Early pregnancy

bleeding
Najihah Zainal
HTM
Bleeding in early
pregnancy
Vaginal bleeding before 20 weeks gestation/
when foetus weighing 500g or less

About 1 in 4 will experience bleeding in early

pregnancy

May cause distress to affected patient

Is the pregnancy safe?
A small amount of painless vaginal bleeding is
more likely to be reassuring

Heavy bleeding + cramps & backache >

High risk!

>50% of women with bleeding in early

pregnancy will have continuing pregnancy &
give birth to a healthy baby
Normal PV bleeding
Implantation bleeding

Around 6-8 weeks

For 1-2 days

May confuse with LMP

Caused by implantation of foetus in the womb

wall > disruption to wall of the womb >
release small amount of blood
 Speck bleeding after sexual intercourse,
lifting heavy items, heavy physical activities

more pronounced as cervix becomes more

vascularised & dilation of blood vessels
during pregnancy
Causes of bleeding in early
pregnancy
Subchorionic Sonographic finding of blood between the chorion and
haemorrhage uterine wall, usually in the setting of vaginal bleeding

Presence of a gestational sac larger than 18 mm

Anembryonic without evidence of embryonic tissues (yolk sac or
pregnancy embryo); this term is preferable to the older and less
accurate term blighted ovum

Abortions Loss of a pregnancy before 20 weeks gestation

Pregnancy outside of the uterine cavity (most

commonly in the fallopian tube) but may occur in the
Ectopic pregnancy
broad ligament, ovary, cervix, or elsewhere in the
abdomen
Complete mole: placental proliferation in the absence
Gestational of a fetus; most have a 46, XX chromosomal
trophoblastic composition; all derived from paternal source
disease Partial mole: molar placenta occurring with a fetus;
most are genetically triploid (69, XXY)

Cervical polyps/
Local causes
Abortions
Termination of pregnancy before the foetus is capable of extrauterine
survival i.e 20 weeks or 500g birthweight

Risk factors

Endocrine (e.g., progesterone deficiency, thyroid disease, uncontrolled

diabetes)

Genetic aneuploidy (accounts for about one half of spontaneous

abortions)

Immunologic (e.g., antiphospholipid syndrome, lupus)

Infection (e.g., chlamydia, gonorrhea, herpes, listeria, mycoplasma,

syphilis, toxoplasmosis, ureaplasma)

Occupational chemical exposure

Radiation exposure

Uterine (e.g., congenital anomalies)

 Bleeding before 20 weeks gestation in
Threatened
the presence of an embryo with cardiac
miscarriage activity and closed cervix
Bleeding in the presence of a dilated
Inevitable
cervix; indicates that passage of the
miscarriage conceptus is unavoidable
Occurs when some, but not all, of
Incomplete
the products of conception have
miscarriage
passed
Complete passage of all products
Complete miscarriage
of conception
Silent miscarriage An embryo larger than 5 mm without
(Embryonic demise) cardiac activity
Incomplete abortion associated with
ascending infection of the
Septic miscarriage endometrium, parametrium, adnexa, or
peritoneum
Threatened miscarriage
Bleeding before 20 weeks gestation in the presence of an
embryo with cardiac activity & closed cervix

Slight vaginal bleeding/ spotting

Pain is minimal

Uterus size corresponds to date

Cervical os is closed

Scan shows viable foetus

At least 50% of women with threatened miscarriage will have

continuing pregnancy
Inevitable miscarriage
Bleeding in the presence of a dilated cervix; indicates that
passage of the conceptus is unavoidable

Low back pain & abdominal cramps

Bleeding continues steadily, contractions have begun; if cervix is

dilated -> miscarriage within 24 H

If there is blood clot mixed with other fluids & pain -> undergoing
spontaneous abortion

In complete & spontaneous miscarriage, all fetal & placental

tissue will be expelled from the uterus

Physically fine in a few days -> uterus will shrink to its pre-
pregnancy size
Incomplete miscarriage
Occurs when some, but not all, of the
products of conception have passed

Experience heavy bleeding

Uterus is not able to contract to stop the flow

Haemorrhaging is possible

Dilatation & curettage (D&C) need to be

performed -> tissues are scraped or suctioned
out
Silent miscarriage
Feotus dies in the first 8 weeks of development - No
cardiac activity

No pain, no bleeding

Patient doesnt feel pregnant anymore

e.g breast tenderness is gone, no more morning

sickness

HCG levels have dropped though foetus & placenta

continue to remain in the womb

Treatment: D&C vs conservative

Septic miscarriage
Incomplete abortion associated with ascending infection
of the endometrium, parametric, adnexa, or peritoneum

Signs & symptoms related to infections (i.e fever, chills,

rigours)

Foul smelling PV discharge + prolonged PV bleeding

Severe abdominal pain & cramping, backache, strong

perineal pressure

Signs of shock (hypotension, hypothermia, oliguria)

Tx: broad spectrum antibiotics, D&C, hysterectomy

Miscarriages

Investigations;

Blood: FBC, Blood group & Rh, Infection

screening, Serum B-HCG

Ultrasound
B-HCG
Serum B-HCG is detectable after implantation of
blastocyst (8-9 days after ovulation or day 23 of a
28 days cycle)

It is produced in the placenta by synctiotrophoblast

Double in every 2 days during early pregnancy ->

indicator or normal pregnancy

B-HCG correlates with ultrasound findings

Can be used for initial diagnosis & follow up

management
Ultrasound
If gestational age <8/52, TVS is preferable

Features that need to be routinely included in early

pregnancy scan;

Presence & no of GS

GS diameter

Presence of yolk sac/ embryo

CRL & estimation of gestational age\

Presence of FH & rate

Findings suggestive of ectopic pregnancy

US -> B-HCG

TVS findings Weeks from LMP B-HCG (ml)

Gestational sac 4-5 1000-2000

Yolk sac
5-5.5 1500-2500
(when GS >10mm)
Fetal pole
(When GS 5-6 2000-5000
>18mm)
Cardiac activity
5.5-6.5 4000-17000
(When CRL>5mm)
 US

Yolk sac at 5-6 weeks

CRL at 10/52 this one measures 38mm

Fetal pole visible (2-5mm) by end of 6/52

US diagnostic criteria for
Nonviable Pregnancy
1. CRL >6mm and no heartbeat

2. Mean sac diameter of >25mm & no embryo

3. Absence of embryo with heartbeat >2/52

after a scan that showed a GS without a yolk
sac

4. Absence of embryo with heartbeat >11 days

after a scan that showed a GS with a yolk sac
Suspicious, but not diagnostic
criteria for pregnancy failure
1. CRL <6mm & no heartbeat

2. Mean sac diameter of 16-24 mm & no embryo

3. Absence of embryo with heartbeat 7-13 days after a scan that showed a
GS without a yolk sac

4. Absence of embryo with heartbeat 7-10 days after a scan that showed a
GS with a yolk sac

5. Absence of embryo >6/52 after LMP

6. Empty amnion (amnion seen adjacent to yolk sac, with no visible

embryo)

7. Enlarged yolk sac (>7mm)

8. Small GS in relation to the size of the embryo (<5mm difference between

mean sac diameter and CRL)
 Management
Medical Surgical
Expectant
(Misoprostol) (D&C)
1st line for 7-14
days
High success rate High success rate
(86%) (100%)
More likely to fail in
89% success rate in
silent miscarriage &
silent miscarriage &
anembryonic
an embryonic
pregnancy by day 7
pregnancy
(29%)
more bleeding more pain than
More outpatient
than surgical but medical but less
visits than medical
less pain bleeding
if no complete
expulsion by day 8 of
medical tx, for
surgical (vacuum
aspiration)
Confirming a negative urine -hCG four to six weeks after
1.Bagratee JS, Khullar V, Regan L, Moodley J, Kagoro H. A randomized controlled trial comparing medical and expectant
management of first trimester miscarriage. Hum Reprod. 2004;19(2):266271.
Ectopic Pregnancy
Implantation of the fertilised ovum outside
the normal endometrial cavity (most common
site fallopian tube)

Fertilized ovum implants in tubal mucosa,

submucosa -> trophoblast proliferates, erodes
submucosal blood vessels -> severe bleeding
into tubal lumen

Account for 10-15% of overall maternal

mortality
Risk factors
Current intrauterine device

History of ectopic pregnancy

History of in utero exposure to diethylstilbestrol

History of genital infection, including pelvic inflammatory disease,

chlamydia, or gonorrhea

History of tubal surgery, including tubal ligation or reanastomosis of

the tubes after tubal ligation

In vitro fertilization

Infertility

Smoking
Ectopic pregnancy
Signs & symptoms;

Acute, severe lower abdominal pain, on the side of the ectopic pregnancy

PV bleeding

Occasionally rupture -> bleeding into peritoneal cavity so that the pain becomes less localised ->
shoulder tip pain

Normal/ slightly enlarged uterus

Pelvic pain with manipulation of the cervix

Palpable adnexal mass

Haemodynamically stable/ unstable ?ruptured

Occasionally rupture -> bleeding into peritoneal cavity so that the pain becomes less localised ->
shoulder tip pain

Rupture usually occurs before patient is aware of pregnancy

Sometimes sustained for several weeks with the endometrium developing deciduall changes and no
haemorrhage
Investigations

FBC

GXM

Serum B-HCG

Ultrasound
TVS US findings
Suggestive of Ectopic

Ectopic cardiac activity

Ectopic gestational sac

Ectopic mass and fluid in pouch of Douglas

Fluid in pouch of Douglas

Ectopic mass

No intrauterine gestational sac

Not suggestive

Normal adnexal region

Intrauterine gestational sac

Investigations suggestive of
ectopic

Serum B-HCG increase <53% in 48 hours

No IUGS seen on TAS when serum B-HCG

>6500

No IUGS seen on TVS when serum B-HCG

>1500
Management criteria -
Expectant
No evidence of tubal rupture

Minimal pain or bleeding

Patient reliable for follow-up

Starting -hCG level less than 1,000 mIU per mL

(1,000 IU per L) and falling

Ectopic or adnexal mass less than 3 cm or not

detected

No embryonic heartbeat
Management criteria -
Medical
Stable vital signs and few symptoms

No medical contraindication for methotrexate therapy (e.g., normal liver enzymes,

complete blood count and platelet count)

Unruptured ectopic pregnancy

Absence of embryonic cardiac activity

Ectopic mass of 3.5 cm or less

Starting -hCG levels less than 5,000 mIU per mL (5,000 IU per L)

Dosage: single intramuscular dose of 1 mg per kg, or 50 mg per m2

Follow-up: -hCG on the fourth and seventh posttreatment days, then weekly until
undetectable, which usually takes several weeks

Expected -hCG changes: initial slight increase, then 15 percent decrease between days 4
and 7; if not, repeat dosage or move to surgery

Special consideration: prompt availability of surgery if patient does not respond to

treatment
Management criteria -
Surgical
Unstable vital signs or signs of
hemoperitoneum

Uncertain diagnosis

Advanced ectopic pregnancy (e.g., high -

hCG levels, large mass, cardiac activity)

Patient unreliable for follow-up

Contraindications to observation or
methotrexate
Methotrexate protocol
Protocol Single dose Multiple dose
Methotrexate 50mg/m2 1mg/kg
Folic acid None 0.1mg/kg
FBC, RFT, LFT at FBC, RFT, LFT at
Blood test
baseline baseline
One dose, repeat Up to 4 doses each MTX/FA
Frequency of dose alternate day until B-HCG
1/52 if needed decline by 15%
D0, D1, D3, D5 & D7 until
B-HCG monitoring D0, D4, D7 B-HCG declines 15% from
previous value

When to 2nd dose on D7 if B- Give 2nd, 3rd, 4th dose if

B-HCG value has not drop
administer 2nd HCG did not drop 15% 15% from previous value,
dose bet. D4-D7 max 4 doses

Surveillance B-HCG
Weekly until not Weekly until not
after initial detectable detectable
response
Conclusion
1 out 4 women will experience vaginal bleeding during
pregnancy

Most would continue to progress well during their

pregnancies & give birth to healthy babies

Most common aetiologies in early pregnancy bleeding are

spontaneous miscarriage & ectopic pregnancy

PV bleeding & abdominal pain in women during

reproductive age is ectopic pregnancy until proven
otherwise

Role of expectant vs medical vs surgical management

Early detection of would result in less need for invasive

treatment
References

Lecture note: Dr. Wan Mohd Nizan Wan Mohamad.

Early Pregnancy Bleeding

Deutchman M, Tubay AT, Turok D. First Trimester

Bleeding. Am Fam Physician. 2009 Jun
1;79(11):985-94. PMID: 19514696

Lozeau AM1, Potter B. Diagnosis and

management of ectopic pregnancy. Am Fam
Physician. 2005 Nov 1;72(9):1707-14.