no anatomic causes for bleeding and coagulopathy is ruled out, then
the diagnosis of hormonal imbalance should be considered. The classic history is that of bleeding that is
unpredictable in amount, duration and frequency without cramping occurring.
• The most common cause of DUB is anovulation* premenaupausal/mood changes and so on. Anovulation results
in unopposed estrogen**. With unopposed estrogen, there is continuous stimulation of the endometrium with
no secretory phase. (never do estrogen hormone alone)
 Vaginal Bleeding in Early Pregnancy
Vaginal bleeding that occurs during the first 22 weeks of pregnancy* early bleeding
May occur in up to 25% of all pregnancies

• Miscarriage; spontaneous SYMPTOMS

• Abortion, actively aborting Bleeding/ spotting
• Ectopic Pregnancy – high HCG level* - common cause Pain
• Hydatidiform mole (molar) – mega high HCG level*
Early pregnancy OK for vaginal pregnancy ± Passage of tissue (passage of conception product)
Late pregnancy NEVER
The major clinical goals: No symptoms, diagnosed at booking scan
First: diagnosis of pregnancy,
and then if pregnant, differentiating ectopic pregnancy from abortion.
Diagnosis
History
Vaginal or speculum examination - very helpful, widely available and used- (look at the os – where bleeding is, is there dilation)*
Ultrasound – transvaginal ultrasound. First trimester why? Look at uterus Where pregnancy, mass, heart beat *7-8wks
Serum Beta-hCG in doubtful cases** peaks at 12-15 weeks
If hCG level rise too high – red flag
Consider ectopic pregnancy in women of childbearing age who report abdominal or pelvic pain or discomfort, vaginal spotting or a cycle of
amenorrhea, or unexplained signs or symptoms of hypovolemia.
There are rare case reports of ectopic pregnancy in patients with ovaries but without a uterus.
No combination of signs or symptoms is sufficient to exclude ectopic pregnancy. If pregnancy is detected, ectopic pregnancy remains in the
differential diagnosis until it can be either confirmed or excluded with conviction
 Causes of bleeding during early pregnancy: ABORTION 2
reasons: 1. induced 2. spontaneous
Loss of a pregnancy during the first 20 weeks of pregnancy, at a time that
the fetus cannot survive. Such a loss may be involuntary (a "spontaneous"
abortion), or it may be voluntary ("induced" or "elective" abortion).
Miscarriage is the layman's term for spontaneous abortion, an unexpected
1st trimester pregnancy loss. Types:
• Threatened abortion
• Inevitable abortion
• Incomplete abortion
• Complete abortion
• Septic abortion – looking toxic
• Missed abortion – didn’t know
Such losses are common, occurring in about one out of every 6
pregnancies.
For the most part, these losses are unpredictable and unpreventable.
Etiology
About 2/3 are caused by chromosome abnormalities* incompatible with
life, autosomal or X-linked dominant or recessive diseases.
About 30% are caused by placental malformations* and are similarly not
treatable.
 1. Threatened Abortion
• Vs. inevitable – os dilation – pass small straw
• Dilation exam – via finger. 3 finger = 3cm
• At least one-third of all pregnant women will
experience these symptoms. Half will go on to
abort spontaneously. The other half will see the
bleeding and cramping disappear and the
remainder of the pregnancy will be normal.
These women who go on to deliver their babies
at full term can be reassured that the bleeding
in the first trimester will have no effect on the
baby and that you expect a full-term, normal,
healthy baby.
• Diagnosis:
• Uterine bleeding
• Pelvic examination: Cervix is closed, no cervical dilation.
• Sonogram finding of a viable pregnancy
• Risk of Complete Abortion: 50%
 1. Threatened Abortion
• Treatment of threatened abortion is individualized.
• Many obstetricians recommend bedrest in some form for
women with a threatened abortion. There is no scientific
evidence that such treatment changes the outcomes.
• Strenuous physical activity is usually restricted, as is
intercourse.
• oral hydration, pelvic rest, and close interval follow-up.
• Medical treatment usually not necessary
• If bleeding persists, assess os opening to evaluate inevitable
bleeding, assess for fetal viability (pregnancy
test/ultrasound) or ectopic pregnancy (ultrasound).
• Persistent bleeding, esp. in the presence of uterus larger
than expected may indicate twins or molar pregnancy.
Do not give medications such as hormones (e.g. estrogens or progestins) or
tocolytic agents (e.g. salbutamol or indomethacin) as they will not prevent
miscarriage.
 Practise question
A 26-year-old woman, gravida 1, para 0, at 14 weeks gestation comes to the emergency
department complaining of scant vaginal bleeding for the past 3 days. She says that she has only
used one pad per day and has not noticed any clots or clumps of tissue. She also
describes cramping abdominal pains, similar to the pain she experiences during her menstrual
period. She denies any nausea, vomiting, or diarrhea. Pelvic examination shows that the cervical
os is closed, and a small amount of blood is pooling in the vagina. Abdominal ultrasound shows a
viable fetus in the uterine cavity. Which of the following is the correct name for her condition?
A. Complete abortion
B. Incomplete abortion
C. Inevitable Abortion
D. Missed Abortion
E. Threatened abortion
 Practise question
A 26-year-old woman, gravida 1, para 0, at 14 weeks gestation comes to the emergency
department complaining of scant vaginal bleeding for the past 3 days. She says that she has only
used one pad per day and has not noticed any clots or clumps of tissue. She also
describes cramping abdominal pains, similar to the pain she experiences during her menstrual
period. She denies any nausea, vomiting, or diarrhea. Pelvic examination shows that the cervical
os is closed, and a small amount of blood is pooling in the vagina. Abdominal ultrasound shows a
viable fetus in the uterine cavity. Which of the following is the correct name for her condition?
A. Complete abortion
B. Incomplete abortion
C. Inevitable Abortion
D. Missed Abortion
E. Threatened abortion
 2. Inevitable Abortion
• When the cervix dilates during a threatened
abortion, it becomes an inevitable abortion,
which has a much worse prognosis.
• Once the os is dilated it’s inevitable***
• If stay open administer prophylactic to prevent infection.
• Any tissues attached to the uterus woman will bleed, can’t
leave any tissue behind.
• Can’t leave an os open. Give it couple of hours or a day, if it
doesn’t close then it’s incomplete then suction or DnC**
• Diagnosis:
• Bleeding and/or rupture of gestational sac <20
weeks
• Pelvic examination: Cervix dilated
• Menstrual-type cramping
• No products of conception expelled yet
 2. Inevitable Abortion
• Treatment
1. emergency suction D&C (dilatation and curettage) - to prevent further
blood loss and anemia** until 8-10 weeks only. This minor operation
can be performed under local anesthesia and takes just a few minutes.
2. Induce contractions with misoprostol - binds to and
stimulates prostaglandin E1 receptors (anything over 8-9 weeks*)
3. Alternatively, bedrest and oxytocin IV, 20 units (1 amp) in 1 Liter of
any crystalloid IV fluid at 125 cc/hour may help the uterus contract
and expel the remainder of the pregnancy tissue, converting the
incomplete abortion to a complete abortion. “getting uterus to
contract and expel fetus”
4. Alternatively, ergonovine 0.2 mg P.O. or IM three times daily for a few
days may be effective.
5. If fever is present, broad-spectrum antibiotics are wise.
6. Any tissue fragments visibly protruding from the cervical os can be
grasped with a ring or dressing forceps and gently pulled straight out.
This simple and safe procedure will have a beneficial effect on the
bleeding.
7. RU486  pill abortion available online only federally allowed abortion
bill works about 70day of pregnancy 8-10 wks, mix misoprostol and
mifiprestol
 3. Incomplete Abortion
• Vaginal bleeding and uterine cramping can lead to dilation and passage
of some, but not all products of conception.
• Diagnosis:
• uterine cramping, continuing bleeding, sometimes very heavy
• Pelvic examination: Incomplete evacuation of products of
conception
• ultrasonic visualization of the fetal heart and noting no movement
• Falling levels of HCG are an ominous sign and strongly suggest the
pregnancy is no longer living.
• Treatment:
• D&C if bleeding is heavy to prevent further blood loss and anemia
• Awaiting a spontaneous abortion. offers the benefit of avoiding
surgery, but commits the patient to a day or more of heavy bleeding
and cramping. A few of these women will experience an incomplete
abortion and will need to have a D&C anyway.
• Induce contractions with misoprostol
 4. Complete Abortion
• Spontaneous happened in first 20 wks. Vaginal bleeding and uterine cramping
can lead to dilation and passage of all products of conception.
• Diagnosis:
• Bleeding and cramping stopped.
• Pelvic examination: Closed os. ****
• sonogram showing no intrauterine contents or debris.
• Concern: physician not missing
• Treatment:
• Evacuation of the uterus usually not necessary
• Observe for heavy bleeding
• b-HCG to not miss ectopic pregnancy
• Ensure followup of woman after treatment
 5. Missed Abortion
• A missed abortion is one in which the
pregnancy becomes nonviable and the fetus
dies, but the products of conception are not
passed spontaneously.
• Diagnosis:
• Pelvic examination: Closed os
• Sonogram finding of a nonviable pregnancy
without vaginal bleeding, uterine cramping
• May cause coagulopathy – bld stasis
• Sometimes embryo is there and dead
embryo high risk for DIC – dissemination
intravascular coagulation if left uncleaned.
• Treatment:
• Scheduled suction D&C - invasive, dialate cervix apply dilation
(mechanically) then scooping uterus, by conservative
management awaiting a spontaneous completed abortion, or
induce contractions with misoprostol
 Practise question
A 30-year-old woman, gravida 2, para 1, at 11 weeks gestation comes to her obstetrician/
gynecologist for a routine prenatal visit. She indicates that this pregnancy has been "easier" than
her first pregnancy, during which she experienced significant morning sickness and breast
tenderness. Review of systems is positive for a light brown stain on
her underwear approximately 1 week ago, but negative for fever, nausea, vomiting, abdominal
pain, or cramping. Medical history shows that her previous pregnancy was uncomplicated. Pelvic
examination shows a closed cervix with no blood in the vault no abdominal, cervical or adnexal
tenderness. Transabdominal sonogram shows a collapsed, intrauterine gestational sac (dead
baby still there); . Which of the following is the most likely diagnosis?
A. Complete abortion
B. Incomplete abortion
C. Missed abortion
D. Threatened abortion
E. Ectopic pregnancy
This is collapsed sac, HcG titer ~2500, Next step: D&C or chemical, suction is too big. What is RH
pills?
 Practise question
A 30-year-old woman, gravida 2, para 1, at 11 weeks gestation comes to her obstetrician/
gynecologist for a routine prenatal visit. She indicates that this pregnancy has been "easier" than
her first pregnancy, during which she experienced significant morning sickness and breast
tenderness. Review of systems is positive for a light brown stain on
her underwear approximately 1 week ago, but negative for fever, nausea, vomiting, abdominal
pain, or cramping. Medical history shows that her previous pregnancy was uncomplicated. Pelvic
examination shows a closed cervix with no blood in the vault; no abdominal, cervical or adnexal
tenderness. Transabdominal sonogram shows a collapsed, intrauterine gestational sac. Which of
the following is the most likely diagnosis?
A. Complete abortion
B. Incomplete abortion
C. Missed abortion
D. Threatened abortion
E. Ectopic pregnancy
 6. Septic Abortion – usually os is open
• During the course of any abortion, spontaneous or induced, infection may set in.
• Such infections are characterized by fever, chills, uterine tenderness, foul
smelling discharge, and occasionally, peritonitis. The responsible bacteria are
usually a mixed group of Strep, coliforms and anaerobic organisms. These
patients display a spectrum of illness, ranging from mild, to very severe.
• Usual treatment consists of stabilize woman, get incomplete embryo, bedrest, IV
antibiotics, IV oxytocin drip, uterotonic agents, and complete evacuation of part
of conception
• If the patient does not respond to these measures and is deteriorating, surgical
removal of the uterus, tubes and ovaries may be life-saving.
• Evacuation of the uterus can be initiated with oxytocin, 20 units (1 amp) in 1 Liter
of any crystalloid IV fluid at 125 cc/hour or ergonovine 0.2 mg P.O. or IM three
times daily. If the patient response is not favorable, or if the patient is quite ill,
D&C is the next step.
25.01.2017 Vaginal Bleeding in Early and Late pregnancy 33
 Causes of bleeding during early pregnancy: ECTOPIC PREGNANCY
• Pregnancy which is outside the uterine cavity
• Can be in the tube, ovary, abdomen or
other locations
• If it ruptures, can lead to hemorrhage and
death
• The result of an abnormality in human
reproductive physiology that allows the
conceptus to implant and mature outside the
endometrial cavity, which ultimately ends in
the death of the fetus.
• Differential Diagnosis for Ectopic Pregnancy
• Threatened abortion
• Acute or chronic PID – STD causing (south east Asia) - ,
any manipulation of uterus causes PID , metal hanger!
Can cause peritonitis
• Ovarian cysts (torsion or rupture)
• Acute appendicitis – child brearing age
 ECTOPIC PREGNANCY: RISK FACTORS
• If healthy uterus, and fallopian healthy no Ectopic.
• Scarring causes ectopic preg.
• Pelvic inflammatory disease, history of sexually transmitted infections
• History of tubal surgery or tubal sterilization
• Conception with intrauterine device in place
• Maternal age 35–44 (age-related change in tubal function)
• Assisted reproduction techniques (cause unknown, as tube is bypassed in implantation)
• Previous ectopic pregnancy
• Cigarette smoking (may alter embryo tubal transport) – ciliary disfunction
• Prior pharmacologically induced abortion
• FYI – reason why CF men are infertility: Bilateral agenesis don’t have Vas Deferens

25.01.2017 Vaginal Bleeding in Early and Late pregnancy 35

 CLINICAL PRESENTATION
Symptoms:
• Unilateral pelvic-abdominal pain: 90-100% of patients
• Amenorrhea/abnormal menses: 75-95%
• Irregular bleeding: 50-80%
• Pregnancy symptoms: 10-25%
Unruptured Ectopic:
• Symptoms of early pregnancy
Irregular spotting or bleeding;
Nausea; Swelling of breasts;
Bluish discoloration of vagina and cervix;
Softening of cervix;
Slight uterine enlargement; Increased urinary frequency
• Abdominal and pelvic pain
Ruptured Ectopic Pregnancy:
• Collapse and weakness
• Fast, weak pulse (≥110/minute)
• Hypotension
• Hypovolemia
• Acute abdominal and pelvic pain
• Abdominal distension
• Rebound tenderness
• Pallor
• Tachychardia
• Loss of fallopian tube
 ECTOPIC PREGNANCY: DIAGNOSIS
On Examination:
• Afebrile
• Abdominal tenderness: 80-95%
• Rebound tenderness: 45% (perotinitis)
• Palpable mass: 50%
• Normal sized uterus: 71%
Laboratory:
• The pregnancy test is positive.
• Do Serial Quantitative HCG levels which often are low* via vaginal ultra
sound seeing heart beat if viable fetus and do not show the normal
doubling every 2 days.
• Progesterone levels are sometimes very low (<5).
Ultrasound:
Visualization of a gestational sac, fetal pole and fetal heartbeat outside of
the uterus.
Free fluid in the abdomen if there is any significant internal bleeding.
Culdocentesis: to assess Hemoperitoneum.
Laparoscopy: very effective method to diagnose ectopic pregnancy.
Laparotomy* if ruptured: At times may be best choice for dealing with an
ectopic pregnancy, particularly if the patient is bleeding heavily or is
clinically unstable. In these cases, the priority is stopping the blood loss.
 ECTOPIC PREGNANCY: MANAGEMANT
• Unruptured ectopic.
• Medical treatment is preferable because of the lower cost, with otherwise similar outcomes.
• Methotrexate – medical management. This folate antagonist attacks rapidly proliferating tissues including
trophoblastic villi. Criteria for methotrexate include pregnancy mass <3.5 cm diameter, absence of fetal heart
motion, b-hCG level <6,000 mlU, given locally injection etc. and no history of folic supplementation. Single dose 1
mg/kg is 90% successful. Patients with an ectopic pregnancy should be advised of the somewhat increased
incidence of recurrent ectopic pregnancies. Follow-up with serial p-hCG levels is crucial to ensure pregnancy
resolution. Rh-negative women should be administered RhoGAM.
• Laparoscopy. If criteria for methotrexate are not met, surgical evaluation is performed through a laparoscopy or
through a laparotomy incision. The preferred procedure for an unruptured ampullary tubal pregnancy is a
salpingostomy, in which the trophoblastic villi are dissected free preserving the oviduct. Isthmic tubal pregnancies
are managed with a segmental resection, in which the tubal segment containing the pregnancy is resected.
• Salpingectomy – may remove fallopian tube. is reserved for the patient with a ruptured ectopic pregnancy or
those with no desire for further fertility. After a salpingostomy p-hCG titers should be obtained on a weekly basis
to make sure that there is resolution of the pregnancy. Rh-negative women should be administered RhoGAM.

• Ruptured ectopic. – no medical treatment.

• Immediate surgical intervention

 Practise question
A 27-year-old woman comes to the emergency department because intense abdominal pain for
2 hours. When asked to describe the pain, she states it has been severe and constant. She states
it began subtly in the right iliac fossa. Examination shows a pale appearing patient. Her
temperature is 37.8°C (99°F), pulse is 112/min, respirations are 23/min, and blood pressure is
101/68 mm Hg (low). Abdominal examination causes severe discomfort, and there are clear
signals of peritonism. There is also a palpable mass in the right iliac fossa. Which of the following
is the most likely diagnosis?

A. Appendicitis – palpate a pass

B. Diverticulitis – too young, needs to be middle aged, no GI symptoms
C. Ectopic pregnancy – young child bearing age
D. Ovarian torsion- very painful, like testicular torsion, cramping
E. Ruptured ovarian cyst
 Practise question
A 27-year-old woman comes to the emergency department because intense abdominal pain for
2 hours. When asked to describe the pain, she states it has been severe and constant. She states
it began subtly in the right iliac fossa. Examination shows a pale appearing patient. Her
temperature is 37.8°C (99°F), pulse is 112/min, respirations are 23/min, and blood pressure is
101/68 mm Hg. Abdominal examination causes severe discomfort, and there are clear signals of
peritonism. There is also a palpable mass in the right iliac fossa. Which of the following is the
most likely diagnosis?

A. Appendicitis
B. Diverticulitis
C. Ectopic pregnancy
D. Ovarian torsion
E. Ruptured ovarian cyst
 Practise question
A 26-year-old woman comes to the emergency department because of lower abdominal
pain and vaginal bleeding for the past 24 hours. Her last menstrual period was 7 weeks ago. She
is sexually active with her boyfriend and they use condoms intermittently. Physical examination
reveals mild tenderness in the left lower quadrant and left adnexa. The cervix is closed with
dried blood visible at the os; there is no active bleeding. A quantitative serum B-HCG is 1,500
IU/L. Transvaginal sonography of the patient's right adnexa reveals an extra-uterine gestational
sac with a diameter of 2 cm.  ectopic pregnancy
Which of the following is the most appropriate management option for this patient?

A. Laparoscopic salpingectomy
B. Open salpingectomy
C. Methotrexate – IV shrinks the embryo, inhibits rapid dividing cells in entire body* (medical mgt)
D. Suction and curettage
E. Misoprostol
 Practise question
A 26-year-old woman comes to the emergency department because of lower abdominal
pain and vaginal bleeding for the past 24 hours. Her last menstrual period was 7 weeks ago. She
is sexually active with her boyfriend and they use condoms intermittently. Physical examination
reveals mild tenderness in the left lower quadrant and left adnexa. The cervix is closed with
dried blood visible at the os; there is no active bleeding. A quantitative serum B-HCG is 1,500
IU/L. Transvaginal sonography of the patient's right adnexa reveals an extra-uterine gestational
sac with a diameter of 2 cm.
Which of the following is the most appropriate management option for this patient?

A. Laparoscopic salpingectomy
B. Open salpingectomy
C. Methotrexate
D. Suction and curettage
E. Misoprostol
Causes of bleeding during early pregnancy MOLAR PREGNANCY

Hydatidiform moles are excessively edematous

immature placentas
• Disorder resulting from abnormal fertilization of an
ovum, characterized by abnormal proliferation of trophoblastic cells
(egg is gone or lost) without presence of embryo it grows into a mass.  Extreme
morning sickness - Nausea! Pregnancy grows very bast exceeds the date – looks too
big to have twins. - Never see a heartbeat****hCG very high*** old age** not seen
in black patients. ****Trophoblast profilerate, and passes grapes like structure*

• The incidence is 7–10 times higher in Southeast Asian

countries compared with the Western world.
• Occurs in 1 of 1500 live births in the United States.
Risk factor for complete mole is increased maternal
age only. Increased maternal age is not a risk factor
for incomplete mole.
 GENETIC ABNORMALITY:
Complete/ Incomplete mole
Hydatidiform mole has two different types:

Complete mole: egg is missing* genetic material is missing* th

comes from father. It is empty egg. Does not fertilizes by sperm
but the cell exists there, doubles its DNA – diploid cell derive
from sperm – only tropophorm is developed. Results from
fertilization of an empty ovum by the haploid sperm. The nuclea
material of the haploid sperm divides and forms diploi
chromosomes (46,XX). Therefore, the complete mole
completely paternal in origin**. Fetal parts are complete
absent.

Partial mole: Results from fertilization of a normal ovum by tw

sperm cells. It has triploid sex chromosomes (69,XXY or 69,XXX
Partial mole is both maternal and paternal in origin and contain
partial or identifiable fetal parts.
 MOLAR PREGNANCY – no heart beat, mole grows to tumor like and metastases*****
HISTOLOGIC FEATURES DIAGNOSIS
• Complete mole: Generalized swelling of chorionic villi (hydropic villi), Complete mole: hCG is excessively elevated.
diffuse trophoblastic hyperplasia, and marked trophoblastic atypia.
Fetal RBCs are absent – grape like structure, uterus grows rapidly and Sonography is sensitive and specific, revealing a
high hCG – looks like snow storm appearance. “snowstorm” pattern.
• Partial mole: Focal swelling of chorionic villi, focal trophoblastic Honeycombed uterus, appearance like a cluster of
hyperplasia, and mild trophoblastic atypia. Fetal RBCs are usually grapes on imaging, and swollen villi without fetal RBCs
present. Vaginal bleeding.
are other important features.
PRESENTATION
• Complete mole: Partial mole: hCG is infrequently elevated above levels
✓ First-trimester vaginal bleeding is the most common presentation that are normal for pregnancy.
✓ excessive elevations in hCG, Sonography shows focal cystic changes in the placenta
✓ theca lutein cysts over 5 cm in diameter, and a ratio of transverse to anteroposterior diameter >
✓ excessive uterine size, 1.5.
✓ hyperemesis gravidarum – morning sickiness
✓ preeclampsia in the first trimester, endocrine dysfunction
✓ hyperthyroidism.
• Partial mole:
✓ Vaginal bleeding
✓ missed or incomplete abortion
✓ The uterus is usually small for date.
 MOLAR PREGNANCY: MANAGEMENT
• Chest x-ray to rule out pulmonary metastases
• Vacuum aspiration or Dilatation and Curretage
• Once HCG level stabilized, birth control management****
• Remove by D&C

• Serial Quantitative HCG levels every 2 weeks until 3 consecutive levels are
negative
• Then monthly HCG levels for 1 year, watching for recurrence
• No pregnancy for 1 year
• If any significant rise in HCG during the year of observation, methotrexate
therapy
• Hysterectomy is acceptable therapy if no further childbearing is desired.
 Practise question
A 25-year-old woman, gravida 1, para 0, comes to the antenatal clinic because
of vaginal bleeding. She is in her first trimester and has felt well during her
pregnancy apart from nausea and the presence of pelvic pressure when asked.
Her blood pressure is 125/80 mm Hg. Physical examination shows an abnormally
large uterus (twin, multiple pregnancy or MOLE) for her gestational age.
Laboratory studies are obtained and show trace amounts of protein and
a hCG concentration of 175,000 mIU/mL. Which of the following is the most likely
diagnosis?
A. Complete molar pregnancy - answer*
B. Eclampsia – convulsion, hyper person
C. Normal pregnancy
D. Partial molar pregnancy – no large fundus
E. Pre-eclampsia - associate HIGH BLOOD PRESSURE, hers fine
 Practise question
A 25-year-old woman, gravida 1, para 0, comes to the antenatal clinic because
of vaginal bleeding. She is in her first trimester and has felt well during her
pregnancy apart from nausea and the presence of pelvic pressure when asked.
Her blood pressure is 125/80 mm Hg. Physical examination shows an abnormally
large uterus for her gestational age. Laboratory studies are obtained and show
trace amounts of protein and a hCG concentration of 175,000 mIU/mL. Which of
the following is the most likely diagnosis?
A. Complete molar pregnancy
B. Eclampsia
C. Normal pregnancy
D. Partial molar pregnancy
E. Pre-eclampsia
Vaginal Bleeding in Late Pregnancy – never touch woman* only ultra sound*
The causes of serious vaginal bleeding in the
second half of pregnancy include abruptio
placentae, placenta previa, and vasa previa.

All can cause severe hemorrhage.

Do not perform a digital or speculum pelvic

examination to assess vaginal bleeding until a
transvaginal US is performed to determine the
location of the placenta.
Mechanical disruption of the placenta by
speculum or digital examination may
precipitate catastrophic hemorrhage.
When transvaginal US is properly and carefully
performed by those experienced in transvaginal
US the technique does not cause hemorrhage.
If there is no evidence of placenta previa or vasa
previa, then a sterile speculum examination may
be performed to determine if premature
rupture of membranes or abruption is present.
 PLACENTA PREVIA
• Placenta previa is a placenta that extends near,
partially over, or beyond the internal cervical os.
• Normal placental implantation is in the corpus or
fundal region, whereas in placenta previa,
implantation is lower in the uterus.
• The cause is unknown.
• Although low-lying or partial placenta previa is
not uncommon early in pregnancy, the placenta
usually migrates to a normal position as the
pregnancy nears term.

Risk factors for placenta previa include:

• cesarean delivery,
• multiple uterine surgeries,
• advanced maternal age,
• cigarette smoking, and
• cocaine use.
 PLACENTA PREVIA: PRESENTATION
• Occurs in 1/200 pregnancies that reach 3rd trimester
Low-lying placenta seen in 50% of ultrasound scans at 16-20 weeks: most
resolve when scan repeated at >30 weeks
• Patients with symptomatic placenta previa present with painless bright-red
vaginal bleeding, which should be differentiated from the normal passage of
blood-stained mucus that occurs near the onset of labor. The uterus is soft and
nontender.
• It may be preceded by trauma, coitus, or pelvic examination

• Classification
• Total, complete, or central previa is found when the placenta completely covers the
internal cervical os. This is the most dangerous location because of its potential for
hemorrhage.
• Partial previa exists when the placenta partially covers the internal os.
• Marginal or low-lying previa exists when the placental edge is near but not over the
internal os.
 PLACENTA PREVIA: PRESENTATION

25.01.2017 Vaginal Bleeding in Early and Late pregnancy 52

 PLACENTA PREVIA: MANAGEMENT
• While proceeding with further patient assessment, place two large-bore IVs for
fluid resuscitation; obtain CBC and coagulation parameters; and type and cross-
match blood. Do not perform a digital or speculum vaginal examination until
normal placental position is confirmed by US, as disruption of the cervical-
placental junction could precipitate catastrophic hemorrhage. Carefully perform
transvaginal US.
• Once placenta previa is identified, consult obstetrics for management options.
• A double setup, in which two teams of staff are available in the operating room
during a vaginal examination, may be indicated in cases where the placenta lies
within 1 to 2 cm of the cervical os and labor is imminent. Otherwise, women in
the second half of pregnancy with placenta previa are usually admitted to the
hospital for observation and fetal monitoring
 PLACENTA PREVIA: MANAGEMENT
• Emergency cesarean delivery—This is performed if maternal or fetal jeopardy is
present after stabilization of the mother.
• Conservative in-hospital observation —Conservative management of bed rest is
performed in preterm gestations if mother and fetus are stable and remote from
term. The initial bleed is rarely severe. Confirm abnormal placental implantation
with sonogram and replace blood loss with crystalloid and blood products as
needed.
• Vaginal delivery —This may be attempted if the lower placental edge is >2 cm
from the internal cervical os.
• Scheduled cesarean delivery —This is performed if the mother has been stable
after fetal lung maturity has been confirmed by amniocentesis, usually at 36
weeks’ gestation.
 Practise question
A 37-year-old G3P2 pregnant woman at 33 weeks gestation is brought to
the emergency department because of the onset of brisk vaginal bleeding. Her
husband says that they were having sexual intercourse when they both noticed
the onset of the bleeding. She says that she has not had any pain with the bleeding
and that she had not noticed any bleeding in the previous few days or weeks.
Physical examination shows that the uterus is non-tender and 32 cm above the
symphysis. Pelvic examination with a speculum reveals the presence of a large
amount of bright red vaginal blood that now seems to be gushing out. The source
of the bleeding cannot be immediately determined. Which of the following is the
most likely diagnosis?
A. Chorioamnionitis
B. Placenta percreta
C. Placenta previa
D. Placental abruption
E. Threatened abortion
 Practise question
A 37-year-old G3P2 pregnant woman at 33 weeks gestation is brought to
the emergency department because of the onset of brisk vaginal bleeding. Her
husband says that they were having sexual intercourse when they both noticed
the onset of the bleeding. She says that she has not had any pain with the bleeding
and that she had not noticed any bleeding in the previous few days or weeks.
Physical examination shows that the uterus is non-tender and 32 cm above the
symphysis. Pelvic examination with a speculum reveals the presence of a large
amount of bright red vaginal blood that now seems to be gushing out. The source
of the bleeding cannot be immediately determined. Which of the following is the
most likely diagnosis?
A. Chorioamnionitis
B. Placenta percreta
C. Placenta previa
D. Placental abruption
E. Threatened abortion
 ABRUPTIO PLACENTAE

• Abruptio placentae is the premature

separation of a normally implanted
placenta from the uterine lining .
• The incidence of spontaneous abruption is
highest between 24 and 28 weeks of
gestation.
• Abruption can cause uteroplacental
insufficiency and fetal distress or demise.
• Maternal complications include
coagulopathy, hemorrhagic shock, uterine
rupture, and multiple organ failure.
FIGURE Abruptio placentae. The placenta has
separated from the superior pole of the uterus.
57
 ABRUPTIO PLACENTAE: Risk factors
• Occurs in 1-2% of pregnancies
• Abruption usually occurs spontaneously but is also associated with trauma, even
minor trauma.

• Risk factors for abruption include:

• abdominal trauma,
• cocaine use,
• oligohydramnios,
• chorioamnionitis,
• advanced maternal age or parity,
• eclampsia, and
• chronic or acute hypertension.
 ABRUPTIO PLACENTAE: PRESENTATION
• Pain = hallmark symptom
• Varies from mild cramping to severe pain
• Bleeding
• May not reflect amount of blood loss
• Retro-placental haemorrhage and some degree of placental separation
• Revealed : visible vaginal bleeding
• Concealed : no vaginal bleeding but collection behind placenta

• Consider placental abruption in pregnant women with acute, painful vaginal bleeding
or with acute abdominal/uterine pain.
• Clinical features depend on the degree of placental abruption.
• Mild abruption is characterized by mild uterine tenderness, no or mild vaginal bleeding,
normal maternal vital signs, no coagulopathy, and fetal distress.
• Signs and symptoms of severe abruption are no or heavy vaginal bleeding, fetal distress,
coagulopathy, severe uterine pain or tenderness, continuous or repetitive uterine
contractions, and maternal hypotension or shock. Nausea, vomiting, and back pain may
also be present.
 ABRUPTIO PLACENTAE: DIAGNOSIS
• Diagnosis is made by the clinical features.
• Electronic fetal monitoring (cardiotocodynamometry) is very sensitive for
identifying fetal distress as a sign of placental abruption and has a 100% negative
predictive value for adverse outcomes when monitoring is reassuring.
• Transvaginal US is fairly specific for the diagnosis, but is not sensitive for the
detection of retroplacental clot because the appearance of clotted blood evolves
in echotexture over time.
• MRI is diagnostic but requires the transport of a potentially unstable patient out
of the ED or intensive care unit for imaging.
 Practise question
A 30-year-old woman, grava 2, para 1, at 36 weeks gestation, comes to
the emergency department because of severe abdominal pain for the past hour.
She describes sudden onset "sharp" and "cramping" pain which began shortly after
she was involved in a motor vehicle accident. She has also noticed a small amount
of vaginal bleeding. Vital signs shows no abnormalities. Physical examination
shows bright-red blood in the vaginal vault and a firm, tender uterus. Tocometer
shows low amplitude regular contractions, approximately every two minutes.
Which of the following is the most likely diagnosis?
A. Placental abruption
B. Placenta accreta
C. Placenta previa
D. Placenta percreta
E. Premature rupture of membranes
 Practise question
A 30-year-old woman, grava 2, para 1, at 36 weeks gestation, comes to
the emergency department because of severe abdominal pain for the past hour.
She describes sudden onset "sharp" and "cramping" pain which began shortly after
she was involved in a motor vehicle accident. She has also noticed a small amount
of vaginal bleeding. Vital signs shows no abnormalities. Physical examination
shows bright-red blood in the vaginal vault and a firm, tender uterus. Tocometer
shows low amplitude regular contractions, approximately every two minutes.
Which of the following is the most likely diagnosis?
A. Placental abruption
B. Placenta accreta
C. Placenta previa
D. Placenta percreta
E. Premature rupture of membranes
 UTERINE RUPTURE
• Uterine rupture is complete separation of the wall
of the pregnant uterus with or without expulsion of
the fetus that endangers the life of the mother or
the fetus, or both. The rupture may be incomplete
(not including the peritoneum) or complete
(including the visceral peritoneum).

• Occult dehiscence vs. symptomatic rupture

• 0.03 – 0.08% of all women
• 0.3 – 1.7% of women with uterine scar Pre-labor uterine rupture
with extrusion of fetus
• Previous cesarean incision most common reason for
scar disruption
• Other causes: previous uterine curettage or
perforation, inappropriate oxytocin usage, trauma
 UTERINE RUPTURE: RISK FACTORS

■Previousuterine surgery ■Adenomyosis

■Congenital uterine anomaly ■Fetal anomaly

■Uterine overdistension ■Vigorous uterine pressure

■Gestational trophoblastic neoplasia ■Difficult placental removal

■Placenta increta or percreta

 UTERINE RUPTURE: PRESENTATION
• Vaginal bleeding
• Pain
• Cessation of contractions
• Absence of FHR
• Loss of station
• Palpable fetal parts through maternal abdomen
• Profound maternal tachycardia and hypotension
• Sudden deterioration of FHR pattern is most
frequent finding
• Placenta may play a role in uterine rupture
• Transvaginal ultrasound to evaluate uterine
wall
• MRI to confirm possible placenta accreta
• Treatment
• Treatment is surgical. Immediate delivery.
• Hysterectomy is performed in the unstable patient
 VASA PREVIA
• Vasa previa is present when fetal vessels
traverse the fetal membranes over the
internal cervical os. These vessels may be
from either a velamentous insertion of the
umbilical cord or may be joining an
accessory (succenturiate) placental lobe to
the main disk of the placenta. If these fetal
vessels rupture the bleeding is from the
fetoplacental circulation, and fetal
exsanguination will rapidly occur, leading to
fetal death.
• Clinical Presentation.
• rupture of membranes
• painless vaginal bleeding
• fetal bradycardia
 VASA PREVIA
• Diagnosis.
• This is rarely confirmed before delivery but may
be suspected when antenatal sonogram with
color-flow Doppler reveals a vessel crossing the
membranes over the internal cervical os.
• The diagnosis is usually confirmed after delivery
on examination of the placenta and fetal
membranes.
Management:
• Immediate cesarean delivery if fetal heart rate
is non-reassuring
• Administer normal saline 10 – 20 cc/kg bolus to
newborn, if found to be in shock after delivery
• In Rhesus negative mothers Anti – D is given to
prevent Rh-isoimmunization