This document discusses early pregnancy bleeding and differentials, implantation in early pregnancy, ultrasound findings, miscarriage definitions and management options, ectopic pregnancy risk factors and treatments, and recurrent miscarriage evaluation. It defines miscarriage as loss of intrauterine pregnancy before 24 weeks and describes expectant, medical, and surgical management options. For ectopic pregnancies, it notes fallopian tubes as the most common site and lists risk factors. Treatment may involve methotrexate or laparoscopic salpingectomy.

1. Early pregnancy bleeding
Done by Merna Hazazah

2. • IMPLANTATION
• DDX OF EARLY VAGINAL BLEEDING
• MISCARRIAGE
• ECTOPIC PREGNANCY

3. Implantation and the establishment of pregnancy
The CL
supports the
pregnancy for
approximately
8 weeks

4. A transvaginal ultrasound scan
(TVUSS) can detect an early
intrauterine gestational sac, the first
sign of a normal pregnancy, at
around 5 weeks’ gestation.
A few days later a circular yolk sac can
be seen within the gestational sac
and the embryonic fetus can usually be
identified after 5.5 weeks’ gestation.
The fetal heartbeat may be visible as
early as 6 weeks’ gestation.

7. DDX…

8. • Abortion
• Ectopic pregnancy
• Hydatidiform mole
• Implantation bleeding
• Cervical lesions

9. UK— Loss of an intra uterine pregnancy before 24 weeks of
gestation
WHO— Expulsion of fetus or embryo weighing 500g or less and
The gestational limit is less than22 weeks of pregnancy
The ending of the fetus before the fetus becomes viable
[depends on the NICU(26wks)]

10. • Chromosomal abnormalities. M.c 50% of cases
• Infections.
• placental abnormalities
• Uterine abnormalities/ fibroids
• Maternal extremes age
• Advanced paternal age
• Previous miscaurriage
• Drugs/chemicals.

12. [1] Expectant management
allows for the avoidance of surgery. After a spontaneous
miscarriage where the pain and bleeding resolve, a repeat
ultrasound scan is not required to confirm completion. Women
may be advised to take a urinary pregnancy test after 3 weeks.

13. [2] Medical management
used in an outpatient setting to allow women to miscarry at home.
It involves the administration of a single, or repeated, vaginal or
sublingual dose of the prostaglandin E analogue misoprostol.
Some centres use pretreatment with the progesterone antagonist
mifepristone (if over 9 weeks’ gestation).
**Women undergoing medical management of miscarriage need to
understand that they may need surgical treatment if medical treatment
fails (10% failure rate) or if they bleed heavily.

14. [3] Surgical management
is preferred if there is persistent excessive bleeding or haemodynamic
instability, or if women favour this option.
It can be done by manual vacuum aspiration under local anaesthetic in an
outpatient clinic setting if the woman is not compromised. More
commonly it is done as a day case under general anaesthesia.
**However, surgical evacuation has its drawbacks including risks such as
uterine perforation, postoperative pelvic infection and cervical trauma and
subsequent cervical incompetence

15. • Recurrent miscarriage is defined as the loss of three or more
consecutive pregnancies and it affects 1% of couples.
• Risk factors include both advancing maternal and paternal
age, obesity, balanced chromosomal translocations, uterine
structural anomalies and antiphospholipid syndrome (APS).
• Investigation of recurrent miscarriage should involve testing
for antiphospholipid antibodies and imaging of the uterus.
Products of conception in subsequent miscarriages should be
sent for cytogenetic analysis and, where testing reports an
unbalanced structural chromosomal abnormality, parental
peripheral blood karyotyping of both partners should be
performed. Aspirin and low-dose heparin can reduce the
miscarriage rate in women with APS by 50%.

16. • implantation of a pregnancy outside the normal uterine cavity
• Most common site is fallopian tube

18. Tubal pregnancy
approximately 98% of ectopic pregnancy implant in the fallopian
tube, the implantation may be within the fimbrial end[5%],
ampullary section[80%], isthmus[12%]
Cornual pregnancy
Rare situation where implantation has occurred in a horn of a
bicornuate uterus
Ovarian ectopic pregnancy
Contraceptive device and fertility treatment are risk factors
Do laparscopy to save ovary

19. Heterotopic pregnancy
presence of multiple gestations, with one being present in the
uterine cavity and the other outside the uterus.
Abdominal ectopic pregnancy
Implantation on to any organ within the peritonial cavity
Scar pregnancy
Life threatening condition because of the occurrence of
abnormally adherent placenta with subsequent heavy bleeding
and the high risk of uterine rupture with related morbidity and
mortality

20. Ectopic pregnancy rates have been linked to trends in pelvic
inflammatory disease, specifically Chlamydia trachomatis
infection
Other risk factors:
• previous ectopic pregnancy .
• previous tubal surgery.
• Functional alterations in the Fallopian tube due to smoking.
and increased maternal age.
• Additional risk factors include previous abdominal surgery
(e.g. appendicectomy, caesarean section).
• Fertility treatment.
• endometriosis.

21. • History and examination
• TVUSS:
identification of an intrauterine pregnancy (intrauterine
gestation sac, yolk sac +/− fetal pole) on TVUSS effectively
excludes the possibility of an EP in most patients except in
those patients with rare heterotopic pregnancy. The presence of
moderate to significant free fluid during TVUSS is suggestive of
a ruptured EP.
• Quantitative B-hcg
• Laparscopy findings

23. • In up to 40% of women with an EP the diagnosis is not made
on first attendance and they are labelled as having a ‘pregnancy
of unknown location’ (PUL).
• A PUL is a working diagnosis defined as an empty uterus with
no evidence of an adnexal mass on TVUSS (in a patient with a
positive pregnancy test).
• The mainstay of investigation of a PUL is consecutive
measurement of serum hCG concentrations.
• An endometrial biopsy can occasionally be helpful when hCG
levels are static.
• All PUL must be investigated to determine the location of the
pregnancy.

24. Expactant
Ectopic implantation is unlikely to succeed and most undergo
spontaneous trophoblastic regression, often before diagnosis

25. Intramuscular methotrexate is a treatment option for patients with
minimal symptoms,
and adnexal mass<40 mm in diameter
and a current serum hCG concentration under 3,000 IU/l.
methotrexate treatment serum hCG is usually routinely measured on days 4, 7 and 11, then
weekly
thereafter until undetectable (levels need to fall by 15% between day 4 and 7, and continue to
fall with treatment).
The few contraindications to medical treatment include: (1) chronic liver, renal or
haematological disorder; (2) active infection; (3) immunodeficiency; and (4) breastfeeding.
There are also known side-effects such as stomatitis, conjunctivitis, gastrointestinal upset and
photosensitive skin reaction, and about two-thirds of patients will suffer from non-specific
abdominal pain.
It is important to advise women to avoid sexual intercourse during treatment and to avoid
conceiving for 3 months after methotrexate treatment because of the risk of teratogenicity.

26. The standard surgical treatment approach is laparoscopy.
Laparotomy is reserved for severely compromised patients or where
there are no endoscopic facilities.
The operation of choice is removal of the Fallopian tube and the EP
within (salpingectomy), or in some cases a small opening can be made
over the site of the EP and the EP extracted via this opening
(salpingostomy), Salpingostomy is recommended only if the
contralateral tube is absent or visibly damaged, and it is associated
with a higher rate of subsequent EP.