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First Trimester Bleeding: Typology and Management

by Veronica Gillispie, MD, FACOG
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    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.


    About the Lecture

    The lecture First Trimester Bleeding: Typology and Management by Veronica Gillispie, MD, FACOG is from the course Antenatal Care. It contains the following chapters:

    • First Trimester Bleeding
    • Management of Bleeding in First Trimester

    Included Quiz Questions

    1. Threatened abortion
    2. Normal pregnancy
    3. Incomplete abortion
    4. Inevitable abortion
    5. Missed abortion
    1. Incomplete abortion
    2. Missed abortion
    3. Threatened abortion
    4. Complete abortion
    5. Normal abortion
    1. Possible missed abortion
    2. Possible threatened abortion
    3. Possible incomplete abortion
    4. Possible inevitable abortion
    5. Possible spontaneous abortion
    1. Surgical dilation and curretage
    2. Administration of Anti-D Immunoglobulin (Rhogam)
    3. Expectant management
    4. Administration of misoprostol
    5. Serial beta-HCG levels until <5 mlU/ml

    Author of lecture First Trimester Bleeding: Typology and Management

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG


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