Vaginal Bleeding in the Pregnant Patient Focus on

Vaginal Bleeding in the Pregnant Patient Focus on Primary Care Management Lopita Banerjee M. Sc, MD, CCFP Andrea Pansoy M. Sc, CCPA

Outline • Anatomy • Definition • Epidemiology • Causes of first trimester bleeding • Management • Final Summary • Questions

Anatomy

Definition • Any bleeding from genital tract in pregnancy • Can be divided according to gestational age: first trimester bleeding (or first 20 weeks of pregnancy) and antepartum hemorrhage (second half of pregnancy) • Remains a major cause of perinatal mortality and maternal morbidity in the developed world

Epidemiology Incidence of First Trimester Bleeding: 25 -30% • • • Miscarriage occurs in 50% of bleeding cases 1 • Even if viable, higher complication risk post-bleed • Half of conceptions miscarry in first 12 weeks Late Trimester Bleeds complicate 4% of pregnancies 1 Am Fam Physician. 2009 Jun 1; 79(11): 985 -992.

Additional articles for reference • Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. 2009 Oct; 114(4): 860 -7. • Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol. 2005 Nov; 106(5 Pt 1): 993 -9. • Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am. 2004 Mar; 42(2): 297 -314.

Case 1 • Vanessa, age 32, G 1 P 0 - you have recently seen her 3 weeks ago at GA 5 for early pregnancy visit • Has been doing everything ‘right’, taking vitamins • Stopped feeling nauseous for a few days, and then bright red spotting last night with mild cramps • Comes in urgently for assessment

First Trimester Bleeding • Implantation bleeding • Subchorionic hemorrhage: blood collected between chorion and uterine wall • Miscarriage: aka spontaneous abortion, <20 weeks • Blighted ovum/anembryonic pregnancy • Ectopic pregnancy • Gestational trophoblastic disease • Cervical/vaginal/uterine lesions, polyps • Trauma • Infection

Implantation Bleeding • Defined as bleeding that occurs 10 to 14 days after conception • Attachment of fertilized egg to endometrium • Lighter and shorter than normal period

Subchorionic Hemorrhage • Blood collected between chorion and uterine wall • Usually can monitor with ultrasounds q 1 -2 weeks depending on active bleeding • Most resorb independently

Miscarriage or SA • Threatened Abortion - bleeding, cervix closed, viable IUG; risk 50% • Inevitable Abortion - bleeding, cervix dilated, cramping, no POC expelled yet • Incomplete Abortion - incomplete evacuation of products

Miscarriage or SA • Missed Abortion - retained non-viable pregnancy up to 4 weeks • Septic Abortion - incomplete SA with secondary infection • Recurrent Spontaneous Abortion - three or more consecutive pregnancy losses • Blighted Ovum - gestational sac + placenta with no yolk sac; failure of embryo development

History & Tests • Accurate dating – LMP • Amount of bleeding - determines stability - 1 regular sanitary pad can hold up to 20 cc of blood; regular period loss 50 cc per day • Vitals • Fetal heart rate • Investigations- serial BHCGs and ultrasound

BHCG • BHCG 1, 500 to 2, 000 m. IU per m. L - gestational sac on ultrasound • BHCG doubles (increases by 80%) every 48 hours in a viable pregnancy

Discriminatory Findings in Early Pregnancy Menstrual Embryologic Lab & U/S Findings Age Event 3 -4 w implantation decidual thickening site 4 w trophoblast peritrophoblastic flow on colour flow Doppler 4 -5 w gestational sac BHCG 1500 -2000 5 -6 w yolk sac embryo cardiac activity gest sac>10 mm gest sac > 18 mm gest sac > 5 mm

Case 1 Initial Findings • Was not really sure of LMP - irregular cycles • Ultrasound - gestational sac with no fetal heart rate detected, no active bleeding, small subchorionic hemorrhage • May be 5 weeks gestation • Next steps?

Management • Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical signs of intraperitoneal bleeding • ? viable pregnancy

Case 1 Continued • 10 days later - ultrasound shows no FHR, gest sac noted • Started to cramp a bit last night and your patient thought it was okay to wait as there was no bleeding; this morning before she came in she noted some bright pink spotting. • What now?

Patient Presentation • May present with bright red bleeding and contractions or lower abdominal pain • Key - how much blood loss (quantity, rate), vital signs • Serial BHCG and ultrasound help guide treatment • Consider speculum exam • Significant stress to patient and family

Management • Watch and wait • Misoprostol - can be done in office • Surgical D&C - referral to OB or speciality clinic • Rho. GAM if required for Rh negative patients

Medical Management of Spontaneous Abortion • Different procedures and protocols available • Misoprostol 800 mcg PV x 1 dose, can repeat in 24 hours and at 48 hours • No significant effect after third dose • Works approximately 84% of the time 1 • Side effects - hypotension, N&V, abdo pain, + bleeding • Warn re: bleeding and when to go to ER 1 Am Fam Physician. 2011 Jul 1; 84(1): 75 -82.

Misoprostol Follow-up • Initial BHCG and ultrasound • Repeat ultrasound in 2 weeks with BHCG • May want to follow BHCG to 0

Case 1 Follow-up Visit • Seen in clinic 2 weeks later • Patient is worried that she did something to cause the SA • Heard that stress can be a factor - work is difficult, and she recently had to travel • “What did I do wrong? ”

Myths About Pregnancy Loss SA not related to: • Stress • Sexual activity • Air travel • Exercise • Contraceptive use • HPV infection • Grief is normal for this loss - supportive counselling and education, other support resources

Risk Factors • Advanced maternal age • Cigarette smoking, Et. OH use, alcohol abuse, drug use • Occupational chemical exposure • Excessive caffeine - 200 mg/day • Uterine anomalies • Incompetent cervix • Diabetes mellitus • Progesterone deficiency • Thyroid disease • Connective tissue disorder • Trauma

Case 2 • Sheryl, age 27 – presents to clinic c/o sharp LLQ pain, started yesterday evening • Has also been having intermittent spotting for past 2 weeks • Has not had a menstrual period in 6 months as she has a Mirena IUD • How would you proceed?

Case 2 Exam Findings • Abdo – N BS, LLQ tenderness to palpation • Speculum exam – cervix closed, IUD strings visualized, small amount of dark red blood • Bimanual – uterus firm, mobile, no CMT, L adnexal tenderness • Urine dipstick – 3+ blood, 1+ leukocytes • Urine BHCG – positive • What do you do next?

Ectopic Pregnancy • Implantation of fertilized ovum outside of the uterus • 2% of all pregnancies • Second most common cause for maternal mortality - accounts for 6% of maternal deaths • Surgical management - referral to OB emergently

Risk Factors for Ectopic Pregnancy • Previous tubal surgery • Previous ectopic pregnancy • • History of chlamydial or gonococcal cervicitis • Documented tubal abnormality • Tubal ligation • Current IUD use In utero DES exposure History of PID History of infertility

Take Home Message • Have high index of suspicion! • History and physical examination alone rarely leads to the diagnosis or exclusion of ectopic pregnancy • Serum BHCG and pelvic u/s are key to confirming the diagnosis

Case 3 • Miranda, 30 years old, G 3 P 2 – seen in clinic c/o 3 day hx. of dark brown vaginal discharge • Newly pregnant, GA ~ 6 wks based on LMP • Has initial prenatal visit booked next week but concerned about the discharge • What next?

Case 3 continued • Speculum exam – cervix closed, dark brown blood noted • Pelvic u/s and blood work ordered • Serum BHCG – 132, 745 m. IU/m. L • Ultrasound report - enlarged uterus, no gestational sac seen, multiple cystic structures in grape-like clusters

Gestational Trophoblastic Disease • A group of rare tumours that form in the tissue (trophoblast cells) that surrounds an egg after it is fertilized, and connect the fertilized egg to the wall of the uterus and form part of the placenta • In GTD, a tumour forms instead of a healthy fetus. • Includes hydatidiform moles (molar pregnancy, usually benign) and gestational trophoblastic neoplasia.

GTD • Malignant transformation to choriocarcinoma in 10 -20% • Locally Invasive Mole: Chorioadenoma destruens (66%) • Gestational Choriocarcinoma (33%) • Hyperthyroidism • Pregnancy Induced Hypertension

Management • Evacuation of Uterus • Dilatation and Evacuation • Dilatation and Curettage • Avoid Hysterectomy, Hysterotomy, or Pitocin • Increased risk of metastasis (Relative Risk: 3. 0) • Clamp uterine vessels early if Hysterectomy needed Chemotherapy Indications after D&C • • Quantitative BHCG persistently elevated • Persistent uterine bleeding • Evidence of trophoblastic metastasis - brain, lungs

Monitoring and Prognosis • Follow quantitative BHCG levels until 0 • Serial BHCG for 6 months to 1 year • Use contraception during this time • Chemotherapy if BHCG rises or does not fall to 0 • Methotrexate usually used • Recurrence rate of complete mole: 20% • May recur as locally invasive or metastatic • Recurrence rate in future pregnancies: 1 -2%

Case 4 • Amanda, 27 years old, G 2 P 0 – new patient to your clinic, currently GA 6 weeks • Seen in clinic today due to c/o post-coital bleeding lasting 1 day, no associated cramping • Speculum exam – cx closed, small amount of dark red blood • What do you do next?

Case 4 Investigations • Next urgent OB u/s appointment is not until 3 days from now • Serial BHCG ordered – initially 28, 674 IU/L; 30, 621 IU/L • OB u/s showed IUP, GA 5 weeks 6 days based on exam, yolk sac seen, no FHR detected • BHCG done on same day of u/s was 32, 356 IU/L • Patient has not had any further bleeding • How would you proceed?

Case 4 Continued • The patient was sent for a repeat OB u/s 10 days later which showed a viable pregnancy

Don’t Always Assume Miscarriage • Serum BHCG has been shown to vary from 440 to 142 230 IU/L among women whose pregnancies resulted in normal term deliveries 1 • BHCG should not be used as the only determinant of a viable pregnancy, must correlate with ultrasound 1 Clin Lab Med. 2003 Jun; 23(2): 257 -64, vii.

Cervical Lesions • May have polyps or other vaginal lesions • Infections • Trauma - remember sexual assault, IPV • Use other resources available

Late Trimester Bleeding • placenta praevia • partial and total

Late Trimster Bleeding • abruptio placentae • surgical emergency

Care After Loss • Rh negative – need for Rho. Gam • Contraception - all methods safe • No good evidence suggesting ideal inter pregnancy interval - folic acid supplementation • Psychological impact - grief counselling

Approaches to Grief Counseling After Miscarriage • Acknowledge and attempt to dispel guilt • Acknowledge and legitimize grief • Provide comfort, sympathy, and ongoing support • Reassure the patient about the future • Counsel the patient on how to tell family and friends about the miscarriage: • Warn patients of the anniversary phenomenon • Include the patient’s partner in your psychological care • Assess level of grief and adjust counseling accordingly Reference: Am Fam Physician. 2009 Jun 1; 79(11): 985 -992

Resources for Grieving Parents • http: //sunnybrook. ca/content/? page=wb-nicgresources

Summary • Have high index of suspicion and keep a broad differential • Transvaginal ultrasound and BHCG titres should be used to investigate early pregnancy bleeding and to monitor management outcome • Don’t hesitate to consult if concerned • Be available to provide support to your patient

Thank you! Questions?