Lecture bleeding in the first 6 months of pregnancy

2021-03-21 12:00 AM

A complete examination of the patient may reveal anaemia due to prolonged bleeding, or the patient in dizziness has a hemodynamic disorder due to acute blood loss.

Define

Include all cases of pregnant women with symptoms of vaginal bleeding during the first 6 months (or in the first 24 weeks) of pregnancy.

Vaginal bleeding during this time is a common symptom, due to many reasons, requiring doctors to diagnose the cause to promptly handle, because there are cases where we need to intervene to But there are also cases where we have to remove the pregnancy as soon as possible.

Symptoms

Vaginal bleeding can occur naturally, not associated with any of these factors. But it can also happen after traumatic effects.

Vaginal bleeding may be bright red blood, but it can also be dark blood or even black blood. Blood may be a lot or a little, lasting.

Vaginal bleeding can be accompanied by other symptoms, such as abdominal pain. Abdominal pain can be dull or intermittent, whole or localized pain.

A complete examination of the patient may reveal anemia due to prolonged bleeding, or the patient in dizziness has a hemodynamic disorder due to acute blood loss.

Vaginal examination:

Depending on the cause of the bleeding, we can detect different symptoms, but during the examination, we must always evaluate:

Does the condition of the cervix see local lesions? Does blood flow from the cervical opening or is it directly above its surface? cervix erase open?

Does the size of the uterus match gestational age? The density of the uterine muscle, and its mobility.

The nature of the appendages around. Especially the last bag (the bag with Douglas).

Subclinical investigations:

Get an hCG test to confirm pregnancy.

Ultrasound to determine the position and properties of the fetus.

Tests evaluate the degree of blood loss of the patient

Causes and direction

Threatened miscarriage

This is one of the most common causes of vaginal bleeding in the first 6 months of pregnancy. Often seen in patients with abnormalities in the uterus such as in patients with uterine fibroids, uterus double, uterus ...

Vaginal bleeding is often accompanied by lower abdominal pain, constant pain, sometimes exacerbating into attacks.

Vaginal examination:

The cervix is ​​closed, still long.

The uterus corresponds to gestational age.

Test:

positive hCG.

Ultrasound: Seeing a pregnancy in the uterus, can see the fetal heart.

Treatment 

Lie down, avoid vigorous exercise.

Use drugs that reduce contraction, soften uterine muscles. If the bleeding is heavy and prolonged, add antibiotics to avoid infection.

Miscarriage

The next course of the phenomenon of threatened miscarriage.

At this time, vaginal blood is often large, bright red blood may contain blood clots. Accompanying the patient has a lot of abdominal pain, downward pain, sometimes the patient has a burning sensation. Patients are often alarmed by heavy bleeding. Failure to intervene in time can lead to shock from blood loss.

Examination: 

The cervix is ​​shortened and slightly opened, or even put in the fingers, through which the placenta can be felt or the fetal organization can be felt. Seeing signs of spinning top.

Tests: Ultrasound shows the fetus in the uterus, but falls low.

Management: Abort the pregnancy as quickly as possible, and give uterotonic drugs afterwards to stop the bleeding. Antibiotics to fight infections.

Stillbirth

Vaginal bleeding is usually sporadic, spontaneous, black blood with no abdominal pain unless there is a threat of abortion.

Exam: The uterine size is usually small, incompatible with gestational age.

Test:

hCG is usually positive because the placenta is still present in the uterus.

Ultrasound: The fetus in the uterus, incompatible with the gestational age, if the baby is small, the amniotic sac is not round, the amniotic sac is irregular, the size of the amniotic sac is large but there is no echo of the pregnancy, also known as a phenomenon "Empty pregnancy". If the fetus is large, there will be no fetal heart.

Fibrinolytics must be performed before the abortion, to avoid the risk of bleeding during the curettage due to a decrease in fibrinolysis caused by the fetus.

Management: Eliminate stillbirth as soon as possible, to avoid the risk of bleeding due to miscarriage.

Out of womb pregnancy

This is considered the most dangerous surgical emergency in the first 3 months of pregnancy, because of the risk of bleeding, the rupture of the pregnancy can cause death.

Extracurricular pregnancy is a phenomenon of pregnancy, but the pregnancy implants outside the uterus. The most common location is at the oviduct.

There are many different clinical forms of ectopic pregnancy, the most dangerous being the ruptured form of ectopic pregnancy that causes acute bleeding, shocking, and even death of the patient without prompt intervention. Therefore it is most important to diagnose ectopic pregnancy when it has not ruptured or recently bleed, so patients with 3 months delay with vaginal bleeding should always be diagnosed with the exclusion of ectopic pregnancy. uterus.

Symptoms: 

Patients often present with black blood, a little, accompanied by abdominal pain in the hypotenic region, sometimes localized in the left or right pelvic fossa.    

Vaginal examination:

There is blood from the cervix, dark blood, the cervix is ​​closed, except for ectopic pregnancy, the cervix may be opened and even the ectopic tissue protrudes in the hole. Cervical.

The small uterus is incompatible with gestational age.

On the side of the uterus, you can feel a lumpy, painful pressure.

The back pocket may feel pain when touched deeply.

Test:

Determine the concentration of hCG in the serum to see if it corresponds to the image on the ultrasound, in the case where the hCG level> 1000IU / L without an image of the amniotic sac in the uterus, always be wary of ectopic pregnancy. child.

In case of doubt, it is possible to do two consecutive tests, spaced 48 hours apart to see the progression of serum hCG levels, because in the case of normal pregnancy, implantation in the uterus is every 48 hours. Now the serum hCG concentration will double.

Ultrasound: The amniotic sac is not found in the uterine cavity, it is necessary to distinguish from some cases of amniocentesis, that is due to fluid retention in the uterine cavity, and around the fluid-containing area there is no image of cytoplasmic rings.

Next to the uterus, a heterogeneous mass of echoes can be seen, even an amniotic sac with a typical "ring-shaped" picture. In more rare cases, a picture of the fetus with the fetal heart can be seen.

The same item later may have some fluids.

Pathological anatomy: in some cases in which abortion or pseudo-miscarriage is present, the specimen will result in a uterine loss under the influence of pregnancy hormones, but there is no picture of the spikes, or Also known as the Ariatte-Stella image.

Treatment: Since this is considered a surgical emergency, surgery as soon as possible should be done to avoid bleeding rupture. If the best conditions are laparoscopy, depending on the size of the pregnancy, the need for delivery, and the quality of the opposite side appendage, it is decided to preserve the oviduct or remove the pregnancy.

Pregnant eggs

Pregnancy is an abnormal fertility phenomenon, leading to the overgrowth of fetuses. There are two types of pregnancy: full and partial pregnancy, in which full pregnancy accounts for two-thirds of all cases.

Symptoms: Vaginal bleeding is common in about 90% of pregnancies, the bleeding is usually a little, spontaneous and can stop on its own. Abdominal pain is not accompanied unless miscarriage is threatening, but up to 40% of pregnancies have severe morning sickness

Exam: The uterus is larger than gestational age, soft density. NHT can be felt on either side of the ovary (accounting for about 35-50% of all pregnancies).

Test:

The hCG concentration increases, usually as high as> 300,000IU / L in serum.

Ultrasound: the uterus is enlarged, in the uterus, there is a picture of "bread intestine" or "snowfall", most typical when the uterus is a gestational age corresponding to a pregnancy of 14 weeks or more. You can see the image of NHT on both sides, with a negative drum image and with many partitions.

Treatment: Eliminate the fetus as soon as possible to avoid bleeding from miscarriage. Depending on the patient's age and the need of delivery, it is possible to perform an abortion of the egg or a mass hysterectomy to reduce the risk of further complications of the disease. After the removal of the fetus, the patient must continue to follow outpatient monitoring for 2 years for early detection of complications of cultured fibroblasts.

Bleeding from causes in the cervix

The cause of vaginal bleeding is common in patients with cervical polyps, which often bleed during an infection or during a local trauma such as intercourse.

A speculum examination will reveal polyps in the cervix. The uterus corresponds to gestational age.

Laboratory: Ultrasound shows the fetus in the uterus, develops normally.

Treatment: It is possible to place anti-inflammatory drugs in place and depending on gestational age, as well as the nature and size of the polyps that can immediately remove polyps or not.

Cases of bleeding due to other damage to the cervix such as gland inflammation, condyloma, and even common cervical cancer are very rare.