Bleeding in Early Pregnancy, Abortion

Causes :
1. Abortion.
2. Ectopic pregnancy.
3. Vesicular mole.
Local gynaecological lesions e.g. cervical ectopy, polyp, dysplasia, carcinoma and
rupture of varicose vein.
4.
ABORTION
Definition:
Termination of pregnancy before viability of the foetus i.e. before 28 weeks (in
Britain) and before 20
weeks or if the foetal weight is less than 500 gm ( in USA and Australia).
When the abortion occurs spontaneously, the term " miscarriage" is often used.
Incidence: about 15% of all pregnancies.
Mechanism of Abortion:
a. Up to 8 weeks:The gestational sac tends to be expelled complete and the
decidua is shed thereafter.
b. From 8-12 weeks: The decidua capsularis ruptures and the embryo is
expelled either entire or after rupture of the amnion.
c. After 12 weeks: The placenta is completely formed and the process of
abortion is like a miniature labour. It is more common for the foetus to be
expelled but for the placenta to be retained due to firmer attachment to the
uterine wall.
Clinical Varieties
Differential Diagnosis of Different Types of Abortion
(A) Threatened Abortion:
Clinical picture:
1. Symptoms and signs of pregnancy coincide with its duration.
Vaginal bleeding slight or mild, bright red in colour originating from the
choriodecidual interface.
2.
3. Pain is absent or slight.
4. Cervix is closed.
5. Pregnancy test is positive.
6. Ultrasonography shows a living foetus.
Prognosis:
If the blood loss is less than a normal menstrual flow and is not accompanied by
pain of uterine
contraction there is a reasonable chance for continuing pregnancy. This occurs in
50% of cases while
other half will proceed to inevitable or missed abortion.
Treatment:
1. Rest in bed until one week after stoppage of bleeding.
No intercourse as it may disturb pregnancy by the mechanical effect and the effect
of semen prostaglandins on the uterus.
2.
3. Sedatives: if the patient is anxious.
4. Treatment of controversy:
l
(B) Inevitable Abortion:
Clinical picture:
1. Symptoms and signs of pregnancy coincide with its duration.
2. Vaginal bleeding is excessive and may accompanied with clots.
3. Pain is colicky felt in the suprapubic region radiating to the back.
The internal os of the cervix is dilated and products of conception may be felt
through it.
4.
Rupture of membranes between 12-28 weeks is a sign of the inevitability of
abortion.
5.
Cervical abortion: is a variety of inevitable abortion in which the products of
conception has been
separated from the uterine cavity but retained in the cervical canal causing its
distension.
Clinical picture:
- The patient complains of considerable bleeding and severe lower abdominal pain
referred to the back.
- On examination, the products of conception is felt through the dilated cervix.
Treatment:
Under anaesthesia, the cervix is dilated, contents is removed and cavity is curetted
to remove the
decidua.
(C) Incomplete Abortion:
Retention of a part of the products of conception inside the uterus. It may be the
whole or part of the
placenta which is retained.
Clinical picture:
1. The patient usually noticed the passage of a part of the conception products.
2. Bleeding is continuous.
On examination, the uterus is less than the period of amenorrhoea but still large in
size. The cervix is opened and retained contents may be felt through it.
3.
4. Ultrasonography: shows the retained contents.
Treatment:
As inevitable abortion.
(D) Complete Abortion:
All products of conception have been expelled from the uterus.
Clinical picture:
1. The bleeding is slight and gradually diminishes.
2. The pain ceases.
3. The cervix is closed.
4. The uterus is slightly larger than normal.
5. Ultrasound : shows empty cavity.
(E) Missed Abortion:
Retention of dead products of conception for 4 weeks or more.
Carneous mole is a special variety of missed abortion in which the dead ovum in
early pregnancy is
surrounded by clotted blood.
Clinical picture:
(A) Symptoms:
1. Symptoms of threatened abortion may or may not be developed.
Regression of pregnancy symptoms as nausea, vomiting and breast
symptoms.
2.
3. The abdomen does not increase and may even decrease in size.
4. The foetal movements are not felt or ceases if previously present.
6. A dark brown vaginal discharge may occur ( prune juice discharge).
(B) Signs:
1. The uterus fails to grow or even decreases in size and becomes firmer.
2. The cervix is closed.
3. The foetal heart sounds cannot be heard by the doptone.
Investigations:
Pregnancy test becomes negative within two weeks from the ovum death, but it
may remain positive for a longer period due to persistent living chorionic villi.
1.
Ultrasound shows either a collapsed gestational sac, absent foetal heart movement
or foetal movement.
2.
Complications:
Disseminated intravascular coagulation (DIC) may occur if the dead conceptus is
retained for more than 4 weeks.
1.
2. Superadded infection.
Treatment:
The dead conceptus is expelled spontaneously in the majority of cases. Evacuation
of the uterus is
indicated in the following conditions:
1. spontaneous expulsion does not occur within four weeks,
2. there is bleeding,
3. infection or DIC developed or ,
patient is anxious. Although some gynaecologists advise evacuation of the uterus
once sure diagnosis of missed abortion is made.
4.
1.SEPTIC ABORTION
It is any type of abortion, usually criminal abortion, complicated by infection.
Microbiology:
E.Coli,bacteroids, anaerobic streptococci, clostridia, streptococci and staphylococci
are among the
most causative organisms.
Clinical picture:
General examination:
- Pyrexia and tachycardia.
- Rigors suggest bacteraemia.
- A subnormal temperature with tachycardia is ominous and mostly seen
with gas forming organisms.
- Malaise, sweating , headache, and joint pain.
- Jaundice and /or haematuria is an ominous sign, indicating haemolysis due
to chemicals used in criminal abortion or haemolytic infection as clostridium
welchii.
Abdominal examination:
- Suprapubic pain and tenderness.
- Abdominal rigidity and distension indicates peritonitis.
Local examination:
- Offensive vaginal discharge. Minimal inoffensive vaginal discharge is
often associated with severe cases.
- Uterus is tender.
- Products of conception may be felt.
- Local trauma may be detected.
- Fullness and tenderness of Douglas pouch indicates pelvic abscess which
will be associated with diarrhoea.
Complications:
Endotoxic ( septic ) shock may develop with its serious sequels as acute renal
failure and DIC.
Treatment:
Antibiotic therapy: Ampicillin or cephalosporin ( as a broad
spectrum) +gentamycin (for gram -ve organisms) + metronidazole
(for anaerobic infection)are given by intravenous route while awaiting
the results of the bacteriological culture. Another regimen to cover the
different causative organism is clindamycin + gentamycin.
5.
.
(G) Therapeutic Abortion:
Abortion induced for a medical indication.
(H) Criminal Abortion:
Illegal abortion induced for a non-medical indication.
(I) Recurrent (Habitual) Abortion:
Definition:
Three (two by some authors) or more consecutive abortions.
(B) Surgical treatment:
(1) Cervical cerclage:
It means encircling the cervix at or as near as possible to
the internal os by a non-absorbable suture.
l
The best time for the operation is about 12-14 weeks, so
that the placenta is formed and there is no possibility of
abortion due to congenital anomalies of the early
embryo.
l
The suture is removed at 38 weeks or if labour started at
any time.
l
l Ultrasonography is done before operation to:
- confirm foetal viability,
- exclude congenital anomalies,
- measure the internal os.
POST-ABORTIVE BLEEDING
Definition:
Persistent or recurrent bleeding within the first 4 weeks after abortion.
Causes:
1. Perforation of the uterus or cervical laceration.
2. Retained products of conception.
3. Infection leading to sloughing of a septic debris.
4. Submucous myoma or a fibroid polyp.
5. Choriocarcinoma.
6. Local gynaecological lesion as cervical polyp or carcinoma.
7. Haemorrhagic blood disease.
8. Dysfunctional uterine bleeding.
18.11.02
Ectopic Pregnancy
Definition
It is implantation of the fertilised ovum outside the normal uterine cavity.
l Common site (95%) : the tubes.
Rare sites (5%) : The ovaries, a rudimentary horn of a bicornuate uterus , broad
ligaments, peritoneum and cervix.
l
TUBAL PREGNANCY
Incidence: about 1:250.
Aetiology
The following risk factors have been implicated:
(A) Mechanical factors:
May prevent or retard the passage of the fertilised ovum into the uterine cavity.
These
may result from:
1- Previous inflammatory disease:
It is the commonest risk factor. Ectopic pregnancy may occur
due to:
- Destruction of tubal ciliated epithelium resulting
in reduction or loss of the ciliary current.
- Intratubal adhesions resulting in partial tubal
obstruction.
- Peritubal adhesions resulting in restricted tubal
motility.
2- Previous pelvic surgery:
Particularly reconstructive tubal surgery.
3- Developmental abnormalities:
as diverticulae, accessory ostia and tubal hypoplasia.
4- Adjacent tumours:
especially in the broad ligament resulting in distortion,
stretching or partial obstruction of the tube.
5- Previous ectopic pregnancy:
where conservative treatment was carried out.
6- Intrauterine contraceptive device:
due to its effect on tubal motility or increased incidence of PID.
(B) Premature implantation:
Premature implantation of the fertilised ovum in the tube may occur due to :
1. Premature shedding of the zona pellucida: from the fertilised ovum.
Transperitoneal migration of the fertilised ovum to the contralateral tube: this
long journey leads to advanced development of the ovum that it becomes ready for
implantation when it reaches the tube. This was proved by presence of the corpus
luteum in the contralateral ovary in 50% of ectopic pregnancy.
2.
3. Presence of ectopic endometrium in the tube.
Pathogenesis
- The trophoblast develops in the fertilised ovum and invades deeply into the
tubal wall.
- Following implantation, the trophoblast produces hCG which maintains the
corpus luteum.
- The corpus luteum produces oestrogen and progesterone which change the
secretory endometrium into decidua. The uterus enlarges up to 8 weeks size
and becomes soft.
- The tubal pregnancy does not usually proceed beyond 8-10 weeks due to :
l lack of decidual reaction in the tube,
l the thin wall of the tube,
l the inadequacy of tubal lumen,
bleeding in the site of implantation as trophoblast
invades.
l
- Separation of the gestational sac from the tubal
wall leads to its degeneration, and fall of hCG
level, regression of the corpus luteum and
subsequent drop in the oestrogen and progesterone
level.
.
Fate of tubal pregnancy:
(I) Tubal mole:
The gestational sac is surrounded by a blood clot and retained in the tube.
(II) Tubal abortion:
- This occurs more if ovum had been implanted in the ampullary portion of
the tube.
- Separation of the gestational sac is followed by its expulsion into the
peritoneal cavity through the tubal ostium.
- Rarely, reimplantation of the conceptus occurs in another abdominal
structure leads to secondary abdominal pregnancy.
- If expulsion was complete the bleeding usually ceases but it may continue
due to incomplete separation or bleeding from the implantation site.
(III) Tubal rupture:
- More common if implantation occurs in the narrower portion of the tube
which is the isthmus.
- Rupture may occur in the anti-mesenteric border of the tube. Usually
profuse bleeding occurs ® intraperitoneal haemorrhage.
- If rupture occurs in the mesentric border of the tube a broad ligament
haematoma will occur.
Clinical Picture
General symptoms:
1- Short period of amenorrhoea:
usually does not exceed 8-10 weeks. This may be lacking if the ectopic pregnancy
is disturbed before
the next menstruation. This may occur particularly with ectopic pregnancy in the
interstitial portion of
the tube.
2- Pain:
is present in almost every case and precedes vaginal bleeding. It may be:
a. Aching due to tubal distension.
b. Colicky in tubal abortion.
c. Stabbing in tubal rupture.
d. Shoulder pain if blood accumulates under the diaphragm.
e. Bladder and rectal irritability in pelvic haematocele.
3- Vaginal bleeding:
Due to shedding of the decidua. It is usually slight and follows the pain.
General signs:
General examination:
Breast signs of pregnancy.
Abdominal examination:
Lower abdominal tenderness and rigidity especially on one side may be present.
Vaginal examination:
- Bluish vagina and bluish soft cervix.
- Uterus is slightly enlarged and soft.
- Marked pain in one iliac fossa on moving the cervix from side to side.
- Ill defined tender mass may be detected in one adnexa in which arterial
pulsation may be felt.
The other manifestations depend upon the clinical variety of the ectopic pregnancy:
(A) Undisturbed Tubal Pregnancy
It is the same general symptoms and signs mentioned before. The pain is aching in
nature and there is
no vaginal bleeding.
(B) Tubal Abortion
The more common so it is called the classical picture of ectopic pregnancy.
Symptoms:
1. The general symptoms and signs are present.
2. Fainting attacks due to pain and intraperitoneal haemorrhage.
3. Nausea and vomiting due to peritoneal irritation.
Signs:
General examination:
1. Anaemia of varying degree depending upon the blood loss.
2. Pulse is usually rapid.
Temperature slightly higher (up to 38oC ) due to absorption of blood from the
peritoneal cavity.
3.4. Blood pressure: falls in proportion to the amount of internal haemorrhage.
Abdominal examination:
Cullen’s sign: a periumbilical bluish discoloration may be present due to
absorption of
the blood in the peritoneal cavity by lymphatics. It is a late sign.
Local examination:
Boggy swelling in the cul-de-sac if pelvic haematocele is present.
(C) Tubal Rupture
The most dramatic although not the most common.
Symptoms:
Short period of amenorrhoea (6-8 weeks) or even there is no missed period.
Signs
General examination:
- Rapidly developed shock, with pallor, sweating, air hunger, rapid thready
pulse and hypotension.
- Shoulder tip pain and hiccoughs due to irritation of the phrenic nerve of the
diaphragm by accumulated blood when the patient lying down
Abdominal examination:
- The abdomen is distended, rigid with generalised tenderness.
- Shifting dullness and periumbilical bluish discolouration due to
intraperitoneal haemorrhage.
Local examination:
The same as in general signs of ectopic, although it is undesirable as it may induce
more disruption
and bleeding.
.
Investigations of Ectopic Pregnancy
(1) Serum b -hCG:
Urine pregnancy tests are positive in only 50-60% of ectopic. Detection of b -hCG
in the
serum by ELISA or radioimmunoassay are more sensitive and can detect very
early
pregnancy about 10 days after fertilisation i.e. before the missed period.
If the test is negative, normal and abnormal pregnancy including ectopic are
excluded.
l
l If the test is positive, ultrasonography is indicated.
Doubling time:
In normal pregnancy, the b -hCG level is doubling every 48 hours during the first
42 days of gestation.
l
Ectopic pregnancy usually shows less than 66% increase in b -hCG level within 48
hours.
l
Unfortunately, this is not specific to ectopic pregnancy. In 15% of normal
pregnancies as well as in abortions there is also slow doubling time.
l
N.B. Alpha-hCG subunit level is higher in ectopic pregnancy than normal
gestations.
(2) Ultrasonography:
In general, a positive b -hCG test with empty uterus by sonar indicates ectopic
pregnancy. This is true if the ß-hCG is at or above the threshold level in which an
intrauterine gestational sac can be detected. This is called discriminatory zone.
Discriminatory hCG zones:
Diagnosis of ectopic pregnancy is made if there is:
An empty uterine cavity by abdominal sonography with b -hCG value
above 6000 mIU/ml.
1.
An empty uterine cavity by vaginal sonography with b -hCG value
above 2000 mIU/ml.
2.
(3) Progesterone:
Serum progesterone level is lower in ectopic than normal pregnancy and usually
less than
15ng/ml.
(4) Culdocentesis:
If non-clotting blood is aspirated from the Douglas pouch through a wide pored
needle,
intraperitoneal haemorrhage is diagnosed. But if not, ectopic pregnancy cannot be
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excluded.
(5) Curettage:
If microscopic examination of the products of curettage reveals decidua and
chorionic villi, the condition is abortion of intrauterine pregnancy.
l
If it reveals decidua only or Arias Stella reaction in the endometrium as well
(cellular atypism, mitotic activity and glandular proliferation), ectopic pregnancy is
diagnosed. The drawback is that in complete abortion also decidua only is curetted.
l
(6) Laparoscopy:
A good diagnostic aid particularly in disturbed ectopic.
(7) Complete blood picture:
- Haemoglobin and haematocrit ---- to assess anaemia.
- Leucocytic count ---- exclude infections as appendicitis and salpingitis.
Uncommon Sites of Ectopic Pregnancy
(I) Cornual angular pregnancy:
- It is implantation in the interstitial portion of the tube.
- It is uncommon but dangerous because when rupture occurs bleeding is severe
and
disruption is extensive that it needs hysterectomy.
- In some cases, the pregnancy is expelled into the uterus and rupture does not
occur.
(II) Pregnancy in a rudimentary horn:
- Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus.
- As such a horn is capable of some hypertrophy and distension, rupture usually
does not
occur before 16-20 weeks.
- Treatment: Excision of the horn. During operation, pregnancy in a rudimentary
horn
can be differentiated from interstitial cornual tubal pregnancy by finding the
attachment
of the round ligament lateral to the first and medial to the later.
(III) Cervical pregnancy:
- Implantation in the substance of the cervix below the level of uterine vessels.
- May cause severe vaginal bleeding.
Treatment :
1. Evacuation and cervical packing with haemostatic agent as fibrin glue and
gauze.
2. If bleeding continues or extensive rupture occurs hysterectomy is needed.
(IV) Ovarian pregnancy:
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Aetiology:
1. Pelvic adhesions.
2. Favourable ovarian surface for implantation as in ovarian endometriosis.
Pathogenesis:
- Fertilisation of the ovum inside the ovary or ,
- implantation of the fertilised ovum in the ovary.
Spiegelberg criteria for diagnosis of ovarian pregnancy:
1. The gestational sac is located in the region of the ovary,
2. the ectopic pregnancy is attached to the uterus by the ovarian ligament,
3. ovarian tissue in the wall of the gestational sac is proved histollogically,
4. the tube on the involved side is intact.
Treatment:
Laparotomy and inoculation of the ectopic pregnancy and reconstruction of the
ovary if
possible. Otherwise, removal of the affected ovary is indicated.
(V) Abdominal (peritoneal) pregnancy:
Types:
1. Primary: implantation occurs in the peritoneal cavity from the start.
Secondary: usually after tubal rupture or abortion. Intraligamentous pregnancy: is
a type of abdominal but extraperitoneal pregnancy. It develops between the
anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy
in the mesosalpingeal border or lateral rupture of intramural (in the myometrium)
pregnancy.
2.
Diagnosis:
(A) History:
of amenorrhoea followed by an attack of lower abdominal pain and slight vaginal
bleeding which
subsided spontaneously.
(B) Abdominal examination:
- Unusual transverse or oblique lie.
- Foetal parts are felt very superficial with no uterine muscle wall around.
(C) Vaginal examination:
- The uterus is soft, about 8 weeks and separate from the foetus.
- No presenting part in the pelvis.
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(D) Special investigations:
Plain X-ray : shows abnormal lie. In lateral view, the foetus overshadows the
maternal spines .
1.
2. Ultrasound : shows no uterine wall around the foetus.
Magnetic resonance imaging (MRI): has a particular importance in preoperative
detection of placental anatomic relationships.
3.
Differential Diagnosis:
Rupture uterus.
Treatment:
The condition should be terminated surgically through laparotomy once diagnosed
as the foetus is
malformed in the majority of cases. In addition, there is risk of massive internal
haemorrhage if
separation of the placenta occurs.
At least 2000 ml of cross-matched blood should be on hand before proceeding to
laparatomy. The
foetus is removed and if the placenta is attached to an excisable structure as
omentum, it is removed
with it. If the placenta is attached to an important structure leave it for autolysis
which may extend to
few months or years. Any attempt to separate placenta will evoke uncontrollable
bleeding. In this
case, methotrexate 12.5 mg IM daily for 5 days will destroy trophoblastic tissue
and accelerates the
involution of the placenta.
In rare cases, the foetus may reach full term where spurious (false) labour occurs
and the foetus dies if
not recognised.
18.11.02
Ectopic Pregnancy - D. El-Mowafi

Hydatidiform (Vesicular) Mole

It is a benign neoplasm of the chorionic villi.
Incidence:
1:2000 pregnancies in United States and Europe, but 10 times more in Asia. The
incidence is higher
toward the beginning and more toward the end of the childbearing period. It is 10
times more in
women over 45 years old.
Pathology:
The uterus is distended by thin walled, translucent, grape-like vesicles of different
sizes. These are degenerated chorionic villi filled with fluid.
1.
There is no vasculature in the chorionic villi leads to early death and absorption of
the embryo.
2.
There is trophoblastic proliferation, with mitotic activity affecting both syncytial
and cytotrophoblastic layers. This causes excessive secretion of hCG,chorionic
thyrotrophin and progesterone. On the other hand, oestrogen production is low due
to absence of the foetal supply of precursors.
3.
High hCG causes multiple theca lutein cysts in the ovaries in about 50% of cases.
It also results in exaggeration of the normal early pregnancy symptoms and signs.
4.
Types:
(i) Complete mole:
- The whole conceptus is transformed into a mass of vesicles.
- No embryo is present.
- It is the result of fertilisation of anucleated ovum ( has no chromosomes)
with a sperm which will duplicate giving rise to 46 chromosomes of paternal
origin only.
(ii) Partial mole:
- A part of trophoblastic tissue only shows molar changes.
- There is a foetus or at least an amniotic sac.
- It is the result of fertilisation of an ovum by 2 sperms so the chromosomal
number is 69 chromosomes.
(A) Symptoms:
1. Amenorrhoea: usually of short period (2-3 months).
2. Exaggerated symptoms of pregnancy especially vomiting.
Vaginal bleeding which is usually dark brown and may be associated
with passage of vesicles.
3.
4. Abdominal pain : may be ,
- dull-aching due to rapid distension of the uterus,
- colicky due to starting expulsion,
- sudden and severe due to perforating mole.
(B) Signs:
General examination:
1. Pre-eclampsia develops in 20% of cases, usually before 20 weeks’ gestation.
Hyperthyroidism develops in 10% of cases manifested by enlarged thyroid gland,
tachycardia and elevated plasma thyroxin level.
2.
3. Breast signs of pregnancy.
Abdominal examination:
The uterus is larger than the period of amenorrhoea in 50% of cases, corresponds
to it in 25% and smaller in 25% with inactive or dead mole.
1.
2. The uterus is doughy in consistency
3. Foetal parts and heart sound cannot be detected except in partial mole.
Local examination :
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1. Passage of vesicles (sure sign).
2. Bilateral ovarian cysts (5-20 cm) in 50% of cases.
(C) Investigations:
1. Urine pregnancy test: is positive in high dilution. 1/200 is highly
suggestive, 1/500 is surely diagnostic. In normal pregnancy it is positive in
dilutions up to 1/100.
2. Serum b -hCG level: is highly elevated ( > 100.000 mIU/m1).
3. Ultrasonography reveals:
The characteristic intrauterine " snow storm" appearance,
no identifiable foetus,
bilateral ovarian cysts may be detected.
4. X-ray : shows no foetal skeleton.
Complications:
1. Haemorrhage.
2. Infection due to absence of the amniotic sac.
3. Perforation of the uterus.
4. Pregnancy induced hypertension
5. Hyperthyroidism.
6. Subsequent development of choriocarcinoma
Treatment:
- As soon as the diagnosis of vesicular mole is established the uterus should
be evacuated.
.
Follow up :
- As choriocarcinoma may complicate the vesicular mole after its
evacuation, detection of serum ß-hCG by radioimmunoassay for 2 years is
essential.
- Detection is done every;
2 weeks after evacuation to ensure regression of b -hCG
level then,
l
l every month for one year then,
l every 3 months for another year.
- Persistent high level indicates remnants of molar tissues which necessitate
chemotherapy ( methotrexate) with or without curettage. Hysterectomy is
indicated if women had enough children.
- Rising hCG, level after disappearance means developing of
choriocarcinoma or a new pregnancy. So combined contraceptive pills
should be used for prevention of pregnancy which can be misleading .
- It is expected that urine pregnancy test is negative 4 weeks after evacuation
and serum b -hCG is undetectable 4 months after evacuation.
- Early features suggesting residual molar tissue include;
l recurrent or persistent vaginal bleeding,
l amenorrhoea,
l

Bleeding in Late Pregnancy (Antepartum

Haemorrhage)
Definition
It is bleeding from the genital tract after the 28th week of pregnancy and before the
end of the second
stage of labour.
Classification
(A ) Placental site bleeding : (62%)
Placenta praevia (22%) : Bleeding from separation of a
placenta wholly or partially implanted in the lower uterine
segment.
Abruptio placentae (30%) : Premature separation of a normally
implanted placenta.
Marginal separation(10%)ý: Bleeding from the edge of a
normally implanted placenta.
(B) Non-placental site bleeding : (28%)
1-Vasa praevia : Bleeding from ruptured foetal vessels.
2-Rupture uterus. 3-Bloody show.
4-Cervical ectopy , polyp or cancer.
5- Vaginal varicosity.
PLACENTA PRAEVIA
Definition
The placenta is partialy or totally attached to the lower uterine segment.
Incidence:
0.5% of pregnancies . It is more common in multiparas and in twin pregnancy due
to the large size of
the placenta.
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Aetiology
Not well known but may be due to:
Low implantation of the blastocyst.
Development of the chorionic villi in the decidua capsularis
leading to attachement to the lower uterine segment.
Large placenta as in twin pregnancy.
Degrees (types)
(1) First degree ( Type I = P.P. lateralis = low-lying placenta):-
The lower edge of the placenta reaches the lower uterine segment but not the
internal os.
(2) Second degree ( Type II= P.P. marginalis):
The lower edge of the placenta reaches the margin of the internal os but does not
cover it.
(3) Third - degree ( Type III= P.P. incomplete centralis):
The placenta covers the internal os when it is closed or partially dilated but not
when it is fully dilated.
(4) Fourth - degree ( Type IV = P.P. complete centralis):
The placenta covers the interanl os completely whether the cervix is partially or
fully dilated.
N.B. Placenta praevia marginalis posterior is of bad prognosis than marginalis
anterior because:
It encroaches on the true conjugate diameter delaying engagement of the
head.
Engagement of the head will compress the placenta against the sacrum,
causing foetal asphyxia.
Mechanism of bleeding
Progressive stretching of the lower uterine segment normally occurs during the 3rd
trimester and
labour, but the inelastic placenta cannot stretch with it. This leads to inevitable
separation of a part of
the placenta with unavoidable bleeding. The closer to term, the greater is the
amount of bleeding.
Diagnosis
Symptoms:
Causeless, painless and recurrent bright-red vaginal bleeding;
It is causeless, but may follow sexual intercourse or vaginal examination.
It is painless, but may be associated with labour pains .
It is recurrent, but may occur once in slight placenta praevia lateralis.
Fortunately, the first attack usually not severe.
Signs:
General examination:
The general condition of the patient depends upon the amount of blood loss. Shock
develops if there is
acute severe blood loss and anaemia develops if there is recurrent slight blood loss.
Abdominal examination:
The uterus is corresponding to the period of amenorrhoea, relaxed and not
tender.
The foetal parts and heart sound (FHS) can be easily detected.
Malpresentations, particularly transverse and oblique lie and breech
presentation are more common as well as non-engagement of the head. This
is because the lower uterine segment is occupied by the placenta.
.
Investigations:
(1) Ultrasound:
It is the most simple, precise and safe method for placental localization. A partially
full bladder is
necessary to identify the lower edge of the placenta. If it is less than 3 cm from the
margin of the
internal os , it is diagnosed as placenta praevia.
The posterior placenta praevia is difficult to be identified due to shadowing
from the presenting part of the foetus. This can be overcome by head-down
tilt of the patient or displacing, the presenting part manually. If difficulty
still present, the distance between the presenting part and the promontory of
the sacrum is measured. If this exceeds 1.5 cm it means that placenta lies
inbetween.
Bleeding in Late Pregnancy (Antepartum Haemorrhage) - D. El-Mowafi
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In mid - pregnancy the placenta reaches the internal os in up to 20% of
pregnancies. With increasing gestational age and the formation of the lower
uterine segment, a gap develops between the placental edge and the internal
os " placental migration". So it is recommended to repeat scan when
placenta praevia is diagnosed in mid - pregnancy.
(2) Soft tissue placentography, isotopes and thermography:
are old methods for placental localization that are obsolete nowadays.
r
If less than 37 weeks (36 weeks by others), conservative
treatment is indicated till the end of 37 (or 36) weeks but not
more.
Conservative treatment:
The patient is kept hospitalized with bed rest and observation till delivery.
Anaemia should be corrected if present.
Observation of foetal wellbeing.
Anti-D immunoglobulin is given for the Rh-negative mother.
(II) If the patient is in labour:
Vaginal examination is done under the previously mentioned precautions.
According to the findings,
the patient will be delivered either vaginally by amniotomy + oxytocin or by
caesarean section.
Vaginal delivery is allowed if the following findings are fulfilled:
Placenta praevia is lateralis or marginalis anterior,
bleeding is slight,
vertex presentation,
adequate pelvis with no soft tissue obstruction.
partialy dilated cervix to allow amniotomy. Amniotomy has 2
benefits:
Allows descent of head so it compresses the
placental site preventing further bleeding.
It abolishes the shearing movement of the placenta
during uterine contractions. As the bulging of fore
bag of water during contractions with intact
membranes will drag the edge of the placenta
evoking more bleeding.
Caesarean section is indicated in :
Placenta praevia centralis whether complete or incomplete even if the foetus
is dead.
Placenta praevia marginalis posterior.
Severe bleeding.
Presentation other than vertex.
Other obstetric indications as contracted pelvis, cord prolapse and elderly
primigravida.
Bleeding in Late Pregnancy (Antepartum Haemorrhage) - D. El-Mowafi
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Vasa praevia.
N.B. Although upper segment C.S. is sometimes advocated to be away from the
placenta, lower
segment C.S. is preferable because:
It allows better control of bleeding from the placental site.
It leaves a stronger scar can withstand subsequent vaginal delivery.
If placenta praevia was anteriorly implanted it is gently displaced laterally to reach
the
foetal head otherwise cut through it (not preferred).
Complications of Placenta Praevia: