First Trimester Bleeding - Evaluation and Management

Introduction

First trimester bleeding is experienced by twenty to forty percent of women. This can be a regular part of early pregnancy in many women.

What Are the Causes of the First Trimester Bleeding?

Implantation Bleeding -

Implantation is a process by which the fertilized egg is implanted into the uterus walls ( an organ where the baby develops). This occurs about 6 to 12 days after conceiving, which may cause light spotting or bleeding.

Subchorionic Hemorrhage -

Bleeding happens when the placenta slightly separates from the walls of the uterus. A sac is formed in the gap between the placenta and the uterus. These vary in size; small ones are common and do not cause severe complications. The larger ones may cause heavy bleeding. Subchorionic hemorrhage in early pregnancy may increase the risk of spontaneous abortion and preterm delivery.

Ectopic Pregnancy -

When the fetus grows outside the womb, it is called an ectopic pregnancy. The baby cannot survive outside the womb, so ectopic pregnancies cannot reach full term. Fallopian tubules (a tube-like structure connecting ovaries and the uterus) are the familiar site of an ectopic pregnancy.

Cervical Polyp -

A cervical polyp is a small finger-like structure on the cervix (narrow lower end of the uterus). If the cervical polyp becomes inflamed or irritated, bleeding happens. They can be easily diagnosed during a pelvic examination.

Physical Examination or Intercourse -

Any poke to the cervix or near the cervix during physical examination or sex can irritate the tissues and cause bleeding.

Miscarriage -

A fall or trauma to the stomach, certain drugs, or any infections can cause miscarriage. This causes heavy bleeding and pain. Mostly miscarriage happens during the first term of pregnancy.

Multiple Babies -

If a mother is pregnant with multiple babies, bleeding may occur due to implantation. Bleeding in the first trimester does not affect the pregnancy.

Molar Pregnancy -

This is an infrequent but severe complication of pregnancy. A molar pregnancy occurs due to a genetic error causing the placental tissues to grow abnormally during fertilization.

Infections -

Any bacterial, viral, or fungal infection of the pelvic area, urinary tract, or bladder can cause bleeding or spotting. This might not cause any complications to the pregnancy.

How Is First Trimester Bleeding Diagnosed?

If a patient has bleeding in the first trimester, the following procedure is carried out in the hospital :

History - doctors will ask about the gestation age ( it describes how far along the pregnancy is), the amount of blood loss, and any pain associated with bleeding. They also check for anemia, thyroid disease, diabetes, and blood pressure.

Examination - Abdominal examination may reveal tenderness, rigidity, and swelling areas. Speculum examination (examination of the vagina using a speculum) checks the amount and origin of bleeding. Tissue in the open cervical is removed and sent for histopathological examination to confirm retained placental or fetal tissues. Bimanual review (to check internal pelvic organs) allows assessment of uterine size, pelvic tenderness, cervical motion tenderness, and dilatation of the cervical.

Investigation -

• Ultrasound Examination - Transvaginal ultrasound (TVS) is used to check the gestational sac(a sac surrounding the fetus), usually visible between four weeks and three days after the last menstrual period. A review scan after a week is recommended in case of any doubt regarding the fetus's growth. If the fetus is not seen in the uterus during the examination, the adnexa ( region containing the ovaries' fallopian tubules) is examined for ectopic pregnancy.

• Serum hCG Levels - The serum hCG level rises rapidly for six to seven weeks of gestation, increasing by at least 66% every 48 hours. Plateaued or very slow to raise serum hCG levels suggests an ectopic or non-viable intrauterine pregnancy. A falling serum hCG is consistent with a non-viable pregnancy and ectopic pregnancy.

Pregnancy of Unknown Location - If there are no signs of an intra- or extra-uterine pregnancy on a transvaginal scan and no superior retained products of conception, the pregnancy is defined as an unknown location.

What Is the Treatment for the First Trimester Bleeding?

Treatment for Miscarriage -

• Expectant Management - The patient is advised to wait carefully as a first-line treatment for incomplete abortion. In more than 90 % of patients, expectant management is successful, whereas it is less effective in patients with an anembryonic gestation or embryonic demise. Patients choosing expectant control over uterine aspiration experience bleeding for many days and increased rates of unplanned surgical intervention. Patients should be informed if signs of infection or hemorrhage happen; immediate hospitalization is required.

• Medical Management - It is more effective than expectant management for anembryonic gestation or embryonic demise. The effective regime is 200 mg of oral mifepristone followed 24 hours later by vaginally administered misoprostol. Nausea and diarrhea are common side effects.

• Uterine Aspiration - This is a preferred form of management for miscarriage. Uterine aspiration causes decreased pain, less blood loss, and shorter procedure duration.

• Follow-up - Ultrasonography is done to confirm the absence of an intrauterine pregnancy. Women who wish to conceive after pregnancy loss should be recommended folic acid.

Treatment for Ectopic Pregnancy

• Surgical Management - It is done for patients with failed or contraindicated medical treatment. Emergency surgery is required in patients with ruptured ectopic pregnancy and signs of peritonitis (inflammation of the abdominal membrane). The surgical options are salpingectomy (removing one or two fallopian tubules) or salpingostomy (creating an opening into the fallopian tube).

• Medical Management - Medical treatment is effective and safe for some patients. A single-dose regimen is most commonly followed, including an intramuscular injection of 50 mg of methotrexate, close monitoring of symptoms, and measurement of β-hCG levels four and seven days after injection. In case of treatment failure, a repeat dose of methotrexate is given.

• Expectant Management - If patients are willing to follow expectant management, the risk of tubal rupture and the importance of close surveillance should be informed. Surgical management is indicated if the patient experiences increased abdominal pain or if β-hCG levels increase. β-hCG levels should be obtained every 48 hours to confirm that they are decreasing, then weekly until they reach zero.

• Follow-Up - Patients with a history of ectopic pregnancy have higher ectopic pregnancy rates and pregnancy loss in subsequent pregnancies, so proper counseling is provided.

Conclusion

Bleeding in the first trimester will be frightening, but in many cases, slight bleeding and spotting are considered a part of normal pregnancy. Heavy bleeding and stomach pain are severe and require immediate attention following proper treatment. Emotional support from family and adequate counseling for future pregnancy should be provided.