First Trimester Bleeding

Posted by e-Medical PPT Saturday, March 26, 2011
It is estimated that 20-25% of clinically recognized pregnancies present with first-trimester bleeding.About half (10-15%) of these episodes progress to spontaneous abortion.Cause of bleeding difficult to determine clinically.

Differential Diagnosis
Implantation of embryo into endometrium (normal)
Spontaneous abortion
Subchorionic hematoma
Ectopic pregnancy
Gestational trophoblastic disease
Arteriovenous malformation
Abnormal placentation (ie. placenta previa) usually does not cause bleeding until later in pregnancy

Spontaneous Abortion
Definition: Passing of a pregnancy prior to 20 weeks gestation (aka: miscarriage)
Half of pregnancies complicated by 1st trimester bleeding end in spontaneous abortion
Causes separated into genetic and environmental (maternal)
Genetic abnormalities in 50-70% of SAs
Trisomy most common anomaly
Other causes include maternal systemic disease (ie. diabetes, hypothyroidism, autoimmune dx), infection, maternal anatomic defects (ie. bicornuate uterus)
Often, exact cause is unknown

Classification of Spontaneous Abortion
Threatened: Vaginal bleeding without cervical dilation
Incomplete: Vaginal bleeding with partial expulsion of products of conception (POC) + cervical dilation
Missed: Embryonic demise prior to 20 wks without expulsion of POC +/- vaginal bleeding
Complete: Vaginal bleeding + expulsion of all POC
Inevitable: Vaginal bleeding + cervical dilation
Septic: Any of the above + uterine infection

*Ultrasound findings vary depending on type

Subchorionic Hematoma
Hematoma from venous bleeding between the uterine wall and chorionic membrane
Present in 20% of women with 1st trimester bleeding
Increases risk of SA, stillbirth, placental abruption, and preterm labor
Rate of pregnancy loss increases with size of hematoma, advancing maternal age, and earlier gestational age


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