Early pregnancy bleeding

1. Dr L.Dabashini Devi
Professor & HOD
Department of OBG Nursing

2. ABORTION
• DEFINITION-
Abortion is the termination of pregnancy
before the period of viability which is
considered to occur at 28th week.However
,for international acceptance ,the limit of
viability is brought down to either 20th week
or fetus weighing 500gm. If the expelled
fetus weighs less than 500gm , it is called as
abortus.

3. INCIDENCE
The incidence of abortion is difficult
to work out, but probably 10% of all
pregnancies end in spontaneous
abortions and another figure of 10% are
induced, illegally 75% abortions occur.

4. ETIOLOGY
 Ovo-Fetal Factors (60%)
(a) Chromosomal abnormality
(b) Interference with the circulation in umbilical cord
(c) Low attachment of the placenta
(d) Twins or hydramnios
 Maternal Factors
(a) Maternal illness
1.Infection
2.Maternal hypoxia and shock
3.Chronic illness,HT ,chronic nephritis, chronic
wasting diseases
4.Endocrine factors; hypothyroidism,
hyperthyroidism and diabetes mellitus

5. (b)Trauma
1. Direct trauma on the abdominal wall by blow or
fall.
2. Psychic –emotional upset or change in
environment.
3. Journey along rough road, internal examination
in early months, sexual intercourse in early
months is enough to excite abortion.
4. Amniocentesis,chorion villus sampling or
abdominal surgery in early months.

6. © Toxic agents
1. Environmental toxins like
lead, arsenic, anesthetic gases,
tobacco, caffeine ,alcohol
,radiation in excess.
2. Drugs used for epilepsy or
antimalarial preparations.

7. (d) Cervico_uterine factors
1. Cervical incompetence either congenital or acquired.
2. Congenital malformation of the uterus ,bicornuate or
septate uterus.
3. Uterine tumour (fibroid), distortion of the uterine cavity
and increased uterine irritability.
4. Adhesions or due to trauma by sexual intercourse or due
to disturbance in uterine vascularity.

8. (e) Immunological
1. Lupus anticoagulant
2. Antiphospholipid antibodies.
(f) Blood group incompatibility
Couples with group A husband and group O wife have got
higher incidence of abortion.
(g) Premature rupture of membranes inevitably.
(h) Dietetic factors folic acid deficiency, vitamin E.

9.  Paternal factors
Defective sperm, contributing half of the number of the
chromosomes to the ovum.
 Unknown (25%)
Abortion causes is unknown.
Common known causes of abortion
First Trimester:
1. Defective germ plasma
2. Hormonal in deficiency
3. Trauma
4. Acute infection

10. Mid Trimester:
1. Cervical incompetence
2. Uterine malformation
3. Uterine fibroid.

11. MECHANISM OF ABORTION
Before 8 weeks
ovum surrounded by the villi
with decidual coverings ,is
expelled out intact. Sometimes
os fails to dilate cervical canal &
is called cervical abortion.

12. MECHANISM OF ABORTION
8-14 weeks
Expulsion of fetus commonly occurs leaving
behind the placenta and the membranes. Apart of
it may be partially separated with brisk
hemorrhage or remains totally attached to the
uterine wall.
 Beyond 14 weeks
The process of expulsion is that of a “mini
labor” .The fetus is expelled first followed by
expulsion of the placenta after a varying interval.

13. CLASSIFICATION
ABORTION
SPONTANEOUS INDUCED

14. 1, SPONTANEOUS ABORTION
It is a type of abortion that occur without medical or other
interventions.
(A) THREATENED ABORTION
It is a condition of pregnancy , occuring before 20th week of gestation ,the patient
usually experiences vaginal bleeding with or without some cramps , and the
cervix is closed. Bedrest is the only measure.

15. DEFINITION
It is a clinical entity where the
process of abortion has started but
has not progressed to a state from
which recovery is impossible.

16. CLINICAL FEATURES
1. Bleeding per vaginam:- usually slight & bright red in
colour.
2. Pain –mild backache or dull pain in lower abdomen.
Pelvic examination
Reveals bleeding through the external os.
uterine size corresponds to the period of amenorrhoea. The
uterus and cervix feel soft.

17. INVESTIGATIONS
1. Blood –Hb , ABO & Rh
grouping
-anti D gamma globulin has to be
given for Rh negative non
immunized women.
2.Urine –immunological test of
pregnancy.

18. Special Investigation
Ultra sonography findings.
A blighted ovum is evidenced by loss of gestational sac,
smaller mean gestational sac diameter,absent fetal echoes
absent fetal cardiac movements
serum progesterone value to 25ng/ml or indicates viable
pregnancy

19. TREATMENT
• BEDREST
• DRUGS-
-Phenobarbitone 30mg or Diazepam 5 mg tablet
twice a day.
-Mild laxatives (milk of magnesium) 4 tsp at
bedtime may be prescribed later on if required.
ENEMA should NOT be given.

20. GENERAL MEASURES
1. Preserve vulval pads for
inspection.
2. Report immediately, if pain or
bleeding becomes aggravated.
3. Routine note of pulse,
temperature and vaginal bleeding.

21. ADVICE ON DISCHARGE
• Avoid heavy work,streaneous
exercises
• Limit work for atleast 2 weeks.
• Coitus is indicated.
• Re-examine after one month.

22. PROGNOSIS
Unpredictable
1. In about 2/3rd ,the pregnancy continuous beyond 28 weeks.
2. In the rest, it terminates either is inevitable or missed
abortion. If pregnancy continuous increased chance of
preterm labour ,placenta previa,I.U.G.R of the fetus and
fetal anamolies.

23. INEVITABLE
ABORTION
DEFINITION:-
It is the clinical type of abortion
where the changes have progressed
to a state from where continuation
of pregnancy is impossible.

24. CLINICAL FEATURES
• Increased vaginal bleeding.
• Aggravation of pain in the lower abdomen.
• Visible blood loss.
• Internal examination-dilated internal os of cervix.
-In 2nd trimester –start with ROM or intermittent lower
abdominal pain.

25. MANAGEMENT
• PRINCIPLES-
*To take appropriate measures to
look after the general condition.
*To accelerate the process of
expulsion.
*To maintain strict asepsis as
outlined in conduction of labour.

26. GENERAL MEASURES
• Morphine 15 mg I/M
• Excessive bleeding –
*Methargin 0.2 mg if cervix is dilated and the size of the
uterus is less than 12 weeks.
• Shock-
*I.V.fluid therapy and blood transfusion.

27. ACTIVE TREATMENT
BEFORE 12 WEEKS-
1. Dilatation and evacuation
followed by curettage of the
uterine cavity under G.A.
2. Suction evacuation followed by
curettage.

28. AFTER 12 WEEKS
1. Uterine contraction is accelerated
by oxytocin drip.(10units in 500
ml of 5% dextrose) 40-60
drops/min.
2. Placenta is removed by ovusm
forceps or evacuated under G.A.
3. Abdominal hysterectomy.

29. COMPLETE ABORTION
DEFINITION:-
When the products of
conception are expelled in
masses, it is called complete
abortion.

30. CLINICAL FEATURES
1. Abdominal pain.
2. Vaginal bleeding becomes frace or absent.
3. Internal examination reveals :
• Uterus is small.
• Cervical os is closed.
• Bleeding is trace.
4. Expelled fleshy mass is found intact.

31. MANAGEMENT
• The effect of blood loss should be assessed
and treated.
• uterine curettage.
• Trans vaginal sonography prevents
unnecessary surgical procedures.
• No treatment other than rest.
• Rh-negative women: Anti D gamma globulin
50 micro gram or 100 micro gram IM in
cases of early abortion or late abortion
respectively within 72 hours.

32. INCOMPLETE
ABORTION
DEFINITION.
When the entire products of
conception are not expelled,
instead a part of it is left inside
the uterine cavity, it is called
incomplete abortion.

33. CLINICAL FEATURESExpulsion of a fleshy mass per vaginum
is followed by-
1. Continuation of pain (colicky) lower
abdomen.
2. Persistence of vaginal bleeding of
varying magnitude.

34. CLINICAL FEATURES
CONT…
3.Internal examination reveals-
• Uterus smaller than the period of
amenorrhoea.
• Patulous cervical os often admitting tip of the
finger.
• Varying amount of bleeding.
4.On examination, the expelled mass is found
incomplete.

35. TERMINATION
The products left behind may lead
to-
1. Profuse bleeding.
2. Sepsis.
3. Placental polyp.
4. Choriocarcinoma.

36. MANAGEMENT
• Early abortion-
D & E under G.A.
• Late abortion-
* Exploration of uterus under G.A.
* D&C.
*Histological examination.

37. MISSED ABORTION
DEFINITION:-
When the fetus is dead and retained
inside the uterus for more than four weeks
,it is called missed abortion.

38. PATHOLOGY
The causes of prolonged retention of the dead
fetus in uterus is not clear.
• Beyond 12 weeks,the retained fetus becomes
macerated or mummified liquor amni get absorbed
and the placenta becomes pale,this and may be
adherent .
• Before 12 weeks ,the pathological process differs
when the ovum is more or less completely
surrounded by the chorionic villi.

39. CARNEOUS MOLE
(BLOOD MOLE ,FLESHY MOLE,OR TUBEROUS MOLE)
• It is pathological missed abortion affecting the
fetus before 12 weeks.
• Small repeated hemorrhage in the chorion-decidual
space disrupt the villi from its attachment.
• The bleeding is slight so it does not cause rupture
of the decidua capsularis.
• The clotted blood with the contained ovum is
known as a blood mole.

40. CARNEOUS MOLE, cont…
• By this time ,ovum becomes dead and is
completely absorbed or remains as a rudimentary
structure .
• Fluid portion of the blood surrounding the ovum
gets absorbed and the wall becomes fleshy ,hence
the term fleshy or corneous mole.
• The wall looks dark red in color ,laminated
appearance showing the presence of degenerated
villi in the blood clot on microscopic examination.

41. CARNEOUS MOLE, cont…
• The amniotic cavity lined by the
smooth amnion is thrown into
irregular bulges by unequal
distribution of laminated organised
clotted blood outside it,resulting
information is known as tuberous
mole.

42. CLINICAL FEATURES
1. Persistence of brownish vaginal discharge.
2. Subsidence of pregnancy symptoms.
3. Retrogression of breast changes.
4. Cessation of uterine growth which in fact
becomes smaller in size.
5. Non audibility of the fetal heart sound –
Doppler cardio scope

43. CLINICAL FEATURES,cont….
6. Cervix feels firm.
7. Immunological test for pregnancy becomes
negative.
8. Radiological evidence of collapsed fetal skeletal.
9. Real time ultra sonography _empty sac or
absence of fetal motion.

44. COMPLICATIONS
 Pre eclampsia
 Ante partum hemorrhage
 Diabetes
 Chronic nephritis
 Severe anemia
FETAL
 Congenital malformation
 Rh incompatibility
 Post maturity

45. MANAGEMENT
• Uterus is less than 12 weeks
Vaginal evacuation can be carried out
without delay. It is effective by suction
evacuation or slow dilatation of the cervix by
laminaria tent followed by dilatation and
evacuation of uterus under GA.
• Uterus more than 12 weeks
The same principles of the management
protocol in the intrauterine fetal death are to
be followed.

46. SEPTIC ABORTION
Definition
Any abortion associated with clinical evidences of
infection of the uterus and its contents is called
septic abortion . Although clinical criteria vary,
abortion is usually considered septic when there
are:
1. Rise of temperature atleast 100.4 degree f
for 24 hours.
2. Offensive or purulent vaginal discharge.
3. Other evidences of pelvic infection – lower
abdominal pain & tenderness.

47. MODE OF INFECTION
1. Anaerobic –bacteroides
group ,anaerobic
streptococci, cl.welchi &
tetanus bacillus
2. Aerobic –E coli ,klebsiela
,staphylococcus.

48. CLINICAL FEATURES
 Pyrexia
 Pain in abdomen
 Rise in pulse rate 100-120b/min.
Offensive purulent vaginal discharge or a
tender uterus.
Clinical grading
Grade 1. infection is localised
Grade 2. infection spreads beyond uterus
Grade 3. generalized peritonitis

49. INVESTIGATION
1. Vaginal swab for culture
2. Blood – Hb, total WBC,ABO & Rh grouping.
3. Urine analysis
4. Ultra sonography
5. X Ray abdomen
6. Serum electrolytes

50. COMPLICATIONS
 Hemorrhage
 Injury
 Spread of infection
 Acute renal failure
 Thrombophlebitis
 Secondary infertility

51. MANAGEMENT
• General management
• Grade 1
-antibiotics
- prophylactic anti gas –gangrene serum 5000
units to 3000 units of antitetanus serum IM is
given.
- Analgesic & sedatives
- Blood transfusion
-Evacuation of uterus.

52. Grade 2
-Drugs –antibiotic
-Clinical monitoring
- -Surgery – Evacuation of uterus
Grade 3
-antibiotics
-Supportive therapy
-Active surgery

53. RECURRENT ABORTION
DEFINITION
Recurrent abortion is defined as a sequence of
three or more consecutive spontaneous
abortions.

54. ETIOLOGY
• First trimester
-Genetics
-Endocrinal
-Infection
-Immunological cause
-All immunity
-Idiopathic
• Second trimester
-Cervical Incompetence

55. INVESTIGATION
1. Blood –glucose, VDRL, thyroid function
test,ABO & Rh grouping.
2. Auto immune screening
3. Ultra sonography
4. Hysterosalpinography
5. Hysteroscopy
6. Karyotyping
7. Endocervical swab

56. TREATMENT
CIRCLAGE OPERATION
• The operations are named after shirodkar
and Mc Donald.
Principle
• A non absorbable encircling suture is placed
around the cervix at the level of internal os.
It operates by interfering with the uterine
polarity, preventing the internal os and the
adjacent lower segment from being “taken
up”.

57. SHIRODKAR’S OPERATION
• The patient is put under GA and placed in
lithotomy position with good exposure of the
cervix by a posterior vaginal speculum. The
lips of the cervix are pulled down by sponge
holding forceps .
• A transverse incision is given anteriorly
below the base of the bladder on the vaginal
wall and the bladder is pushed up to expose
the level of the internal os.A vertical incision
is given posteriorly on the cervicovaginal
junction.

58. SHIRODKAR’S
OPERATION,cont..• The non absorbable suture material –no 4
braided nylon or mersilence (dacon) is passed
submucously with the help of an aneurysm needle
or cervical needle so as to bring the suture ends
through the posterior incision.
• The ends of the suture are tied up posteriorly by a
reef knot. The bulging membranes if present must
be reduced before hand into uterine cavity. The
anterior and posterior incisions are repaired by
interrupted stitches using chronic catgut.

59. MC DONALD OPERATION
The non absorbable suture material is
placed as a purse string suture as high as
possible at the junction of the rugose
vaginal epithelium and the smooth
vaginal part of the cervix below the level
of the bladder. The suture starts at the
anterior wall of the cervix .Taking
successive deep bites it is carried around
the lateral and posterior walls back to the
anterior wall again where the two ends of
the suture are tied.

60. Removal of stitch
• The stitch should be removed at 38th week or
earlier of labor pain starts or features of abortion
appear. The stitch is not cut in time , uterine
rupture or cervical tear may occur .If the stitch
is cut prior to the onset of labor.

61. CONTRAINDICATIONS
• Intrauterine infection
• Ruptured membranes
• History of vaginal bleeding
• Severe uterus irritability

62. INDUCTION OF ABORTION
• MEDICAL TERMINATION OF PREGNANCY
• Serious risk of life or grave injury to the physical
and mental health of pregnant women.
• Risk of the child being born with serious
physical and mental abnormalities.
• When the pregnancy life is caused by rape.
• Pregnancy caused as a result of failure of
contraceptives.

63. INDICATIONS FOR
TERMINATION UNDER THE
MTP ACT
1. To save the life of the
mother .
2.Social indications.
3.Eugenic .

64. RECOMMENDATIONS
• Terminations can only be performed in
hospitals.
• Termination only on written consent of the
women.
• Pregnancy in minor girl, can’t be terminated
without written consent of parents.
• Termination done only upto 20th week of
pregnancy.
• Abortion is confidentially done and reported to
the director of health services of the state.

65. METHODS OF
TERMINATION
• First trimester termination.
•Mid trimester termination.
*Between 13-15 weeks.
*Between 16-20 weeks.

66. FIRST TRIMESTER
TERMINATION
ADVANTAGES.
• Done as an outdoor procedure.
• Hazards of GA are absent.
• Termination for therapeutic indications.
DRAWBACKS.
• Method is not suitable for bigger size uterus.
• Requires electricity to operate and machine is
costly.

67. FIRST TRIMESTER
TERMINATION CONT…
• DILATATION AND EVACUATION.
1. Rapid method- introduction of laminaria
tents into the cervical canal for slow
dilatation, intra vaginal prostaglandin E2
gel 2mg into the posterior fornix at least 12
hours before hand.
2. Slow method-further dilatation by metal
dilators followed by evacuation of uterus.

68. FIRST TRIMESTER
TERMINATION CONT…
2. Drugs.
• Prostaglandins-1mg PGE1 vaginal pessary
in the posterior fornix. This is done 3
hours before the procedure.
• Mifepristone (Ru 486) It is effective upto 9
weeks of pregnancy. A single dose of
600mg is given orally.
• Methotrexate is effective up to 8 weeks of
pregnancy.Methotrexate 50 mg IM
followed by PGE1 vaginally is given.

69. MID TRIMESTER
TERMINATION.
• Between 13-15 weeks.
- Allow the pregnancy to continue, so that the
uterus will be enlarged to about 16 weeks
- Prostaglandins
- Transcervical intra amniotic instillation of
hypertonic saline (20%) or extra amniotic
installation of 0.1%ethacrydine lactate
- Hysterectomy

70. MID TRIMESTER
TERMINATION, cont…• Between 16-20 weeks
-Intra amniotic—amniocentesis is done by a 15 cm
18 gauge needle. A fine polythene tube is passed
through the needle into the amniotic sac followed
by withdrawal of the needle. The polythene tube is
connected with the drip set containing the required
amount of hypertonic saline. The amount of saline
to be instilled is calculated as number of weeks of
gestation multiplied by 10 ml.

71. PRECAUTIONS OF INTRA
AMNIOTIC INSTILLATION
1. Be sure that the needle is in the amniotic cavity
evidenced by clear liquor.
2. Instillation should be in slow process.
3. Vital signs should be checked immediately after the
instillation and she should be kept at bed rest for atleast 1
hour.
4. Stop procedure if abdominal pain,headache,thrist, or
tingling in the fringers appear. A rapid infusion of 1000ml
dextrose in water along with intravenous diuretics .
5. Strict vigilance
6. Routine antibiotic 3-5 days.

72. MID TRIMESTER
TERMINATION, cont…-Extra amniotic instillation of 0.1% ethacrydine
lactate (estimated amount is 10 ml per week) is
done transcervically through a no 16 Foleys
catheter. The catheter is passed up the cervical
canal for about 10 cm above the internal os between
the membranes and myometrium and the balloon
is inflated (10 ml) with saline. It is removed after 4
hours. Stripping the membranes with liberation of
prostaglandins from the decidua and dilatation of
the cervix by the catheter for initiating abortion.

73. Extra amniotic instillation cont…
• Prostaglandins
Routes of administration
-Vaginal
1. PGE1 200mg every 12 hours
2. PGE2 suppository 20 mg every 3 hours are every
effective.
- Intra muscular : The following preparations are
used
1. 15 Methyl PGF22 250mg 3 hourly
2. Sulprostone (PGE2) 500MG 8 HOURS.

74. Extra amniotic instillation cont…
• Oxytocin –Iv drip method along intra amniotically or in
extra amniotic space. The drip rate can be increased up to 5
milli units or more per minute.
• Hysterotomy
It is an operative procedure of extracting the products of
conception out of the womb before 28th week by cutting
through the anterior wall of the uterus.

75. COMPLICATIONS OF MPT
• Immediate
1. Trauma to the cervix- hemorrhage and
shock
2. Hemorrhage and shock due to trauma in
complete abortion.
3. Thrombosis or embolism
4. Related to the methods. Vomiting,
diarrhoea ,fever, uterine pain and cervico
uterine injury, water intoxication and
convulsions.

76. • Remote
-- Gynecological complication include
1. Menstrual disturbance
2. Chronic pelvic inflammations
3. Infertility due to cornual block
4. Scar endometriosis
---Obstetrical complications
1. Recurrent abortion
2. Ectopic pregnancy
3. Premature labor
4. Rupture of uterus
5. Rh isoimmunisation
6. Dysmaturity

77. PHYSICAL CONSEQUENCES
AFTER ABORTION
• Death
• Breast cancer
• Cervical ,ovarian and liver cancer
• Uterine perforation
• Cervical laceration
• Placenta previa
• Complications of labor
• Handicapped new borns in later pregnancy
• Ectopic pregnancy
• Pelvic inflammatory disease
• Endometritis
• Lower general Health