Vaginal bleeding in early pregnancy

1. VAGINAL BLEEDING IN
EARLY PREGNANCY
PRESENTED BY
INT. DR. AMIT POUDEL

2. INTRODUCTION
Bleeding occurring from the vagina of a pregnant women before the 22nd week of pregnancy

3. CASE NO 1
A 24-year-old nulliparous women, presented with 3 months amenorrhea to the ER with vaginal
bleeding and severe abdominal pain particularly confined to the left iliac fossa.
Her UPT is (+).
Vaginal examination revealed
• CMT (+)
• normal-sized uterus.
USG and urine hCG levels were ordered.
The quantitative β-hCG is 2300 mIU/mL and TVS examination revealed
an adnexal mass (about 1 cm in size) and an empty uterus.

4. CASE NO 2
• A 20 yr old primigravida female from Tansen Palpa presented to the Gopd of lmc on
2071/08/18 with c/o
Amenorrhoea x 4 months
vaginal bleeding for 2 days a/w clots
passage of grape like vesicles p/v for 2 days
Excessive vomiting

5. ON EXAMINATION
• GC -fair P/v examination
GPE normal os – tip of the finger
• P/A examination mass about 2x3 cm felt in the right adnexa
Uterus 22 wk size CMT (-)
Fetal parts could not be felt.
FHS(-)
USG abdomen was ordered which showed the characteristic
‘’ Snow Storm ‘’ appearance.

6. CASE NO 3
A 35-year-old woman at 8 weeks’ gestation c/o
• crampy lower abdominal pain and
• vaginal bleeding.
She states that the pain was intense last night, and that something that looked like liver
passed per vagina. After that, the pain subsided tremendously as did the vaginal
bleeding.

7. • O/E, her BP is 130/80 mm Hg,
HR 90 bpm, and temp. is 98°F
Her abdominal examination is unremarkable.
• The pelvic examination
reveals normal external female genitalia. The cervix is closed and nontender and no
adnexal masses were appreciated
• Usg abdomen was ordered which revealed empty uterus with about 20 ml of RPOC

8. • Case 1 Ectopic pregnancy
• Case 2 Molar pregnancy
• Case 3 Complete abortion

9. ECTOPIC PREGNANCY
• An ectopic pregnancy is one in which implantation occurs outside the uterine
cavity

12. UNRUPTURED VS RUPTURED ECTOPIC PREGNANCY
UNRUPTURED ECTOPIC RUPTURED ECTOPIC
Symptoms of early pregnancy Collapse and weakness
Abdominal and pelvic pain Fast, weak pulse (110 per minute or
more)
Hypotension
Hypovolemia
Acute abdominal and pelvic pain
Abdominal distension and rebound tenderness
Pallor

13. SYMPTOMS AND SIGNS
• The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding.
• symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low
abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia.
• pelvic tenderness
• enlarged uterus
• adnexal mass
• Tenderness
• Peritoneal irritation may produce muscle guarding, frequency of micturition, and later a
degree of fever

14. SEQUELAE OF ECTOPIC PREGNANCY

15. DIFFERENTIAL DIAGNOSIS
• 1. Salpingitis.
• 2. Miscarriage.
• 3. Appendicitis.
• 4. Torsion of pedicle of ovarian cyst.
• 5. Rupture of corpus luteum or follicular cyst.
• 6. Perforation of peptic ulcer.

16. AIDS TO DIAGNOSIS
• Always take a careful history. Inquire in detail about supposed LMP
• Always think of tubal pregnancy; a woman with lower abdominal pain in
whom there is a possibility of pregnancy should be regarded as having an
ectopic until proved otherwise.
• Pregnancy test
• β-hCG
• Ultrasound
• Laparoscopy
• Culdocentesis

17. MANAGEMENT
If haemorrhage and shock are present, restore the blood volume by the
transfusion of red cells or a volume expander and proceed with operation. The
patient's condition will improve as soon as the bleeding is controlled.

19. MEDICAL MANAGEMENT
• Methotrexate (mTX)
folate antagonist that inactivates dihydrofolate reductase enzyme, leading to a fall in tetrahydrofolate
Dose
50 mg/m2 (approximately 1 mg/kg body weight).

20. INDICATION
• The women should be haemodynamically stable.
• Ectopic pregnancy should be unruptured.
• Serum β-hCG level should not exceed 6500-10,000 mIU/ml.
• The size of the gestation sac should not exceed 3-5 cm in its longest diameter.
• Fetal cardiac activity should be absent.
• The patient should be willing to come for follow-up.
• There should be no contraindication to mTX (liver disease, anaemia).
• The patient should be desirous of future fertility.

21. CONTRAINDICATION
• Serum creatinine level >1.3 mg%, liver function test serum SGOT and SGPT
>50 IU/L, low Hb and platelet count contraindicate its use.
• Chronic alcoholism and liver disease
• Pre-existing blood dyscrasia
• Acute pulmonary disease
• Peptic ulcer
• Immunodeficiency disease
• Breast feeding
• Known drug sensitivity or presence of allergic diathesis
• Gestational sac >3.5 cm
• Presence of fetal cardiac activity

22. Other surgically administered medical (SAM) drugs
• Mifepristone
• Prostaglandins
• 20% KCl solution
• Glucose solution
all injected into the gestation sac under ultrasound/laparoscopic control.
Of all these, mTX has proved most effective.

23. Post-medication management :
•No alcohol
•no folic acid.
•Avoid pregnancy until ectopic pregnancy resolves and serum hCG is undetected.
•Use barrier method consistently
The disadvantage of medical treatment lies in the prolonged follow-up and rarely resorting to surgery in failed cases

24. SURGICAL MANAGEMENT
• Types of surgery
• Salpingectomy
if the gestation sac is >4 cm, most of the tube is damaged and the other tube
is healthy

25. • Partial salpingectomy
if more than 6 cm of the tube can be preserved. Later, tubal anastomosis can be performed .

26. • Salpingostomy
Antimesenteric border is incised, conceptus removed,
haemostasis secured and the wound left open for secondary
healing.
• Salpingotomy
The wound is closed with Vicryl sutures.
• Milking of the tube
is possible with fimbrial pregnancy but prolonged bleeding and
persistent trophoblastic tissue do not favour this technique.

27. SUBSEQUENT MANAGEMENT
• Prior to discharge, provide counselling and advice on prognosis for fertility.
• Given the increased risk of future ectopic pregnancy, family planning counselling and
provision of a family planning method, if desired, is especially important.
• Correct anaemia with ferrous sulfate or ferrous fumerate 60 mg by mouth daily for six
months.
• Schedule a follow-up visit at four weeks

28. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
• Heterogeneous group of related lesions
• Arise from abnormal proliferation of trophoblast of the placenta
• Unique because the maternal lesions arise from fetal (not maternal) tissue
• Most GTD lesions produce the beta subunit of human chorionic gonadotropin (B-hCG)

29. OVERVIEW
Hydatidiform Mole:
• Complete
• Partial
** Benign
Gestational Trophoblastic Neoplasia (GTN):
• Persistent/Invasive Mole
• Choriocarcinoma
• Placental-Site Trophoblastic Tumor (PSTT)
** Malignant

30. HYDATIDIFORM MOLE
• North America: 0.6-1.1 per 1000 pregnancies
• Asia: 2-10 per 1000 (3x Western countries)
• Difference possibly related low dietary intake of carotene (vitamin A deficiency) and animal
fat
• More common at reproductive extremes in age (>35y or <20y)

31. Risk Factors:
• History of previous GTD
• If one previous mole, 1% chance of recurrence (vs. 0.1% in general population)
• If 2 previous moles, risk of recurrence increases to 16-28%
• Smoking
• Vitamin A deficiency

32. Clinical Manifestations:
• Vaginal bleeding/anemia
• Enlarged uterus (size > dates)
• Pelvic pain
• Theca lutein cysts
• Hyperemesis gravidarum
• Hyperthyroidism
• Preeclampsia <20 weeks gestation
• Vaginal passage of hydropic vesicles
• Fetal parts are not palpable

34. HYDATIDIFORM MOLE - DIAGNOSIS
• Evaluate for coexisting conditions:
- History and physical examination
- CBC, coagulation profile, serum biochemistry
- thyroid function
- blood type and crossmatch
- chest radiography
- pelvic ultrasonography

35. Pelvic USG
• main method of diagnosing hydatidiform
mole
• Extremely accurate provided that the mole is
sufficiently developed, as the echoes
produced from the mass of vesicles produce
a characteristic 'snowstorm' appearance.

36. HUMAN CHORIONIC GONADOTROPHIN
• Since most of the trophoblast cells secrete HCG, its assay is a measure of the amount of
• tumour tissue
• Grossly elevated levels of HCG are found with hydatidiform moles.
• Beta HCG is much more specific
• Is useful during the follow up of the disease

37. MANAGEMENT
• Once hydatidiform mole is diagnosed, the uterus should be evacuated.
• Risks before evacuation:
• 1. Haemorrhage.
• 2. Trophoblastic invasion and perforation of myometrium.
• 3. Dissemination of possibly malignant cells.
• Risks during evacuation:
• 1. Haemorrhage.
• 2. Perforation by instruments.
• 3. Dissemination of possibly malignant cells.

38. The following plan of management is suggested.
• 1. After miscarriage, the uterus should be completely emptied by
suction.
• 2. If miscarriage does not occur, an attempt should be made to empty
the uterus by suction.
• If bleeding becomes severe, oxytocics must be given, and on rare
occasions an emergency hysterectomy or hysterotomy may be
unavoidable.
• 3. If the uterus is of such a size as to deter the obstetrician from
attempting suctioncurettage, abortion should be induced using
prostaglandin together with oxytocin if necessary. Subsequent
surgical evacuation of the uterus may also be required.
• 4. In the case of the older woman whose family is complete,
hysterectomy may be justified, especially as dissemination of
trophoblast cells can be almost completely prevented by early
clamping of the uterine vessels.

39. FOLLOW UP
• Follow up is required because in about 10% of cases it will
persist and undergo malignant change invarying degrees
• all patients must be followed up for prolonged periods by
radioimmune assays of serum or urinary HCG.
• Normally, the test becomes negative in about 6-8 weeks' time
following evacuation of a molar pregnancy
• Pelvic examination is done to rule out any vulval and vaginal
metastasis,
• the uterine size is recorded.
• The size of any ovarian cyst and reduction in its size are noted.
• A radiograph of the chest is taken to detect lung metastasis.
• Persistent uterine bleeding calls for a curettage, and the
curettings are sent for histopathological examination for
choriocarcinoma.
• Pelvic ultrasound scan can detect residual or locally invasive
tumour as well as an ovarian cyst.

40. PREGNANCY AND CONTRACEPTION
• Pregnancy should be avoided preferably by barrier methods for at least 1 year as a fresh
pregnancy would interfere with the hCG levels.
• Intrauterine device and progestogen-only pills cause irregular bleeding and are best
avoided.
• Combined oral pills can be offered once the β-hCG level becomes undetected.
• Oral combined pills lower the luteinizing hormone (LH) level and thereby hCG level and can
cause misinterpretation of the results.

41. PROPHYLACTIC CHEMOTHERAPY
• indicated in the following conditions :
• High-risk case, i.e. a very young woman and a multiparous woman above age 40 who
refuses hysterectomy.
• A patient with an initial very high level of hCG or a patient in whom the level of hCG persists
or does not regress satisfactorily or there is a rise in the hormone. Patients with urine hCG
level more than 30,000 IU/24 hours after 6 weeks or more than 24,000 IU/24 hours at 10
weeks after evacuation and patients with serum hCG level more than 20,000 mIU/ml if the
serum β-hCG level plateaus over 4 weeks or rises over 3 consecutive weeks also need
prophylactic therapy.
• If a woman cannot come for the follow-up, prophylactic chemotherapy is better than no
follow-up.

42. PROPHYLACTIC CHEMOTHERAPY ….
• Prophylactic chemotherapy comprises administration of :
mTX 5 mg five times a day for 5 days, and three courses repeated at the interval of 7-10
days, provided hb % and WBC count remain above the critical level

43. • Subsequent Pregnancies:
• Send placenta for pathology
• Check B- hCG 6 weeks postpartum

44. MISCARRIAGE ( ABORTION )

45. Definition
• It is expulsion or extraction of products of conception before fetal viability i.e. before
24 weeks of gestation.
Incidence :
• Is the commonest gynaecological & obstetric disorder
• About 15% of clinically recognized pregnancies end in abortion (this rise to 30% if
unrecognized pregnancies are included).
• Most abortions occur between 8 and 12 weeks of pregnancy.
Miscarriage ( Abortion )

46. ETIOLOGY
A. First trimester abortion :
1. Fetal chromosomal abnormalities - particularly trisomy , triploidy & monosomy
• is the commonest cause of abortion
• 50– 70 % of the first trimester abortions are due to chromosomal abnormalities
• the incidence of these abnormalities increased with the increase in the maternal age
2. Anembryonic pregnancy - Blighted ovum
3. Multiple pregnancy

47. ETIOLOGY
A. First trimester abortion :
3. Parental balanced translocation
4. Infections: genital tract infection , systemic infection with pyrexia & ToRCH
syndrome
5. Endocrine disorders : Diabetes, thyroid disorders , PCOS & corpus luteum
insufficiency
6. Uterine disorders: Uterine anomalies , submucus fibroid & Asherman’s syndrome

48. ETIOLOGY
A. First trimester abortion :
8. Thrombophilia: Congenital deficiency of protein C & S, & anti-thrombin III
9. Immunological disorders : Anticardiolipin syndrome and SLE
10. Cigarette smoking , anaesthetic agents & chemical agents .
11. Psychological disorders

49. ETIOLOGY
B. Second trimester abortion :
1. Multiple pregnancy
2. Cervical incompetence (congenital & acquired )
3. Uterine anomalies and submucous fibroid
4. Genital tract infection and PROM

50. TYPES
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Missed abortion
6. Septic abortion
7. Recurrent abortion

51. THREATENED ABORTION
(FEATURES)
1. History  Mild vaginal bleeding.
 No abdominal pain or mild abdominal pain
2. Examination  Good general condition.
 The cervix is closed
 The uterus is usually the correct size for date
3. USG which is essential for the diagnosis shows the
presence of fetal heart activity

52. THREATENED ABORTION
(MANAGEMENT)
1. Reassurance If fetal heart activity is present, > 90% of cases will be progressed
satisfactorily
2. Advice: Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse
3. Hormones i.e. Progesterone & hCG Which are used in the first trimester to support
pregnancy, (but they are of no proven value)
4. Anti- D: An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients,
whose husbands are Rh +ve
5. ANC as high risk patients
Because those patients are liable to late pregnancy complications such as APH and preterm
labour .

53. INEVITABLE AND INCOMPLETE ABORTIONS
(FEATURES)
1. History
Heavy vaginal bleeding.
 with no passage of products conception (inevitable)
 with the passage of products of conception
(incomplete abortion)
Severe lower abdominal pain which follows the bleeding

54. INEVITABLE AND INCOMPLETE ABORTIONS
(FEATURES)
2. Examinations
 Poor general condition.
 The cervix is dilating and products of conception may be
passing trough the os
 The uterus may be the correct size for date (inevitable
abortion) or small for date (incomplete abortion)
3. USG  Fetal heart activity may or may not present in inevitable
abortion or retained products of conception ( RPOC ) in
incomplete abortion

55. INEVITABLE AND INCOMPLETE ABORTIONS
(MANAGEMENT)
1. CBC , blood grouping , XM 2 units of blood
2. Resuscitation  large IV line, fluids & blood transfusion
3. Oxytoxic drugs  Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline)
4. Evacuation & curettage.
5. Post-abortion management.

56. COMPLETE ABORTION
(FEATURES)
1. History
 Heavy vaginal bleeding which has been stopped.
 lower abdominal pain which follows the bleeding which has been
stopped.
2. Examination
 The cervix is closed
3. USG
 Shows empty uterine cavity or RPOC

57. COMPLETE ABORTION
(MANAGEMENT)
1. Evacuation & curettage in the presence of RPOC.
2. Post-abortion management.

58. MISSED ABORTION
(FEATURES)
1. Most of missed abortions are diagnosed accidentally during
routine U/S in early pregnancy .
In some cases there may be a history of :
 Episodes of mild vaginal bleeding
 Regression of early symptoms of pregnancy .
 Stop of fetal movements after 20 weeks gestation.
2. Examination
 The uterus may be small for date

59. MISSED ABORTION
(FEATURES)
3. USG (which is essential for diagnosis ) diagnosed if two ultrasound ( T/V or
T/A) at least 7days apart showed an embryo of > 7 weeks gestation ( CRL >
6mm in diameter and gestational sac > 20 mm in diameter ) with no
evidence of heart activity .

60. MISSED ABORTION
(MANAGEMENT)
1. CBC , blood grouping , XM 2 units of blood
2. Platelets count, – to exclude the risk of DIC
NB : DIC does not occur before 5 weeks of missed abortion or IUFD and if occurred will be of
mild grade

61. MISSED ABORTION
(MANAGEMENT)
3. Options of treatment
Conservative treatment:  if left alone spontaneous expulsion will occur
Surgical evacuation of the uterus; by D & C:
Indicated in 1st trimester missed abortion
Medical termination of pregnancy: by Misoprostol (PGE1)
4. Post-abortion management.

62. ANEMBRYONIC PREGNANCY
(BLIGHTED OVUM)
 It is due to an early death and resorption of the embryo
with the persistence of the placental tissue
 It is diagnosed if two ultrasound ( T/V or T/A) at least 7
days apart showed after 7 weeks of gestation i.e.
gestational sac > 20mm , an empty gestational sac with
no fetal echoes seen .
 It is treated in a similar way to missed abortion .

63. SEPTIC ABORTION
Definition :
It is an incomplete abortion which complicated by infection of the uterine contents .
This may be due to criminal interference
Features : Poor general condition
Include the features of incomplete abortion i.e. severe vaginal bleeding with passage of
product of conception, with or without history of evacuation.
Features of pelvic infection i.e. pyrexia , tachycardia , general malaise , lower abdominal
pain , pelvic tenderness & purulent vaginal discharge .

64. SEPTIC ABORTION
Bacteriology : Mixed infection
 The commonest organisms are :
1. Gram -ve : E.coli , strepto & staphylococcus
2. Anaerobics : Bacteroides
 Rarely Cl. tetani , which is potentially lethal if not treated adequately .
Types :
 Mild  the infection is confined to decidua : 80%
 Moderate the infection extended to myometrium15%
 Severe the infection extended to pelvis + Endotoxic shock + DIC 5%

65. SEPTIC ABORTION
Management :
1. Investigations :
 CBC , blood grouping , XM 2 units of blood .
 Cervical swabs (not vaginal) for culture and sensivity
 Coagulation profile , serum electrolytes & blood culture if pyrexia > 38.5
2. Antibiotics : Cephalosporin I.V + Metronidazole I.V
3. Surgical evacuation of uterus  usually 12 hrs after antibiotic therapy ( until a reasonable
tissue levels of antibiotics have been achieved )
4. Post-abortion management.

66. COMPLICATIONS OF ABORTION
1. Haemorrhage .
2. Complication related to surgical evacuation ie E&C and D&C.
• Uterine perforation- which may lead to rupture uterus in the subsequent pregnancy.
• Cervical tear & excessive cervical dilatation – which may lead to cervical incompetence.
• Infection – which may lead to infertility & Asherman's syndrome.
• Excessive curettage – which may lead to Adenomyosis
3. Rh- iso immunisation  if the anti –D is not given or if the dose is inadequate .
4. Psychological trauma .

67. POST - ABORTION MANAGEMENT
In cases of incomplete, inevitable, complete, missed & septic abortions
1. Support: from the husband, family& obstetric staff
2. Anti D – to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve
3. Counseling & explanation:
A. Contraception (Hormonal, IUCD, Barrier) Should start immediately after abortion
if the patient choose to wait , because ovulation can occur 14 days after abortion
and so pregnancy can occur before the expected next period .

68. POST - ABORTION MANAGEMENT
3. Counseling & explanation:
B. When to try again ?
 Best to wait for 3 months before trying again . This time allow to regulate cycles and
to know the LMP, to give folic acid, and to allow the patient to be in the best shape
(physically and emotionally) for the next pregnancy
C. Why has it happened ?
 In the fiIn the majority of cases there is no obvious cause
 In the first trimester abortion , the most common cause is fetal chromosomal
abnormality

69. POST - ABORTION MANAGEMENT
3. Counseling & explanation:
D. Can it happen again?
 As the commonest cause is the fetal chromosomal abnormality which is not a
recurrent cause , so the chance of successful pregnancy next time in the absence of
obvious cause is very high even after 2 or 3 abortions
E. Not to feel guilty  as it is extremely unlikely that anything the patient did can
cause abortion
 No evidence that intercourse in early pregnancy is harmful
 No evidence that bed rest will prevent it ..

70. RECURRENT ABORTION
Definition :
Is defined as 3 or more consecutive spontaneous abortions
It may presented clinically as any of other types of abortions .
Types :
Primary : All pregnancies have ended in loss
Secondary : One pregnancy or more has proceeded to viability(>24 weeks gestation)
with all others ending in loss
Incidence :
occurs in about 1% of women of reproductive age .

71. RECURRENT ABORTION
Causes
• Idiopathic recurrent abortion, in about 50%, in which no
cause can be found .
• The known causes include the followings :
1. Chromosomal disorders:
 Fetal chromosomal abnormalities & structural
abnormalities
 Parental balanced translocation
2. Anatomical disorders:
Cervical incompetence: →congenital and aquired
Uterine causes: → submucous fibroids, uterine anomalies &
Asherman’s syndrome

72. RECURRENT ABORTION
Causes
3. Medical disorders:
 Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus luteum
insufficiency .
 Immunological disorders : Anticardiolipin syndrome & SLE.
 Thrombophilia: congenital deficiency of Protein C&S and antithrombin III,
& presence of factor V leiden.
 Infections
 ToRCH - CMV may be a cause of recurrent abortion, but ToRH are
not causes of recurrent abortion.
 Genital tract infection e.g Bacterial vaginosis
 Rh – isoimmunization

73. RECURRENT ABORTION
Diagnosis :
1. History :
 Previous abortions : gestational age and place of abortions & fetal
abnormalities.
 Medical history : DM , thyroid disorders, PCOS, autoimmune diseases &
thrombophilia.
2. Examination :
 General : weight , thyroid & hair distribution
 Pelvic: cervix ( length & dilatation ) and uterine size.

74. RECURRENT ABORTION
Diagnosis :
3. investigations :
A. Investigations for medical disorders:
 Blood grouping & indirect Coomb’s test in Rh –ve women
 Endocrinal screening: Blood sugar , TFT & LH /FSH ratio
 Immunological screening: Anti anticardiolipine antibodies & lupus inhibitor.
 Thrombophilia screening: Protein C & S, antithrombin III levels, factor V leiden, APTT
and PT.
 Infection screening
 High vaginal & cervical swabs
 ToRCH profile ( which scientifically is not necessary )

75. RECURRENT ABORTION
Diagnosis :
3. investigations :
B. Investigations for anatomical disorders:
 TV/US: fibroids, cervical incompetence & PCOS.
 Hysteroscopy or HSG, fibroids, cervical incompetence, uterine anomalies &
Asherman's syndrome
C. Investigations for chromosomal disorders:
 Parental karyotyping: Parental balanced translocation.
 Fetal karyotyping: Fetal chromosomal anomalies.

76. RECURRENT ABORTION
Management:
3. in idiopathic recurrent abortion.
With support and good antenatal care , the chance of successful spontaneous pregnancy is
about 60-70%
Support : from husband, family & obstetric staff.
Advice : stop smoking & alcohol intake, decrease physical activity
Tender loving care
Drug therapy
• Progesterone & hCG: start from the luteal phase & up to 12 weeks.
• Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks
• LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37 ws

77. RECURRENT ABORTION
Management:
3. In the presence of a cause treatment is directed to control the cause
Endocrine disorders
• Control DM and thyroid disorders before pregnancy
• Ovulation induction drugs , ovarian drilling or IVF in PCOS.
• Progesterone or hCG in corpus luteum insufficiency .
:In anti-cardiolipin syndrome:
• Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg / day), starting when
pregnancy is diagnosed till 37 weeks.
• These drugs are not teratogenic.

78. RECURRENT ABORTION
Management:
In thrombophilia:
• Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low
molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart activity
diagnosed & to continue both till 37 weeks .
In uterine disorders
• Cervical cerclage in cervical incompetence, best time at the 14 weeks of pregnancy.
• Myomectomy in submucus fibroid, excision of uterine septum in septate &
subseptate uterus & adhesolysis in Asherman's syndrome.

79. RECURRENT ABORTION
Management:
In infection:: treatment of the genital tract infection.
In Rh isoimmunization: Repeated intrauterine transfusion
In parental balanced translocation
• Explain the risk of fetal chromosomal disorders ( about 30% )
• Encourage to try again or adoption.

80. SO TO SUM IT UP…….

81. Presenting Symptom and Other
Symptoms and Signs Typically
Present
Symptoms and Signs
Sometimes Present
Probable Diagnosis
• Light bleeding
• Closed cervix
• Uterus corresponds to dates
• Cramping/lower abdominal
pain
• Uterus softer than normal
Threatened abortion,
•Light bleeding
• Abdominal pain
• Closed cervix
• Uterus slightly larger than
normal
• Uterus softer than normal
• Fainting
• Tender adnexal mass
• Amenorrhoea
• Cervical motion tenderness
Ectopic pregnancy
• Light bleeding
• Closed cervix
• Uterus smaller than dates
• Uterus softer than normal
• Light cramping/lower
abdominal pain
• History of expulsion of
products of conception
Complete abortion

82. Presenting Symptom and Other
Symptoms and Signs Typically
Present
Symptoms and Signs
Sometimes Present
Probable Diagnosis
• Heavy bleeding
• Dilated cervix
• Uterus corresponds to dates
• Cramping/lower abdominal
pain
• Tender uterus
• No expulsion of products of
conception
Inevitable abortion,
• Heavy bleeding
• Dilated cervix
• Uterus smaller than dates
• Cramping/lower abdominal
pain
• Partial expulsion of products
of conception
Incomplete abortion,
• Heavy bleeding
• Dilated cervix
• Uterus larger than dates
• Uterus softer than normal
• Partial expulsion of products of
conception which resemble
grapes
• Nausea/vomiting
• Spontaneous abortion
• Cramping/lower abdominal
pain
• Ovarian cysts (easily
ruptured)
• Early onset pre-eclampsia
• No evidence of a fetus
Molar pregnancy,

83. THANK YOU