Bleeding in early pregnancy

From Ganfyd

Definition

Vaginal bleeding in the first half pregnancy before the age of viability. Currently considered less than 24 weeks gestation (or 500g) but subject to review in light of recent medical progress^[1]

Medically, the terms "abortion" and "miscarriage" are synonyms. In lay terms, the word abortion is mainly used as a contraction of therapeutic abortion, commonly referred to by doctors as termination of pregnancy.

Incidence

• 15-20% pregnancies
• 80% within 12 weeks
• 50% continue to viability

Increase risk of pre-term delivery by 1.57x^[2]

Aetiology

• foetal factors
  • commonest cause of miscarriage
  • occurs early (<8 weeks)
  • usually chromosomal abnormalities (up to 50%)
  • autosomal trisomies - 50%
• paternal factors
  • balanced translocation
  • carrier state
  • ? increased abnormalities with ageing sperm
• idiopathic
• maternal factors
  • Failure of the active processes involved in maternal-fetal tolerance to paternal alloantigens^[3]
    • These active processes may explain why filgrasim in early pregnancy reduces rate of miscarriage
  • endocrine disorders
    • polycystic ovary syndrome
    • hyperthyroidism
    • uncontrolled diabetes mellitus
    • luteal phase deficiency
  • anti-phospholipid syndrome
  • chronic renal disease
  • chronic cardiovascular disease
  • anatomical abnormalities
    • submucous fibroids
    • congenital uterine abnormalities
      • septate / bicournate / unicournate uterus
    • cervical incompetence
    • intra-uterine adhesions (Asherman's syndrome)
  • infections
    • listeria
    • toxoplasmosis
    • Mycoplasma
    • Syphilis
  • environmental
    • toxins
    • radiation
    • drugs
    • smoking
    • alcohol

Management

Medical management of miscarriage there is more than one regime mifepristone orally about 48 hours later misoprostol PV 100mg diclofenac PR at same time as the misoprostol expect miscarriage to occur in next 6 hours analgesia - co-codamol as required

• supportive - physically and emotionally
• treatment of known causes between pregnancies
• non-viable pregnancies
  • RU486 / mifepristone
  • conservative management
  • salpingostomy
  • salpingectomy
  • methotrexate

Conservative management of missed miscarriage about 50% will miscarry within 1 month from diagnosis

Differential diagnosis

• threatened abortion
  • painless vaginal bleeding with a closed cervix
• inevitable abortion
  • vaginal bleeding with cervical dilatation with or without rupture of membranes
• incomplete abortion
  • bleeding and pain with an open cervical os. Some foetal tissue is expelled.
• complete abortion
• blighted ovum
  • anembryonic pregnancy
• missed abortion
  • retention of dead foetal tissue, pregnancy symptoms become absent. May lead onto disseminated intravscular coagulation.
• septic abortion
  • fever,pain and tenderness. Often related to retained products of conception
• hydatidiform mole
  • hydropic placental villi may be passed.
• recurrent abortion
• ectopic pregnancy
• local genital factors
  • cervical polyps
  • chronic cervicitis

References