Hemorrhage in early pregnancy refers to bleeding from the genital tract occurring before 20 weeks of gestation.
Causes:
- Abortion (Miscarriage)
- Ectopic Pregnancy
- Molar Pregnancy (Hydatidiform Mole)
1. Abortion (Miscarriage)
Abortion is the termination of pregnancy before the fetus is viable, usually defined as pregnancy loss before 20 weeks or fetus weighing <500g.
Types of Abortion:
1. Threatened Abortion
- Bleeding per vagina with closed cervix.
- No passage of products of conception (POC).
- Management: Bed rest, progesterone support, avoid intercourse.
2. Inevitable Abortion
- Bleeding with open cervix and painful uterine contractions.
- No passage of POC, but expulsion is inevitable.
- Management: Expectant, medical, or surgical evacuation.
3. Incomplete Abortion
- Partial expulsion of POC with persistent bleeding.
- Cervix remains open.
- Management: Manual vacuum aspiration (MVA) or dilation and curettage (D&C).
4. Complete Abortion
- All POC are expelled, uterus contracts, and bleeding stops.
- Cervix is closed.
- Management: No further intervention needed.
5. Missed Abortion
- Embryo or fetus dies but is retained in the uterus for weeks.
- No bleeding initially, but pregnancy symptoms disappear.
- Diagnosis: Absent fetal heartbeat on ultrasound.
- Management: Medical or surgical evacuation.
6. Septic Abortion
- Infected abortion due to unsafe abortion or retained POC.
- Symptoms: Fever, foul-smelling vaginal discharge, pelvic pain.
- Management: IV antibiotics, surgical evacuation, supportive care.
2. Ectopic Pregnancy
Ectopic pregnancy is implantation of the fertilized ovum outside the uterine cavity, commonly in the fallopian tube (95%).
Risk Factors:
- Previous ectopic pregnancy.
- Pelvic inflammatory disease (PID).
- Tubal surgery or sterilization.
- Use of intrauterine contraceptive device (IUCD).
- Assisted reproductive techniques (IVF).
Clinical Features:
- Amenorrhea followed by vaginal bleeding.
- Unilateral lower abdominal pain.
- Adnexal mass on examination.
- Ruptured ectopic pregnancy signs: Severe pain, shock, shoulder tip pain.
Diagnosis:
- Serum β-hCG: Suboptimal rise.
- Ultrasound: Empty uterus, adnexal mass, free fluid in pouch of Douglas.
Management:
- Unruptured: Methotrexate (medical management).
- Ruptured: Emergency laparotomy/laparoscopic salpingectomy.
3. Molar Pregnancy (Hydatidiform Mole)
Molar pregnancy is a gestational trophoblastic disease (GTD) where abnormal trophoblastic tissue proliferates in the uterus.
Types:
- Complete Mole:
- No fetal tissue, only trophoblastic proliferation.
- "Snowstorm appearance" on ultrasound.
- Partial Mole:
- Some fetal tissue present.
- Triploid karyotype (69 chromosomes).
Clinical Features:
- Excessive vomiting (Hyperemesis Gravidarum).
- Excessively high β-hCG levels.
- Uterus larger than gestational age.
- Painless vaginal bleeding, passage of vesicles.
Diagnosis:
- Ultrasound: "Snowstorm pattern" with no fetal parts (complete mole).
- Serum β-hCG: Very high levels.
Management:
- Evacuation by suction curettage.
- Follow-up with serial β-hCG levels to monitor for persistent disease.
- Avoid pregnancy for at least 1 year.
Summary of Hemorrhage in Early Pregnancy
|
Condition |
Key Features |
Diagnosis |
Management |
|
Abortion |
Vaginal bleeding, variable pain |
Ultrasound, hCG |
Expectant, medical, surgical |
|
Ectopic Pregnancy |
Amenorrhea, severe pain, adnexal mass |
Serum β-hCG, Ultrasound |
Methotrexate or surgery |
|
Molar Pregnancy |
Excessive vomiting, large uterus, high β-hCG |
"Snowstorm" USG, hCG |
Suction evacuation, β-hCG follow-up |
