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VAGINAL BLEEDING IN PREGNANCY PowerPoint Presentation
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VAGINAL BLEEDING IN PREGNANCY

VAGINAL BLEEDING IN PREGNANCY

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VAGINAL BLEEDING IN PREGNANCY

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  1. VAGINAL BLEEDING IN PREGNANCY Craig T. Carter, D.O. Department of Emergency Medicine University of Kentucky

  2. VAGINAL BLEEDING DURING PREGNANCY 1. DURING PREGNANCY -FIRST 20 WEEKS -SECOND 20 WEEKS

  3. PREGNANCY AND VAGINAL BLEEDING • By the Numbers: • 40% EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY • Up to 20% OF PREGNANCIES TERMINATE IN MISCARRIAGE • 2% OF PREGNANCIES ARE ECTOPIC • 9%-13% OF FIRST TRIMESTER MATERNAL DEATHS ARE DUE TO ECTOPIC PREGNANCIES

  4. BLEEDING AND THE FIRST 20 WEEKS • Three primary causes: • SPONTANEOUS MISCARRIAGE/ABORTION • ECTOPIC PREGNANCY (EP) • TROPHOBLASTIC DISORDERS

  5. Spontaneous Abortion • Incidence-1 in 5 pregnancies • 80% occur in the first trimester • Incidence decreases with gestational age • If fetal heart activity/viability is noted on ultrasound, the loss rate is only 2-3% • Loss rate is 20% in those with first trimester bleeding • Risk increases with increasing maternal age, paternal age, and parity

  6. Spontaneous Abortion Etiology- • Maternal factors • Infectious-Mycoplasma, Toxoplasmosis,Listeria • Environmental-Alcohol abuse, Smoking • Uterine - Septum, Fibroids, Cervical Incompetence • Systemic Disease-Thyroid, Diabetes 􀂋 • Paternal factors-Chromosomal translocation • Fetal Factors-Chromosomal • 50% of 1st trimester abortions caused by chromosomal anomalies

  7. Spontaneous Abortion-Symptoms Vaginal bleeding in almost all patients • Cramping and pelvic pain very common • Hemorrhage can lead to syncope from hypovolemia/shock • Often discovered when fetal heart activity cannot be detected on exam

  8. SPONTANEOUS MISCARRIAGE • 20% OF PREGNANCIES WILL MISCARRY • IS A NATURAL PROCESS THAT ELIMINATES ALMOST 95% OF CYTOGENETIC DEFECTS BEFORE BIRTH • COMMON CAUSE OF VAGINAL BLEEDING DURING PREGNANCY

  9. Spontaneous Abortion Differential Diagnosis • Threatened Abortion - bleeding, cervix closed • Inevitable Abortion - cervix open or membranes ruptured • Incomplete Abortion - passed some of the P.O.C. • Treatment – Suction, Dilitation and Curettage or Observation • Complete Abortion - passed all products of conception (P.O.C.)

  10. THREATENED MISCARRIAGE • UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION • ULTRASOUND MAY DETECT AN IUP, INDETERMINATE OR EMPTY UTERUS. CORRELATE WITH BHCG TO RULE OUT EP

  11. THREATENED MISCARRIAGE • THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

  12. THREATENED MISCARRIAGE - Treatment • SUCCESS RATES ARE SIMILAR (93%) FOR BOTH UTERINE CURETTAGE VS. EXPECTANT MANAGEMENT

  13. THREATENED MISCARRIAGE • DISCHARGE HOME IS SAFE • MUST INCLUDE MANDATORY OB FOLLOW UP • SERIAL BHCG IN 48 HRS

  14. INEVITABLE / INCOMPLETEMISCARRIAGE • BOTH HAVE EARLY PREGNANCY LOSS • BOTH PRESENT AND ARE TREATED SIMILARLY

  15. INEVITABLE / INCOMPLETEMISCARRIAGE • INEVITABLE: VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION: OPEN CERVIX IS AN IMPORTANT FINDING • INCOMPLETE: INCOMPLETE PASSAGE OF TISSUE

  16. INEVITABLE / INCOMPLETEMISCARRIAGE TREATMENT OF CHOICE: UTERINE CURETTAGE (D&C)

  17. COMPLETE MISCARRIAGE • OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

  18. Products of Conceptoin

  19. MISSED MISCARRIAGE • OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

  20. SEPTIC MISCARRIAGE • UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS • OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE • LATE COURSE: SEPTIC SHOCK

  21. SEPTIC MISCARRIAGE • INFECTION IS POLYMICROBIAL • TRIPLE ANTIBIOTIC COVERAGE IS REQUIRED • GRAM (+) COVERAGE: PENICILLIN, AMPICILILN OR CEPHALOSPORIN • GRAM (-) AREOBIC COVERAGE: AMINOGLYCOSIDE OR AZTREONAM • GRAM(-) ANAEROBIC COVERAGE: CLINDAMYCIN OR METRONIDAZOLE

  22. Induced Abortion • More complicated the further along in pregnancy the procedure is done • Dilitation and Curettage until 12 weeks the Dilitation and Evacuation 􀂄 • Medical Rx possible until 9 weeks • RU-486 (mifepristone)/Misoprostil • Methotrexate/Misoprostil

  23. Induced Abortion • Complications • Perforation of uterus • Infection • Hemorrhage Septic Abortion -Sepsis, shock, hemorrhage -Follows infected complete or incomplete AB -More common before induced abortion was legalized

  24. Ectopic Pregnancy • Pregnancy anywhere outside uterine cavity • Fallopian tube most common location • Second leading cause of maternal mortality • COMMON THEME IS SCARRED FALLOPIAN TUBE

  25. GREATEST RISK PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE Ectopic Pregnancy Risk Factors

  26. Ectopic Pregnancy Risk Factors MODERATE RISK -PREVIOUS PID -IN VITRO FERTILIZATION -MULTIPLE SEXUAL PARTNERS

  27. Ectopic Pregnancy Risk Factors LESS RISK: • PREVIOUS PELVIC/ABDOMINAL SURGERY • CIGARETTE SMOKING • AGE OF FIRST INTERCOURSE <18

  28. ECTOPIC PREGNANCY -PATHOPHYSIOLOGY TROPHOBLAST IMPLANTS ON THE TUBAL WALL, GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT IT’S SIZE.

  29. ECTOPIC PREGNANCY • MEAN GESTATIONAL AGE OF RUPTURE IS 7.2 WEEKS • UP TO 23 % OF EP RUPTURE • UP TO 11% OF EP RUPTURED AT BHCG <100

  30. ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

  31. ECTOPIC PREGNANCY • CLINICAL PRESENTATION CLASSIC HX : -UNILATERAL ABDOMINAL PAIN -VAGINAL BLEEDING -AMENORRHEA -SYNCOPE +/- BUT…

  32. ECTOPIC PREGNANCY • ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

  33. ECTOPIC PREGNANCY • PHYSICAL FINDINGS • Vaginal bleeding • Hypotension, tachycardia(shock) • Adnexal mass or tenderness in one sided adnexa • Uterus-normal size • Peritoneal Signs

  34. ECTOPIC PREGNANCY • DIAGNOSTIC MODALITIES – LABS HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66%) EVERY 48 HOURS NORMALLY • IN EP, BHCG LEVELS FALL, PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION.

  35. ECTOPIC PREGNANCY DIAGNOSTIC MODALITIES – LABS • PROGESTERONE -SINGLE LEVEL >25 CORRELATES TO A VIABLE GESTATION -LEVEL<5 MAY INDICATE A NONVIABLE GESTATION

  36. ECTOPIC PREGNANCY • ULTRASOUND SINGLE MOST VALUABLE MODALITYAVAILABLE -BHCG DISCRIMINATORY THRESHOLD FOR : TVU: 1500 FOR TAU: 6500

  37. ECTOPIC PREGNANCY • ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP) • GESTATIONAL SAC • YOLK SAC • EMBRYONIC POLE • FETAL CARDIAC ACTIVITY

  38. ECTOPIC PREGNANCY • ED ULTRASOUND • SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG > THE DISCRIMINATORY THRESHOLD

  39. ECTOPIC PREGNANCY • OTHER DIAGNOSTIC MODALITIES CURETTAGE IN PATIENT WITH AN ABNORMAL REPEAT BHCG OR LOW PROGESTERONE: ABSENCE OF VILLI INDICATES A HIGH SUSPICION OF EP CULDOCENTESIS CAN BE ACCURATE IN UP 90% OF RUPTURED EP

  40. CULDOCENTESIS

  41. ECTOPIC PREGNANCY • PREVENTING MISDIAGNOSIS • EP CAN RUPTURE AT BHCG AS LOW AS 100 • UP TO 40% OF EP WERE MISDIAGNOSED AT 1ST ED VISIT • ABOUT 50% OF TRANSABDOMINAL ULTRASOUND WERE NONDIAGNOSTIC • ED US – If non diagnostic – need “official” study • PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

  42. ECTOPIC PREGNANCYTreatment • MEDICAL MANAGEMENT • METHOTREXATE: DRUG OF CHOICE • unruptured, small, no cardiac activity, compliant patient CONTRAINDICATIONS: -OBVIOUS SIGNS OF RUPTURE -BHCG > 2000 -SUSPECTED HETEROTOPIC PREGNANCY

  43. ECTOPIC PREGNANCY Treatment • SURGICAL TREATMENT - MAINSTAY OF TREATMENT • Laparoscopy • Salpingostomy • Salpingectomy • Laparotomy LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

  44. ECTOPIC PREGNANCY Prognosis for Subsequent Fertility • Overall subsequent pregnancy rate is 60%, other 40% are infertile • One-third of pregnancies after an ectopic pregnancy are another ectopic pregnancy one-sixth are spontaneous abortions • Only 33% of women with ectopic pregnancy will have a subsequent live birth

  45. Ectopic Pregnancy-Unusual Variants • Heterotopic Pregnancy • Simultaneous IUP and ectopic gestations • Rare- 1 in 30,000 pregnancies • Abdominal Pregnancy-can occur anywhere in peritoneal cavity • Cervical Pregnancy (1 in 10,000) • May need hysterectomy 􀂄 • Ovarian Pregnancy (1 in 7,000) • Oophorectomy usually required

  46. TROPOBLASTIC DISORDERS • ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE • E.G.: COMPLETE/PARTIAL MOLE, INVASIVE HYADTIFORM MOLE, CHORIOCARCINOMA