Dutta’s Obstetrics Haemorrhage DK Dutta
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2Early Pregnancy Haemorrhage

Threatened AbortionCHAPTER 1

 
4DEFINITION (FIG. 1.1)
Threatened abortion is defined as bleeding from the gravid uterus before 28th week of gestation when there is a viable foetus and no evidence of cervical dilatation.
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Fig. 1.1: First trimester haemorrhage
 
AETIOLOGY
  • Below twenty years (12%) and
  • Above forty years (20%),
  • Luteal-phase defects,
  • Uncontrolled IDDM (30%),
  • Thyroid dysfunction with hypo hyperfunction,
  • High LH in polycystic ovarian disease,
  • High androgen level,
  • Coexisting insulin resistance in PCOD cases,
  • Antiphospholipid antibody syndrome,
    5
  • Infections including group B beta haemolytic streptococci infection of vagina and bacterial vaginosis,
  • Acite malarial fever,
  • Severe emotional stress,
  • Myomas are known to be associated with higher abortion rate especially with the submucous variety. Degenerating myomas of other sites may threaten the pregnancy due to myometrial irritability.
  • Lying placenta on sonography,
  • Exogenous factors like exposure to high dose of irradiation, chemotherapeutic agents, smoking, alcohol, anaesthetic, etc. may cause abortion,
  • Sexual intercourse, falls or blows to the abdomen,
  • Uterine contraction by oxytocin, prostaglandin from semen or abdominal injury.
 
DIAGNOSIS (FIG. 1.2)
Clinical history of amenorrhoea, pregnancy sign symptoms with mild bleeding suggests threatened abortion. On clinical examination closed os with uterine size corresponding to period gestations is the basis of clinical diagnosis. But the mainstay of diagnosis and prognosis is by the ultrasound examination. Sonographically yolk sac in early pregnancy, cardiac activity and subchorionic haematoma help us to confirm the viability of pregnancy.
Yolk sac appears at five weeks of gestation and disappears at nine weeks. A large irregular mobile yolk sac is an abnormal observation suggesting abnormal concepts. When normal, it has a very regular circular structure, bright echogenic rim around a conolucent centre. In patient between 8 and 12 weeks yolk sac less than or equal to 2 mm is associated with poor outcome. Abnormal embryonic development is highly probable of a yolk sac is not visible in gestational sac larger than 8 mm. It is invariably abnormal if a high quality sonogram fails to show a yolk sac when gestational sac measures 10 mm or more (Nyberg et al 1992).6
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Fig. 1.2: Causes of abortion
Subchorionic haematoma appearing as crescent shaped hypoechoic area next to gestational sac is a common sonographic finding on threatened abortion. Size of haematoma is directly proportional to the risk of abortion. Subchorionic bleeding can be demonstrated using colour Doppler imaging. Length of the cervical canal, dilatation of the internal os and ballooning of membranes can also be diagnosed by USG which denotes inevitable abortion. USG has a role play in diagnosing uterine fibroids with its localisation and signs of degeneration.7
 
MANAGEMENT PREVENTION
 
Prevention
Preventive measures consist of early and comprehensive prenatal care. It is preferable to detect and treat known maternal disorders before conception occurs. Avoiding (coitus) environmental hazards such as X-rays and infective diseases also decrease the risk.
In the general management bed-rest and sedation played a major role in the past. With the advent of USG the duration of bed-rest or hospitalization is reduced. Sedatives are used to alleviate anxieties. Constipation should be treated with mild laxatives but no purgation is advised which may stimulate uterine contraction. Diet should be nutritious and easily digestible. Tender loving care (TLC) has been seen to reduce the miscarriage rate in cases without any obvious pathology.
Literature suggests not to use progesterone unless there is obvious deficiency as in luteal phase defect. The choice is either dydrogesteron (duphaston) with a dose of 20–60 mg (oral) or micronised progesterone vaginally for better absorption with a dose of 300–400 mg/day in divided doses. Age old use of oral progesterone without having androgenic effect also gives comparable result in the outcome of pregnancy.
Data suggest that hCG is equally effective as progesterone in LPD. But empirial use of hCG is controversial and not cost effective. Luteinising hormone releasing hormone agonist is also tried in PCOD in some studies which needs more trial to be established.
In autoimmune conditions like APA syndrome without SLE aspirins in low doses are helpful. Low dose heparin with aspirin also shows promising results.
Follow-up care with USG is useful for the appearance of cardiac activity and to see the size of subchorionic haematoma.8
 
CONCLUSIONS
It is difficult to differentiate threatened from missed abortion by clinical methods such as symptoms, signs and qualitative pregnancy tests. Cardiac activity is definitive evidence of foetal viability. The gestation sac can be identified by fourth week of amenorrhoea using TVS but a pseudosac of ectopic pregnancy may resemble a gestational sac. Foetal cardiac activity is observed by the end of fifth week and beginning of sixth week.
About 20–40 per cent of pregnancies do not take place on day fourteen but usually weeks later. Hence, wrong gestational age should always be kept in mind before evaluating cases.
Treatment of threatened abortion is essentially empirical. The patient should rest. Folate, progesterone and hCG injection may be given at clinicians discretions. About 90–95 per cent threatened abortion carry on to viable births.
BIBLIOGRAPHY
  1. Barnea ER, Taj J. Stress related reproductive failure. Jr of IVF and ET 1991;8(1):15–23.
  1. Crowther C, Chalmers I. Bed-rest and hospitalization during pregnancy. In Murray Enkin, Marc JNC Keirse, James Neilson et al (Eds): A Guide to Effective Care in Pregnancy and Childbirth.
  1. Homkburg R, Jacobs HS. Etiology of miscarriage in polycystic ovary syndrome. Fertil and Steril 1989;51:196.
  1. Pratap Kumar, Sridivi Vellanki. Yolk sac and its significance in first trimester pregnancy. The Jr of Obs and Gynae of India 1995;45(1):5–8.
  1. Regan L, Owen EJ. Hypersecretion of LH, infertility and miscarriage. Lancet 1990;2:1141–4.
  1. Sutherland HW, Pritchard CW. Increased incidence of spontaneous abortion in pregnancies complicated by material diabetes mellitus. Am J of Obs and Gynae 1987; 15:135–8.