Bleeding In Early Pregnancy

This is bleeding from the genital tract before 24th week of pregnancy. Approximately, a 20% of pregnant women experience bleeding during the first trimester. Vaginal bleeding in pregnancy is abnormal. Any report of it should be viewed seriously by the midwife. When it occurs, the volume of blood loss, colour and if associated with pain or not should be established.

Causes

· Abortion

· Implantation bleeding

· Cervical lesions.

· Erosion, mucous polyps and carcinoma of the cervix

· Hydatidiform mole.

· Ectopic Pregnancy.

Abortion

This is bleeding or expulsion of the fetus before 24th week of gestation or viability or less than 500g of weight (WHO). Abortion may be spontaneous or induced.

Incidence: 15% of pregnancies abort spontaneously with peak period of 6-10 weeks – This may not be unconnected with low progesterone secretion (About 65% occurs at this period) 80% happens in the 1st trimester. Bleeding in the 2nd& 3rd trimester carries a greater risk to the mother & child because the placenta is already firmly attached.

Causes

Fetal causes:

· In about 60% of cases the cause is multiple resulting from chromosomal abnormalities of the conceptus.

· Mal-development

· Defective implantation

Maternal Causes;

· Infection – Acute fevers, rubella, syphilis, Chroni c Nephritis, thyroid dysfunction

· Environmental factors – Effect of drugs, cigarette and alcohol,

· ABO incompatibility, High blood lead, Diabetes, Hormonal imbalance, High parity, Local disorders of genital tract, retroverted or Bicornuate uterus, Cervical incompetence, Environmental stress. Local Causes :

· Conditions that interfere with embedding and nutrition of the ovum (anemia), Trauma and Fibroid tumors.

Social Causes:

Teenage pregnancy, unmet needs, failed family planning, rape conception.

Types of Abortion

Abortion is classified into the following clinical types

1. Threatened Abortion

2. Inevitable Abortion

3. Incomplete Abortion

4. Complete Abortion

5. Missed Abortion

1. Threatened Abortion

Vaginal bleeding during the first 20 weeks of pregnancy, whether the bleeding is associated with uterine contraction or not.

It can be distinguished from implantation bleeding which is usually bright red colour and stops quickly.

Signs and Symptoms

· Slight bleeding

· Os is closed and not effacement

· Slight uterine contraction

· Slight abdominal discomfort & cramping with backache

· On speculum examinations cervix is closed and membranes intact

· Ultrasound scan

Treatment

· Admission in the hospital

· Reassure client

· Assess general condition – history, vital signs etc .

· Routine Observation bid or 4hrly

· No Vaginal Examination and enema

· Save all discharges – Pads, soiled clothing, linens etc.

Blood Test: Grouping and Gross matching, Hb, Rh factor, plasma Human placenta lactogen level – helps to determine prognosis as low level indicate that pregnancy will terminate (inevitable abortion)

Drugs

Valium 5mg tds

Amylobarbitone sodium (sodium Amytal) 200mg nocte Pethidine 50-100mg to relief pain of uterine contractions, Morphine 15mg.

Speculum examination to rule out bleeding from local lesion.

Monitor fetal condition – FH by sonicaid/Dipltone

Do pregnancy test.

Allow up and about after bleeding has stopped for 3 days

Nutritious diet and personal hygiene Prognosis: 70-80% - continue with pregnancy

Prognosis is better if bleeding becomes brownish from bright red-only about 10% will abot, while initial brown blood becomes red 66% will abort. If accompanied with severe uterine contraction there is increased possibility of abortion.

Advice on Discharge

Rest, less activities, no lifting, or coitus for 2-3 weeks, she should report any case of bleeding.

2. Inevitable Abortion

Definition: Abortion is inevitable when bleeding is accompanied with uterine contractions, bleeding becomes severe and dilatation of the cervix. It is impossible for the pregnancy to continue. It may end up complete or incomplete.

Signs & Symptoms

· Slight or severe vaginal bleeding

· Increase contraction of the uterus – Pain

· Dilatation of the cervix

· Membranes may or may not be ruptured, it may bulge through the Os or in the vagina

· Shock may be present

· Product may protrude through the cervical Os or in the vagina

Treatment

Treat as threatened abortion until Dr’s arrival. If bleeding is severe, give 0.5mg ergometrine or 1ml syntometrine ,keep all blood loss for Dr’s inspection.

Give analgesics – Pethidine 100mg or Morphine 15mg .

Oxytocin drip is given or prostaglandin E2 if it is after 16 weeks.

Evacuate the uterus under G.A.

Blood transfusion if necessary.

3. Complete Abortion

When the entire products of conception are passed, abortion is considered complete. It occurs usually before the 8th week. Bleeding is reduced to mere staining.

There are signs of pregnancy regresses.

4. Incomplete Abortion

The fetus has been expelled but parts of the placenta and membranes are retained in-utero. Lochia is heavy, bleeding may be profuse, pain may or may not be present .Os is partly closed – cervix patulous, there is sub -involution.

Treatment

In the District

Send for medical Aid

Give syntometrine 1ml or 0.5mg ergometrine 1m and can be repeated 5-10 minute later if bleeding is profuse, Pethidine 100mg if there is pain,

Resulscitate if in shock,

5-10 units of oxytocin in 5% glucose

Accompany to nearby Hospital and give post abortion care.

In Hospital

Give syntometrine or ergometrine 0.5mg. Take blood for grouping and cross matching. Take high vaginal swab, evacuation of the uterus is done.

If in Shock

Receive into a warm bed, elevate foot of the bed, give ergometrine- i.v.

Infusion 5% dextrose with Ringers lactate, syntocinon 10unit may be added to drip. Observe vital signs – pulse every 5 minutes B/P – every 30 minutes.

When condition improves – evacuate under G.A.

Treat for anemia if present.

Antibiotic coverage.

Discharge on the 5th day.

5. Missed Abortion

This term is applied when the fetus is dead and is retained with it’s placenta in the uterus. Death usually occurs before 8 weeks though mother may not know. Ultrasound may diagnose it even before the woman notices it.

Treatment

· Some obstetrician will prefer to leave it as spontaneous expulsion will take place: this may cause anxiety and distress to the mother.

· Protaglandin E2 may be given to induce labour in conjunction with i.v oxytocin

· Mannual Vacuum aspiration of the content may be performed

· Blood coagulation disorder may develop if up to 6-8 weeks

· Plasma fibrinogen estimate weekly

· If several weeks have elapsed between death and expulsion of the conceptus give fresh compatible blood.

6. Habitual Abortion

Abortion is said to be habitual if it has occurred spontaneously for at least three or more consecutive occasions. The risk of further abortion with subsequent pregnancies is high. Occurrence is about 1% of all pregnancies and in the early weeks of pregnancy if pregnancy continues till mid – trimester there is r isk of threatened abortion or premature labor.

Causes

Most time unknown occurs more with incompetent cervix Local causes: fibroid, displacement of the uterus medical

condition include diabetes mellitus, nephritis, and tuberculosis.

Treatment

Early booking ,no coitus, hospitalization may be imperative

Shirodker stitches – (cervical serclage) at about 1 4th –16 th week complete bed rest - ventolin tablets 2-4mg bid or daily

7. Septic Abortion

Most common complication of induced or incomplete abortion. It is due to ascending infection.

Signs & Symptoms

Anemia, Signs of Miscarriage, Feeling unwell, lower abdominal pain, headache, vomiting, Pyrexia, rapid pulse, lochia are profuse and offensive.

May be localized or as generalized septicemia with peritonitis

Treatment

V. antibiotic for a start, followed by broad spectrum antibiotic that is effective against anaerobic infection.

Blood Mole

Occasionally mixed abortion may progress to blood mole. This is a smooth brownish red mass which contains the fetus and the placenta and it is completely surrounded by the capsular deciduas. The mole usually forms before 12th week and it is retained in the uterus for a period of months. Later the fluid is extracted from the blood and the fleshy, firm hard mass that is remaining is known as a Carneous Mole. On histological investigation the fetus may be found in the centre of the mass.

Treatment

Protaglandin E2 pessaries will be inserted into the vagina to ripen the cervix followed by i.v. oxytocin – dosage adjusted according to uterine activities. Analgesic to relief pains. Observation of the mother.

Extra-uterine Pregnancy

When fertilized ovum embeds outside the uterine cavity, the pregnancy is said to be extra uterine. Commonly in the fallopian tube, abdominal cavity, cervix and rarely ovaian .

Tubal Pregnancy /Ectopic Pregnancy Causes:

Congenital abnormality of the tube, Previous infection, Surgery on the tube IUCD, Assisted reproductive techniques

Physiology:

The blastocyst rapidly erodes the epithelial lining of the fallopian tube and becomes attached to the muscle layer.

Signs & Symptoms

· History of amenorrhea

· Mild lower abdominal discomfort or acute Abdominal pain

· Occasional attack of sharp and stabbing pain which is localized in nature

· Accompanied by nausea

· There may be brownish vaginal discharge, dizziness, shoulder pain – bleeding into the peritoneal cavity

Other signs of pregnancy may be absent

· Ultrasound may assist diagnosis

· Shock may be present

Possible outcome:

If occurs near the distal end of the tube

1. Tubal abortion may result

2. Tubal mole

3. Tubal rupture which may be gradual or sudden

4. Abdominal pregnancy

Abdominal Pregnancy

This is a rare condition. The fetus develops outside the uterine cavity following abortion or rupture. Uterine tube placenta attaches to neighbouring organs. Majority do not survive. If it occurs in early pregnancy, the product gets re-absorbed . Infection may occur leading to abscess – peritonitis or septicaem ia. Rarely proceed to term

Diagnosis:

On Palpation – lie is abnormal, fetal part is readi ly felt

Management:

Delivery is by laparatomy

Plaenta may or may not be removed – later is safer.

Prophylatic antibiotic is given.

Baby:

May have compression deformities due oligohydramnios

Hydatidiform Mole

Case of gross malformation of the trophoblast. The chorionic villi proliferate and become vesicles which looks like a bounch of English grape. Risk is higher in a woman who has had it before – (1 in 50) and under the age of 20 and above 40 years. There are 2 types:

Complete. No evidence of embryo, cord or membrane .

Incomplete has evidence of embryo, fetus or amniotic sac.

Signs & Symptom:

These vary according to type of mole. Exaggerated pregnancy symptoms by 6 – 8 weeks. Bleeding or blood stained vaginal discharge after a period of amenorrhea.

· Slight pink or brownish discharge,

· Passage of vesicles per vaginam,

· Anaemia,

· High chorionic gonadotrophic hormone (CGTH) level,

· Pre-eclampsia in early pregnancy,

· On palpation – uterus larger than date, feels dough y or elastic, no fetal parts, no fetal height can be mapped, no fetal movement.

Diagnosis

Ultrasound, Increase CGTH,

Treatment

Remove all the trophoblastic tissues, Terminate pregnancy, Follow up to 2 year until CGTH is negative, Give psychological support.

Post Abortion Care (PAC)

This is an approach for reducing morbidity and mortality from incompetent and unsafe abortion and resulting complications and for improving women’s sexual and reproductive health lives.

Elements of PAC:

There are 5 elements of PAC which are:

· Treatment of incomplete and unsafe abortion and abortion related complications that are potentially life threatening

· Counseling to identify and respond to women’s emotional and

· Physical health needs and other concerns

· Contraceptives and family planning services to

o Help women prevent unwanted pregnancy

o Encourage the practice of birth spacing

o Reproductive and other health services that are: Provided on-site

o Provide via referrals to other facilities in providers’ networks

· Community and service provider partnerships to:

o Prevent unwanted pregnancies and unsafe abortion

o Mobilize resources for timely care for complications from abortion

o Ensures health services reflect and meet community expectations and needs

Principles that Support Patients’ Rights in PAC Setting

o Having empathy and respect for patients

o Maintaining positive interaction and communication with patients

o Respecting privacy and confidentiality

Roles of the Midwife in PAC

The midwife is the general overseer or manager of the totality of Manual vacuum Aspiration (MVA) services within the facility

o The midwife has the responsibility of ensuring that the facilities and the necessary equipments are always available at the MVA room. Portable water should be made available.

o She should ensure proper cleaning and setting of trolley. She must also ensure completeness of the items on both shelves of the trolley

o Pre and post procedure care of the patients is an important responsibility of the midwife.

o Her role in the actual MVA procedure depends on whether she is permitted to carry out the procedure or to assist the doctor during a procedure. In which ever situation, she must have a good grip of the procedure.

o She must posses a proper understanding of cleaning and sterilization/or disinfecting of equipment used during the procedure and disposal of wastes, aspirates and sharp instruments in order to prevent infection especially HIV/AIDS

o She is responsible for keeping record of details of the procedure.

Manual Vacuum Aspiration (MVA)

This is a procedure carried out to evacuate uterine contents in incomplete abortion. The indications are:

o Threatened or imminent abortion, Inevitable abortion, Incomplete abortion

o Infected abortion, Missed abortion, An embryonic pregnancy, Hydatidiform mole

o Retained placental products

Advantages

· Requires only slight dilatation and scrapes gently

· Lower risk of complications, Lower cost of services, Can be used in low resource setting, Decreased need for hospitalization, is a day case.

The procedure is usually carried out by trained heath personnel. (Refer hand book for nurses and midwives for details)