INTRODUCTION
Bleeding per vaginum in the first trimester is one of the most common obstetric problems. It is also one of the commonest cause for the majority of the emergency admissions to the obstetrics department and also a common reason for ultrasound examination in the first trimester.
Nearly 25% of all pregnant women in their first trimester complain of bleeding.1,2 In these women who present with bleeding per vaginum, during their first trimester, several diagnostic possibilities can be considered. By mere clinical history and examination, definitive diagnosis is usually impossible. The causes of bleeding are many and cover a spectrum of conditions ranging from a viable pregnancy to nonviable pregnancy.
A woman who presents with poor history poses a diagnostic challenge both to the obstetrician and to the sonologist. Clinical history and pelvic examination are inadequate in assessing the cause and the prognosis. Ultrasound (both transabdominal and transvaginal sonography) plays an important role in the evaluation of the causes of first trimester bleeding, prognosticate and predict the status of abnormal pregnancy. Real-time sonography is a noninvasive modality, i.e., extremely useful to arrive at an accurate diagnosis.
Ultrasound in a woman who presents with bleeding in the first trimester helps:
In confirming the pregnancy
To know if the pregnancy is intrauterine or extrauterine
To know the period of gestation
In early recognition of any associated pelvic abnormality
To know the viability of the fetus
To confirm or rule out suspected hydatidiform mole
To look for the presence of intrauterine contraceptive device (IUCD) and confirmation of pregnancy associated with IUCD
Helps in prompt management of the patients
Helps in early detection of anembryonic pregnancy, i.e., commonly associated with chromosomal anomalies
Evaluation of suspected blighted ovum and threatened, incomplete, complete, or missed abortion
Localization and textural evaluation of placenta
MATERIALS AND METHODS
We studied 50 cases of pregnant women who presented with bleeding per vaginum during the first trimester between November 2015 and August 2016. The main sources of data for this study are patients from teaching hospitals attached to Rohilkhand Medical College & Hospital, Bareilly, Uttar Pradesh, India. All patients referred to the Department of Radiodiagnosis with clinically suspected first trimester bleeding were evaluated with clinical history, clinical examination, and ultrasonography (USG). Ultrasonographic examination of patients was done using the following machines: (1) Phillips 350 (2) G.E. logiq V5 (3) Toshiba 1000.
DISCUSSION
Bleeding per vaginum in the first trimester is one of the most common obstetric problems. It is also one of the commonest cause for the majority of the emergency admissions to the obstetrics department and also a common reason for ultrasound when clinical history and pelvic examination are inadequate in assessing the cause and the prognosis. Ultrasound (both transabdominal and transvaginal sonography) plays an important role in the evaluation of the causes of the first trimester bleeding, prognosticate, and predict the status of abnormal pregnancy.
Table 1
Age wise distribution of study subjects
| Age in years | Number | Percent |
|---|---|---|
| 18–20 | 13 | 26 |
| 21–25 | 21 | 42 |
| 26–30 | 14 | 28 |
| 31–35 | 2 | 4 |
| Total | 50 | 100 |
| Mean ± SD | 24.00 ± 4.16 |
Table 2
Parity distribution in number and percentage of study subject
| Parity distribution | Number | Percent |
|---|---|---|
| Primi | 15 | 30 |
| Multi | 35 | 70 |
| Total | 50 | 100 |
Table 4
Duration of amenorrhea
| Duration | Number | Percent |
|---|---|---|
| < 8 weeks | 9 | 18 |
| 8—10 weeks | 26 | 52 |
| > 10 weeks | 15 | 30 |
| Total | 50 | 100 |
Table 7
Findings of physical examination
| Physical examination | Number (n = 50) | Percent |
|---|---|---|
| UT Size | ||
| <10 | 22 | 44 |
| 10–12 | 27 | 54 |
| Bulky | 1 | 2 |
| Cervix | ||
| Closed | 48 | 96 |
| Open in position | 2 | 4 |
| Fornices | ||
| Fornices free | 45 | 90 |
| Tenderness | 5 | 10 |
Table 8
Findings of USG examination
| Ultrasonography examination | Number (n = 50) | Percent |
|---|---|---|
| Gestational sac | 28 | 56 |
| Fetal node | 21 | 42 |
| Fetal cardiac activity | 18 | 36 |
| Yolk sac | 12 | 24 |
| Sub chorionic bleed | 7 | 14 |
| Placenta | 6 | 12 |
| Less Liquor | 3 | 6 |
Table 9
Final comparison of clinical, USG and final study
| Clinical findings | Clinical | Ultrasonography | Final | |||
|---|---|---|---|---|---|---|
| Number | Percent | Number | Percent | Number | Percent | |
| AG | – | – | 2 | 4 | 2 | 4 |
| CA | – | – | 6 | 12 | 5 | 10 |
| EG | 4 | 8 | 4 | 8 | 5 | 10 |
| HM | 1 | 2 | 2 | 4 | 2 | 4 |
| IA | 16 | 32 | 10 | 20 | 10 | 20 |
| In A | 2 | 4 | 4 | 8 | 4 | 8 |
| MA | 1 | 2 | 4 | 8 | 4 | 8 |
| TA | 26 | 52 | 18 | 36 | 18 | 36 |
| Total | 50 | 100 | 50 | 100 | 50 | 100 |
Real-time sonography is a noninvasive modality, i.e., extremely useful to arrive at an accurate diagnosis. The sonographic landmarks of the first trimester of pregnancy have been well recognized and they include identification of gestational sac (GS), fetal pole, fetal cardiac activity, movements, yolk sac, and amnion. The invaluable role of these landmarks, GS, and fetal biometry in diagnosing pathological pregnancies and predicting the pregnancy outcome has been clearly documented.
In the present study, various abortions contributed to a major chunk of first trimester bleeding,3,4 with 86% ectopic pregnancy and hydatidiform mole making up the rest of the cases with frequencies of 10 and 4% respectively, when compared with the study of Patil and Ramacharya5 and Sofat (Table 14).6
In our study, only 18 clinically diagnosed cases were confirmed on ultrasound, with a disparity of 64%. The present study, when compared with that of Malhotra et al7 and Patil and Ramacharya,5 has got more disparity between clinical and ultrasound diagnosis (Table 15).
Table 10
Follow-up of cases diagnosed on ultrasound
Table 11
Follow-up of cases diagnosed clinically
In our study, all cases of threatened abortion, missed abortion, incomplete abortion, blighted ovum, hydatidiform mole, and inevitable abortion were diagnosed correctly on ultrasound with an accuracy of 100%. One out of five cases of ectopic pregnancy and one out of six complete abortions were misdiagnosed, with accuracy of 80 and 83% respectively. The results of the present study are comparable with those of Sofat6 and Gupta et al8 in diagnosing threatened abortion, missed abortion, blighted ovum, and hydatidiform mole with 100% accuracy (Table 16).
CAUSES OF FIRST TRIMESTER BLEEDING
Threatened Abortion
Threatened abortion is vaginal bleeding before 20 weeks without cervical dilatation or effacement. Sonographic findings depend on the stage of gestation and may show an empty bulky uterus or intrauterine GS with or without an embryo. The findings at ultrasound examination in patients with threatened abortion are often both crucial and pivotal because in most cases the sonographic findings not only can determine the precise diagnosis but can also be used to guide therapy.
Complete Abortion
Complete abortion is vaginal bleeding with complete expulsion of all products of conception before 20 weeks. Sonography shows empty uterus.
Incomplete Abortion
Incomplete abortion is vaginal bleeding with partial expulsion of products of conception before 20 weeks of gestation. Sonographic findings are blood clots and residual trophoblastic tissue in the endometrial cavity.
Missed Abortion
Missed abortion is intrauterine embryonic demise before 20 weeks of gestation without expulsion of products of conception; it may or may not present with vaginal bleeding. Sonographic findings are intrauterine embryo without cardiac activity. The embryo and GS may be small for gestation age and are disproportionate.
Recurrent Abortion
Recurrent abortion is three or more consecutive spontaneous abortions. Sonographic findings depend on the stage of gestation and type of abortion.
Septic Abortion
Septic abortion is uterine infection associated with any of the above-described abortions. Sonographic findings are thick and irregular endometrial lining with fluid in the endometrial cavity.
Table 14
Comparison of causes of bleeding in first trimester pregnancy with few studies
| Study | Shivanagappa et al3 | Hanamshetty et al4 | Patil and Ramacharya5 | Sofat6 | Present study | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Cause of bleeding | No | Percent | No | Percent | No | Percent | No | Percent | No | Percent |
| Abortion | 138 | 83 | 45 | 60 | 61 | 61 | 70 | 77.5 | 43 | 86 |
| Ectopic pregnancy | 21 | 13 | 4 | 5.33 | 21 | 21 | 8 | 9 | 5 | 10 |
| Hydatidiform mole | 6 | 4 | 3 | 4 | 18 | 18 | 5 | 5.5 | 2 | 4 |
Table 15
Disparity among cases
| Study | Clinical diagnosis | Ultrasonography diagnosis | Disparity | |
|---|---|---|---|---|
| No | % | |||
| Malhotra et al7 | 150 | 102 | 48 | 32 |
| Patil and Ramacharya5 | 100 | 58 | 42 | 42 |
| Present study | 50 | 18 | 32 | 64 |
Inevitable Abortion
Patients with an open cervical os found on pelvic examination but without a history or evidence of passage of tissue are diagnosed as having an inevitable miscarriage.
On ultrasound examination, an anechoic area is seen around the sac, where the sac has dissected away from the uterine wall. The separated sac is seen lying low in the uterus. The dilated cervical canal confirms the diagnosis even though a heartbeat may still be detected. Sometimes, the sac will be seen to move in position during the course of the scan.
Ectopic Pregnancy
The term ectopic gestation refers to a gestation where the fertilized ovum gets implanted in a site other than intrauterine cavity. Tubal pregnancy is the commonest site accounting for 95 to 97%. Ampullary region is the common site in the tubal pregnancy. Less common sites include ovaries (0.5—1%), cervix (0.1%), and abdominal cavity.
Molar Pregnancy
The trophoblastic elements of the developing blastocyst are thought to undergo proliferative changes initiated by the persistence of chorionic villi from a blighted ovum and continue to undergo hydrated swelling. It can be complete mole or partial mole. In complete molar pregnancy, trophoblastic hyperplasia occurs with absence of identifiable embryo and amniotic membrane. Approximately 90% of molar pregnancies are this type. In partial form, the hydatidiform changes are focal and affect only a variable portion of the placenta. An abnormal placenta may coexist.
Table 16
Causes of Bleeding due to different types of abortion
CONCLUSION
Vaginal bleeding in the first trimester of pregnancy is a common obstetric problem and is a cause of anxiety and worry both to the patients and to the obstetrician. Clinical history and pelvic examination are inadequate in assessing the cause and the prognosis. The common causes of bleeding during first trimester include abortions, ectopic pregnancy, and molar pregnancy. Ultrasound is a noninvasive, nonionizing, and easily available method of investigation to assess the patients with first trimester bleeding, which is highly accurate in diagnosing the actual causes of bleeding and guides the clinician in choosing the appropriate line of management and prevents mismanagement of the cases. Ultrasound can assess some findings that are helpful in predicting the prognosis of the pregnancy. In the present study, 48 out of 50 cases were correctly diagnosed on ultrasound compared with 18 out of 50 cases on clinical diagnosis, with a disparity of 64% (Table 17).9,10