First Trimester Bleeding
Prepared By :
Ass,Professor Dr Fahmi El-Uri
MB,ChB(Hons), MRCOG,FRCOG
First Trimester Bleeding
Causes;
1- Spontaneous abortion / miscarriage
2- Ectopic pregnancy
3-Trophoblastic disease
4- Cervical polyps
5- Friable cervix
6- Trauma
7- Cervical cancer
First Trimester Laboratory Tests
1- Quantitative βhCG
a- Correlate with gestational age& U/S
b- 2 measurements,2days apart-doubling
c- Falling or plateauing ,signal problem
2- Progesterone
a- < 5ng/ml likely predicts poor outcome
b- > 25 ng/ml associated with living IUP
Lab & Ultrasound correlates
Gestational
age by
LMP
TAS
Abdominal
scan
< 5 weeks
None
5-6 weeks
Gestational
sac
7 weeks
5-10mm
embryo
TVS
Serum
βhCG
Vaginal
mIU/ml
scan
Possible
1500
gestational
sac
Gestational 4000-6000
sac,yolk
sac
Same as
> 20,000
TAS with
FH
Indications for First Trimester
Ultrasound
1- Suspect miscarriage or fetal death
2- Vaginal bleeding
3- Gestational age (uncertain dates )
4- Adjunct to procedures ( e.g. CVS )
5- Suspected multiple gestation
6- suspected hydatidiform mole
7- suspected ectopic pregnancy
8- IUD localization
9- Evaluation of maternal pelvic masses
First Trimester Ultrasound
- Best when performed in combination with 
history,physical examination & relevant
laboratory tests
- Often used as primary tool in evaluating 
first trimester complications
- Transvaginal and transabdominal should 
be obtained
Miscarriage
1. A variety of terms have been used to describe
and define early pregnancy loss
2. We have to differentiate between abortion &
miscarriage
3. Abortion means terminate of unwanted
pregnancies by a variety of methods , and illegal
abortion has been the source of considerable
maternal morbidity and mortality
Miscarriage
Definition
The loss of an early pregnancy is the commonest
medical complications of the first trimester of
pregnancy
Many conceptions are lost during the first month
after the last menstrual period and are often
ignored, particularly if they occur around the
time of an expected menstrual
period
Definitions
1- Spontaneous miscarriage
Involuntary loss during the first 20 weeks
2- Threatened miscarriage
Uterine bleeding, closed cervix, no products
of conception passed
3- Incomplete miscarriage
Some , but not all , products have passed
4- Inevitable miscarriage
Cervix dilated , products not passed
Definitions ( continue )
5- Missed miscarriage
Fetus dead, but no tissue passed, cervix
closed.
6- Septic miscarriage
Incomplete miscarriage with ascending
infection .
7- Blighted ovum
Identifiable sac & placental tissue, but no
embryo.
Definitions ( continue )
8- Subchorionic hemorrhage
Blood between chorion and uterine wall.
9- Decidua
Endometrium of pregnancy that is frequently
passed as part of a miscarriage.
When the decidua is passed intact it is
called a decidual cast, which often
signifies an ectopic pregnancy .
Pathophysiology of miscarriage
1- Major genetic anomaly
At least one half of all spontaneous miscarriages are the result of a
major genetic anomaly , trisomy,triploidy or monosomy
2- Internal environmental factors
Uterine : anomalies, leiomyomata, incompetent cervix
Maternal diethylstillbestrol ( DES ) exposure
Luteal phase defect
Immunologic factors
3- External environmental factors
Tobacco, alcohol, cocaine
Irradiation
Infection
Occupational chemical exposure
4- Advanced maternal age
Clinical course of miscarriage
1- Missed menses, pregnancy symptoms
2- Positive βhCG
3- Vaginal bleeding
4- βhCG falls or plateaus
5- Lower abdominal cramping, backache
6- Products of conception passed
Physical Examination
1- Abdominal exam
Pain location , rebound, distension
2- Speculum exam
To assess cx dilatation
To rule out non-uterine causes of bleeding
3- Bimanual exam
To assess uterine size, adnexal masses
Fetal Heart tones
Listen after 9-10 weeks with Doppler
Sensitivity enhanced by elevating uterus
during bimanual exam
Management of Miscarriage
1- 50% loss when bleeding present
2- Presence of FHTs reassuring
3- Majority do not require medical or surgical
intervention
4- Identify patients at risk for bleeding,
infection
5- Address contraceptive needs
Ectopic Pregnancy
Pregnancy outside the uterus , usually in the
Fallopian tube .
Occurs in >1:100 pregnancies .
Second most common cause of M. Mortality.
Early diagnosis critical !
Definition
It is a gestation that implants outside the
endometrial cavity.
>95% of ectopic pregnancies implant in
various anatomic segment of ‘ fallopian
tube including ;
1% in the interstitial
5% in the isthmic
85% in the ampullary portion
9% in the infundibular & fimbrial portion.
Other sites of ectopic
Other less sites of ectopic pregnancies are;
The ovary , cervix , the peritoneal cavity .
Introduction
The Diagnosis & management of ectopic
pregnancy has undergone a revolution a century
after Lawson Tait successfully performed a
laparotomy to ligate ‘broad ligament& remove a
ruptured tube in 1883(Tait 1884).
Improved technology allows to diagnose ectopic
pregnancy before it ruptures thus making less
invasive treatment possible,
Resulting in reduced Maternal Mortality and
Morbidity .
Incidence
1- In USA deaths due to ectopic pregnancy was
9% of all maternal deaths in 1992and its
incidence has apparently increased fourfold
(from 4.5 to 20/1000pregnancies between 1970
& 1992(Centers of Disease Control 1995 )
2- In UK it represent 4.2% of Maternal death in
1991-1993, its incidence apparently doubling
between 1973-75 and1991-93 (from 4.9 to 9.6
per 1000pregnancies) Department of
Health1994.
Risk factors for Ectopic
1- History of previous ectopic pregnancy
2-Prior tubal surgery
3-Prior tubal infection
4-Progestin-only contraception
5-Contraceptive IUD
6- In utero Diethylstilbestrol(DES) exposure
Many occur in women with no risk
factors!
Clinical Presentation
It can vary from vaginal spotting of old blood
to vasomotor shock with
hematoperitoneum.
The classic triad of ;
a- Delayed menses ,
B- Irregular vaginal bleeding ,
C- Abdominal pain ,
The above is not commonly encountered (
speroff el al 1994 )
General Examination
A- Pulse rate & blood pressure , because in
vascular instability BP is low ,fainting,
dizziness and rapid Heart rate .
B- Shoulder pain , occurs due to blood
irritating the diaphragm as a result of
rupture ectopic causing intra-abdominal
bleeding .
Gynaecological Examination
Speculum or Bimanual examination must be
performed in Hospital because it may lead
to rupture of the tube .
Diagnosis of Ectopic
1- Failure of βhCG to double in 48 hours
2- Low serum progesterone
3- Ultrasound ( transvaginal )
a- IUP rules out ectopic
b- No gestational sac+βhCG>1500, highly
suggestive
c- Gestational sac/embryo outside of uterus confirms
ectopic
d- Pitfalls: pseudogestational sac,ruptured corpus luteum
4- Laparoscopy – gold standard
Extrauterine signs of Ectopic
Finding
Risk of Ectopic
No mass or free fluid
20%
Any free fluid
71%
Echogenic mass
85%
Moderate to large amount of fluid
95%
Echogenic mass with fluid
100%
Culdocentesis
The test is used to exclude hemoperitoneum
which is associated with ruptured ectopic
pregnancy, therefore it is not useful in
detecting an early ectopic pregnancy .
18 or 20 gauge needle passed through the
posterior fornix to aspirate for fluid .
Bloody fluid with hematocrit >15%represents
active intraperitoneal bleeding .
TVS has replaced nowadays culdocentesis.
hCG & Vaginal ultrasound
hCG can be detected in the urine as early as
14days(Post conception), by sensitive
enzyme-linked immunosorbent assays
(detection limits 25-40IU/L, and sensitivity
98%-100%) .
It can be detected in the serum 5-9 days
post-conception by immuno-radioactive
assays.
hCG ( Continue )
Between 2-4 weeks after ovulation serum hCG
levels double approximately every
2days(48hours) in normal pregnancy ,and a
lesser increase ( <66% over 48 hours) is
associated with ectopic pregnancy and
spontaneous abortion .
However,15%of normal pregnancy will have an
abnormal doubling time and 13% of ectopic
pregnancy will have a normal doubling time .
CONTINUE
Therefore in order to increase the sensitivity of
Quantitative hCG ,a discriminatory zone DZ has
been described whereby a titre of 10001500IU/L will be associated with the presence of
an INTRA-UTERINE sac on transvaginal Scan
and 4500-6500 IU/L for trans-abdominal Scan.
In multiple pregnancy the Discriminatory zone
would be a little higher, requiring an extra 2-3
days for a sac to become visible .
CONTINUE
1- The demonstration of a viable IUP does not
exclude ‘ possibility of Heterotopic Pregnancy
frequency 1 in 30,000 event .
2-TVS( Transvaginal scan), has resulted in the
diagnosis of normal & abnormal pregnancy
approximately 1 week earlier than using Trans
abdominal scan TAS.
In Ectopic there are an empty uterus,pseudo-sac,
a tubal ring ( doughnut or bagel sign) with fluid in
the pouch of douglas .
Management Of Ectopic
Pregnancy
1- Expectant Management
2- Medical Management
3- Surgical Management
Expectant Management
Criteria include :
a- Minimal pain or bleeding
b- Reliable follow-up
c- No evidence of tubal rupture
d- βhCG < 1000 and falling
e- Adnexal mass < 3cm, or not detected
f- No embryonic heart beat
Medical Management:
Methotrexate
1- Safe, effective ,less costly than surgery
2- Equal or better fertility preservation
3- Criteria for use :
Stable vital signs , few symptoms
No contraindication to drug
Unruptured ectopic
Absence of embryonic heart activity
Ectopic mass ≤ 4cm
βhCG levels < 5000 mIU/ml
Methotrexate Dosing
1-Single dose IM regimen with 1mg/kg or 50mg/m²
Obtain serum βhCG on 4th & 7th day posttreatment ( fall 15% should be expected )&
continue follow up until level reaches 5mIU/ml in
3-4 weeks
2-Serum progesterone, a drop to 1.5mg/ml
means successful treatment & usually occurs by
about 2-3 weeks
3-Surgical consultation if we need more than
one dose
Surgical Management
Mainstay of treatment
Conservative – conservation of tube Extirpation removal of tube Criteria for selecting surgery Unstable vital signs or hemoperitoneum Uncertain diagnosis Advanced ectopic pregnancy Unreliable follow-up Contraindication to expectant or methotrexate
management
-
Gestational Trophoblastic Disease
GTD
Definition
It is a term commonly applied to a spectrum
of inter-related diseases originating from
the placental trophoblast
Trophoblastic Disease
Gestational trophoblastic disease , has three basic
configurations:
A- Complete hydatidiform mole
B- Partial mole
C- Mole recurrence → metastatic
choriocarcinoma.
GTD is an occasional cause of first trimester
bleeding & should be considered in the
differential diagnosis until proven otherwise .
GTD ( Continue )
Complete hydatidiform mole
It consists of placental proliferation in the
absence of a fetus. The placental villi are
swollen & often resemble bunches of
grapes.
Most complete moles have a 46XX
chromosomal composition , all derived
from paternal sources
Contnue
Partial Mole ;
This refers to molar placenta occuring
together with a fetus , which is usually
non-viable
Genetic testing usually reveals triploidy
( 69 XXY )
Partial mole is less common than a
complete mole & carries a lower risk of
recurrence
Recurrence 0f trophoblastic
disease
About 20% 0f women with a complete mole
will experience recurrence in the form of
mole that invades the myometrium or
becomes aggressively metastatic
(metastatic choriocarcinoma)
Epidemiology
GTD occurs in the USA at a rate of in one in 1000
to 1500 pregnancies, in Asian women in the USA
( 1 in 800 )
Higher incidence in Asia ( Taiwan 1in every 125 to
200 pregnancies )
Two factors predispose to trophoblastic disease :
A- Pregnancy at the extremes of reproductive life(
specially women over 45) B- Previous molar
disease
Clinical Manifestations
1-Vaginal bleeding 1st/early 2nd trimester
Which is often dark in color
Grape-like vesicles are passed in cases that progress in
the 2nd trimester
2-Higher than expected βhCG levels
3-Uterine size>dates without heart tone
4-Hyperemesis
5-Early pregnancy-induced hypertension
6-Thyrotoxicosis
7-Ovarian enlargement( theca-lutein cysts ) due to high
hCG levels
Diagnosis
A high index of suspicion is required for
early diagnosis
Ultrasound is the gold standard for
diagnosis and will show multiple vesicular
spaces within the uterus ,with an absence
of a fetus
Enlarged cystic ovaries are common
Treatment of GTD
1- Prompt evacuation of the uterus is the
primary treatment
2- Serial βhCG monitoring for 6-12 months
with contraception
3-Recurrence occurs in 20% with complete
mole invades myometrium or become
metastases, so treat with chemotherapy (
methotrexate )
Most can conceive , carry normal pregnancy
Treatment of GTD
Treatment has 3 components ;
1- Evacuation of the uterus
The standard therapy for hydatidiform mole is
suction evacuation followed by sharp curettage
of ‘ uterine cavity ,regardless of ‘ duration of
pregnancy.
IV oxytocin is given simultaneously to help
stimulate uterine contraction & ↓ blood loss. This
technique is associated with low incidence of
uterine perforation & trophoblastic embolization
Treatment ( Continue )
2- Monitoring levels of the βhCG
Following ‘ evacuation of a hydatidiform
mole, ‘ patient must be monitored with
weekly serum assays of βhCG , the level
should decline to 1-5 mIU/ml usually within
12-16 weeks.
Treatment ( Continue )
3- Chemotherapy
Prophylactic chemotherapy is not indicated in
patients with molar pregnancy because 90% of
these individuals have spontaneous remissions .
If the βhCG levels plateau or rise at any time
Chemotherapy should be initiated ;
Methotrexate 1mg/Kg/day on days 1,3,5,7 followed
24hr later by 0.1mg/kg/day of folinic acid on
days 2,4,6,8
Prognosis for Future Pregnancies
There is 1-2% recurrence rate, most patients
can conceive & carry a normal pregnancy
after trophoblastic disease
Chemotherapeutic agents used to treat
recurrences have not been shown to affect
future pregnancies
Clinician should help their patients to
overcome the psychological impact of this
bizarre condition
Summary of first trimester bleeding
Miscarriage can cause significant physical &
psychological morbidity
Ectopic pregnancy is a potential cause of
maternal mortality
Serum hormone testing & ultrasonography
important in diagnosis
Many patients can be managed
nonsurgically