First Trimester Bleeding: Typology and Management

00:01 Now let's discuss bleeding in the 1st trimester.

00:06 So the initial assessment.

00:07 One of the first things we want to do is get the blood type and the Rh factor for mom.

00:11 No matter what the cause of bleeding is, if mom is Rh negative, she will need Rhogam.

00:17 So we always want to start with getting the blood type in the Rh factor.

00:22 Next, we want to get our quantitative beta-hcg.

00:25 If the beta-hcg is less than 2000, we may or may not see anything in the uterus.

00:31 If it is greater than 2000, we should definitely see something in the uterus.

00:36 That information is going to help us determine if this is a normal pregnancy or if this is ectopic pregnancy.

00:43 The next thing we'll need is an ultrasound to document the location and the viability of the pregnancy.

00:49 Again remember if that beta-hcg is less than 2000, we may or may not be able to determine the location of the pregnancy.

00:57 However, ultrasound is very important.

00:59 And the next thing is the complete blood count.

01:03 We want to able to determine if mom is hemodynamically stable or not.

01:06 And we want to know where her blood count is starting, when we're going into issues with 1st trimester bleeding.

01:14 So bleeding in pregnancy prior to 20 weeks of gestation with a documented intrauterine pregnancy constitutes a type of abortion.

01:22 Now we have many types of abortions.

01:24 And so we'll go through those through our next slides here.

01:28 So first is a threatened abortion.

01:31 Now this is a documented pregnancy.

01:33 Cervix is closed, but mom is having bleeding.

01:37 Next is incomplete abortion.

01:39 So mom has passed some products of conception and is bleeding.

01:43 But there's still products of conception within the uterus.

01:46 Next is inevitable abortion.

01:48 In this situation the cervix is already dilated.

01:51 And so mom is inevitably going to lose that pregnancy.

01:55 And then the fourth type of abortion is a missed abortion.

01:58 So in this situation, this is a patient who has absolutely no symptoms, no bleeding, no pain.

02:05 Quite commonly this is a diagnosis made in the office when a doctors goes to listen to the heart tones for the baby, no heart tones are found.

02:15 So again this is how we define missed abortion.

02:18 So let's talk about how we manage each of these.

02:22 So threatened abortion.

02:23 So our management is actually expectant.

02:26 A lot of these pregnancies will go on to be normal pregnancies.

02:29 So we don't want to do anything that will interfere with that.

02:32 We do advise the mom that if she has heavy bleeding or she has increased pain, that she should seek medical care.

02:39 Because that threatened abortion maybe going on to be an incomplete abortion.

02:44 And then remember if mom is Rh negative, we need to make sure she gets Rhogam.

02:49 So for incomplete abortions, we have three ways that we can manage it.

02:54 Expectant management, medical management and that's with misoprostol or surgical management.

03:00 With expectant management we allow the body to naturally complete the process of passing the products of conception.

03:07 With medical management we give again, misoprostol to help expedite that process of passing the products of conception, whatever is still left in the uterus.

03:17 And then surgical options would be D&C.

03:20 Now important to know, if a patient is hemodynamically unstable, they must have a D&C.

03:26 So if they are bleeding because of this incomplete abortion and have become hemodynamically unstable, expectant management and medical management is not appropriate.

03:36 For inevitable abortion, these patients can be managed again, medically, expectantly or surgically.

03:42 They can be managed expectantly if they are stable.

03:45 Medically if they are stable.

03:47 But surgically if they are hemodynamically unstable.

03:52 So missed abortion.

03:53 So again remember this is our patient that has no symptoms, no bleeding, no pain.

03:58 And has no fetal heart tones on ultrasounds or Doppler.

04:02 So this can be managed expectantly.

04:04 We tell the patients that they can go home, come back within a week and we expect that they will have passed products of conception.

04:11 If they've not then we need to progress to our other options which are medical and surgical.

04:15 And medical is administering misoprostol which helps the uterus evacuate the abnormal products of conception.

04:22 And then surgically, which is performing a D&C.

04:26 Again if expectant management is chosen by the patient, they need to be monitored weekly to make sure they do indeed pass those products of conception.

04:34 If the retain them, then they are at risk for developing a septic abortion.

04:39 Spontaneous or complete abortion.

04:41 This again means that mom has passed all of the products of conception.

04:45 We do need to confirm that by ultrasound however.

04:48 And we need to do serial beta-hcg's to make sure our hcg level falls back to prepregnancy levels which is less than 5 micrograms per decalitre.

04:58 So here's a case for you.

05:00 Anna is a 27 year old gravida 2 para 0 female that presents to the emergency room with complaint of heavy vaginal bleeding.

05:08 She has a last menstrual period of 8 weeks and 2 days.

05:11 She had a positive pregnancy test at home.

05:14 She has a history of ectopic pregnancy 2 years ago that was treated with methotrexate.

05:19 She denies any medical or surgical history.

05:22 On physical exam, vital signs are stable, and she is a afebrile.

05:26 On pelvic exam, uterus is gravid, non-tender.

05:29 And the cervix admits one finger.

05:33 So based on that, what is her most likely diagnosis? A. Is this a normal pregnancy B. Is it a missed abortion C. Is it inevitable abortion or D. Is it a threatened abortion.

05:46 The answer in this case is inevitable abortion.

05:50 So it's not a normal pregnancy because she is having bleeding and her cervix ix already open.

05:55 It's not a missed abortion because she is having symptoms.

05:58 It is inevitable abortion because the cervix is already dilated.

06:02 And it's not a threatened abortion because her cervix did not close.