VAGINAL_BLEEDING_IN_EARLY_PREGNANCY_UPDATED.pptx

vaginal bleeding in early pregnancy

1. VAGINAL BLEEDING IN EARLY PREGNANCY DR ALI SAINE MBCHB, MWACS SPECIALIST OBS AND GYNAE 37 MILITARY HOSPITAL

2. OBJECTIVES TO UNDERSTAND THE CLINICAL IMPORTANCE OF THE TOPIC To understand the common causes of bleeding in early pregnancy To recognize the clinical presentation of bleeding in early pregnancy To discuss the diagnostic workup and management principles To explore prevention strategies for reducing the risk of bleeding in early pregnancy Understand the pathophysiology of vaginal bleeding in early pregnancy Identify the differential diagnoses based on clinical presentation Develop a management plan for patients presenting with early pregnancy bleeding Discuss the role of patient education and follow-up care Vaginal bleeding in early pregnancy 2

3. OUTLINE INTRODUCTION EPIDEMIOLOGY CAUSES OF BLEEDING DURING EARLY PREGNANCY CLINICAL PRESENTATION DIAGNOSIS MANAGEMENT OF EACH CONDITION PREVENTION CONCLUSION/ SUMMARY QUESTIONS/ COMMENTS Vaginal bleeding in early pregnancy 3

4. INTRODUCTION

5. What is vaginal bleeding in early pregnancy? Definition: Bleeding in the first trimester or first 20 weeks of pregnancy. Spans a wide range of causes from benign to potentially life-threatening. It usually results from disruption of blood vessels in the decidua (pregnancy endometrium) or from a discrete cervical or vaginal lesion. The clinician typically makes a provisional clinical diagnosis based upon the gestational age and the character of bleeding (e.g., spotting, light or heavy flow, intermittent or constant, associated with pain or painless). Physical examination and laboratory and/or imaging tests are then used to support or revise the initial diagnosis. Bleeding can be associated with an adverse pregnancy outcome or an ectopic pregnancy, which can be life-threatening. Vaginal bleeding in early pregnancy 5

6. How often do women bleed during the first trimester? Incidence quoted ranging from 20 to 30 percent in the first trimester. 50 percent of vaginal bleeding in pregnancy will end as a miscarriage ( Dongol et al. 2011) According to ACOG ( Bleeding in the first  trimester  happens in 15 to 25 in 100 pregnancies) Vaginal bleeding in early pregnancy 6

7. CLINICAL PRESENTATION Presentation could come in various forms. Characteristics of the bleeding: - Associated symptoms - Patterns of bleeding - Impact of bleeding in pregnancy Use images or diagrams to illustrate different symptoms. Highlight key clinical signs and symptoms. Vaginal bleeding in early pregnancy 7

8. Physical examination General exam Systemic examination Speculum examination is performed to assess the amount and origin of ongoing bleeding . Pelvic and cervical motion tenderness need immediate further investigation and discussion with a specialist. Vaginal bleeding in early pregnancy 8

9. EVALUATION AND DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN EARLY PREGNANCY

10. DIFFERENTIAL DIAGNOSIS Principles of Management: - Expectant - Medical - Surgical Organize this section into subsections for each condition (e.g., ectopic pregnancy, miscarriage). Provide detailed management plans including medical, surgical, and expectant approaches. Vaginal bleeding in early pregnancy 10

11. Vaginal bleeding in early pregnancy 11

12. MANAGEMENT STRATEGIES Principles of management Expectant Medical Surgical Vaginal bleeding in early pregnancy 12

13. Ectopic pregnancy Incidence: 2% of all pregnancies. 96% of cases found in the fallopian tubes. Leading cause of pregnancy-related maternal mortality in the first trimester, accounting for 4% of all pregnancy-related deaths. A high burden seen in Ghana; a study done in KBTH found 32.9/1000 deliveries (Obed et al., 2006). Include recent data and statistics from Ghana. Add visual aids to illustrate the condition and treatment options. Vaginal bleeding in early pregnancy 13

14. Management options Expectant- not a likely practice Medical About one-third of patients with ectopic pregnancy are suitable for medical management with methotrexate. Initial treatment is with a single intramuscular dose of methotrexate (50 mg/m 2 ), with 14% of women requiring a further dose. Success rates are up to 85%, which is similar to salpingostomy. 9  Up to 15% of women may require surgical intervention. Surgical Salpingectomy Salpingostomy Salpingotomy

15. Miscarriages Types of Miscarriages: - Threatened miscarriage - Inevitable - Incomplete - Complete miscarriage Management Options: - Expectant - Medical - Surgical Include case studies or examples to illustrate different scenarios. Discuss the role of patient counseling and follow-up care. Vaginal bleeding in early pregnancy 16

16. MISCARRIAGES Vaginal bleeding in early pregnancy 17

17. The MIST trial, 11  a large, randomised controlled trial, compared expectant, medical and surgical management options for the treatment of miscarriage. It showed comparable efficacy and no significant difference in infection rates (2–3%). The trial reported that unplanned hospital admissions were significantly increased in the expectant (49%) and medical (18%) groups, compared with the surgical group (8%). Surgical management was required in 44% of the expectant group and 13% of those given medication; 5% of the surgical group required a further surgical procedure. Vaginal bleeding in early pregnancy 18

18. Gestational trophoblastic disease Types: - Hydatidiform mole - Choriocarcinoma Include images to illustrate the conditions. Discuss management and prognosis. Vaginal bleeding in early pregnancy 19

19. Prognosis and management consideration Not all bleeding in early pregnancy leads to poor pregnancy outcome. Should we admit or manage as outpatient? Role of anti-D Vaginal bleeding in early pregnancy 20

20. PROGNOSIS Not all bleeding in early pregnancy leads to poor outcomes. Should we admit or manage as outpatient? Role of anti-D Summarize key points about prognosis for different causes of bleeding. Discuss the importance of follow-up care and patient counseling. Vaginal bleeding in early pregnancy 21

21. General practice Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice Christopher Everett Termination 1 Miscarriage Moved away 27 449 *Includes stillbirths. BMJ 1997;315:32–4 32 BMJ VOLUME 315 5 JULY 1997 Vaginal bleeding in early pregnancy 22

22. Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study Joshua L. Weiss, MD,* Fergal D. Malone , MD, John Vidaver, MA, Robert H. Ball, MD, David A. Nyberg, MD, Christine H. Comstock, MD, Gary D. Hankins, MD, Richard L. Berkowitz, MD, Susan J. Gross, MD, Lorraine Dugoff, MD, Ilan E. Timor-Tritsch, MD, Mary E. D’Alton, MD, for the FASTER Consortium Columbia Presbyterian Medical Center, New York, NY Received for publication May 13, 2003; revised August 20, 2003; accepted September 4, 2003 – Objective: The purpose of this study was to determine whether patients with first-trimester threat- ened abortion are at increased risk for poor pregnancy outcome. Study design: A large prospective multicenter database was studied. Subjects were divided into three groups: (1) no bleeding, (2) light bleeding, and (3) heavy bleeding. Univariate and multivari- able logistic regression analyses were used. Results: The study comprised 16,506 patients: 14,160 patients without bleeding, 2094 patients with light bleeding, and 252 patients with heavy bleeding. Patients with vaginal bleeding, light or heavy, were more likely to experience a spontaneous loss before 24 weeks of gestation (odds ratio, 2.5 and 4.2, respectively) and cesarean delivery (odds ratio, 1.1 and 1.4, respectively). Light bleeding subjects were more likely to have preeclampsia (odds ratio, 1.5), preterm delivery (odds ratio, 1.3), and placental abruption (odds ratio, 1.6). Heavy vaginal bleeding subjects were more likely to have intrauterine growth restriction (odds ratio, 2.6), preterm delivery (odds ratio, 3.0), preterm premature rupture of membranes (odds ratio, 3.2), and placental abruption (odds ratio, 3.6). Conclusion: First-trimester vaginal bleeding is an independent risk factor for adverse obstetric outcome that is directly proportional to the amount of bleeding. © 2004 Elsevier Inc. All rights reserved. KEY WORDS Threatened abortion Spontaneous pregnancy loss Preterm delivery Placental abruption Preterm premature rupture of membranes – First-trimester vaginal bleeding is a common compli- cation that affects 16% to 25% of all pregnancies. 1,2 When pregnant patients have bleeding, it may cause stress and anxiety for the mother-to-be about the future outcome of the pregnancy. In general, the incidence of spontaneous abortion after first-trimester bleeding is quoted to be 50% before sonographic evaluation for fe- tal viability. 1,3 If a viable fetus is noted at ultrasound ex- amination after first-trimester vaginal bleeding, 95% to 98% of such pregnancies will still continue beyond 20 weeks of gestation. 1,4 Supported by grant No. RO1 HD 38652 from the National Institutes of Health and the National Institute of Child Health and Human Development. * Reprint requests: Joshua L. Weiss, MD, Columbia Presbyterian Medical Center, 622 W 168th St, PH-16-66, New York, NY 10032. E-mail: [email protected] www.elsevier.com/locate/ajog American Journal of Obstetrics and Gynecology (2004) 190, 745 e 50 0002- 9378/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2003.09.023 Vaginal bleeding in early pregnancy 23

23. What is the role of bed rest? Does bed rest play a role in the management of bleeding in early pregnancy Vaginal bleeding in early pregnancy 24

24. What is the role of progesterone in the management of vaginal bleeding in early pregnancy Summarize key points: - Importance of understanding the causes and management of vaginal bleeding in early pregnancy. - Early diagnosis and appropriate management can improve outcomes. - Patient education and follow-up care are crucial. Reinforce the key take-home messages. Vaginal bleeding in early pregnancy 25

25. Conclusion and summary

26. references https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884141/ Karimi A, Sayehmiri K, Vaismoradi M, Dianatinasab M, Daliri S. Vaginal bleeding in pregnancy and adverse clinical outcomes: a systematic review and meta-analysis. J Obstet Gynaecol . 2024 Dec;44(1):2288224. doi : 10.1080/01443615.2023.2288224. Epub 2024 Feb 2. PMID: 38305047. https://www.acog.org/womens-health/faqs/bleeding-during-pregnancy#:~:text=Bleeding%20in%20the%20first%20trimester,are%20developing%20in%20this%20area. Yang J, Savitz DA, Dole N, et al. Predictors of vaginal bleeding during the first two trimesters of pregnancy.  Paediatr Perinat Epidemiol .  2005;19:276–83. [ PubMed ] [ Google Scholar ] 6.  Batzofin JH, Fielding WL, Friedman EA. Effect of vaginal bleeding in early pregnancy on outcome.  Obstet Gynecol.  1984;63:515–8. [ PubMed ] [ Google Scholar ] 7.  Sipila P, Hartikainen-Sorri AL, Oja H, Von Wendt L. Perinatal outcome of pregnancies complicated by vaginal bleeding.  Br J Obstet Gynaecol .  1992;99:959–63. [ PubMed ] [ Google Scholar ] 8.  Axelsen SM, Henriksen TB, Hedegaard M, Secher NJ. Characteristics of vaginal bleeding during pregnancy.  Eur J Obstet Gynecol Reprod Biol.  1995;63:131–4. [ PubMed ] [ Google Scholar ] 9. French JI, McGregor JA, Draper D, Parker R, McFee J. Gestational bleeding, bacterial vaginosis, and common reproductive tract infections: risk for preterm birth and benefit of treatment.  Obstet Gynecol.  1999;93:715–24. Hasan, R., Baird, D. D., Herring, A. H., Olshan, A. F., Jonsson Funk, M. L., & Hartmann, K. E. (2010). Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Annals of Epidemiology , 20 (7), 524. https://doi.org/10.1016/j.annepidem.2010.02.006 Vaginal bleeding in early pregnancy 27

27. References https://www.draliabadi.com/obstetrics/abnormal-pregnancy-conditions/ectopic-pregnancy/ https://www.racgp.org.au/afp/2016/may/early-pregnancy-bleeding/ Bouyer J, Coste J, Fernandez H, Pouly JL, Job- Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod . 2002 Dec;17(12):3224-30. doi : 10.1093/ humrep /17.12.3224. PMID: 12456628. Creanga AA, Shapiro-Mendoza CK, Bish CL, Zane S, Berg CJ, Callaghan WM. Trends in ectopic pregnancy mortality in the United States: 1980-2007. Obstet Gynecol. 2011 Apr;117(4):837-843. doi : 10.1097/AOG.0b013e3182113c10. PMID: 21422853. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010 Dec;116(6):1302-1309. doi : 10.1097/AOG.0b013e3181fdfb11. PMID: 21099595. Baffoe S, Nkyekyer K. Ectopic pregnancy in Korle Bu Teaching Hospital, Ghana: a three-year review. Trop Doct . 1999 Jan;29(1):18-22. doi : 10.1177/004947559902900108. PMID: 10418275. Obed S. Diagnosis of Unruptured Ectopic Pregnancy is Still Uncommon in Ghana. Ghana Med J. 2006 Mar;40(1):3-7. PMID: 17299556; PMCID: PMC1790838. Vaginal bleeding in early pregnancy 28

28. Introduction Estimates of bleeding prevalence in early pregnancy range from 7 to 24%. Vaginal bleeding during pregnancy, especially during the first trimester, can lead to adverse maternal and infant outcomes. Use visual aids like graphs or charts to illustrate prevalence and risk factors.

29. How Often Do Women Bleed During the First Trimester? Incidence quoted ranges from 20 to 30 percent in the first trimester. 50 percent of vaginal bleeding in pregnancy will end as a miscarriage. According to ACOG, bleeding in the first trimester happens in 15 to 25 in 100 pregnancies. Use bullet points for clear information. Add references to recent studies.

30. Evaluation and Differential Diagnosis Differential Diagnosis: - Implantation bleeding - Subchorionic hemorrhage - Pregnancy of unknown location - Miscarriage (threatened, blighted ovum, missed, complete/incomplete, inevitable) - Vanishing twin - Ectopic pregnancy/Heterotopic pregnancy - Gestational trophoblastic disease - Cervical changes (e.g., infections, polyps, cancer) - AV malformation of the uterus in pregnancy - Thrombophilia Use flowcharts to show the diagnostic workup. Highlight the importance of specific tests (e.g., hCG levels, ultrasound findings).