Vaginal Bleeding in Early Pregnancy/ Abortion - antibiotic prophylaxis

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ICD10 CODE: O20

This is almost always abnormal, and patients may need to be admitted or referred. The most common causes of bleeding in the first six months (<26 weeks gestation) are abortion and ectopic pregnancy
Abortion (miscarriage) occurs when the foetus is lost before 28 weeks of pregnancy.

Cause

  • Not known in the majority of patients
  • May be intentional (induced abortion)
  • May be spontaneous (often as a result of fever)
  • If mother has more than 2 miscarriages, refer for assessment

Differential diagnosis

  • Pregnancy outside the uterus (ectopic pregnancy)
  • Other causes of bleeding from the vagina, e.g. cancer
  • Other causes of lower abdominal pain, e.g. PID

Investigations

  • Urine: Pregnancy test
  •  Ultrasound
  • Blood: Complete count

Clinical features, terminology and management

  • Depend on the stage of the abortion See table below.

 

FEATURES MANAGEMENT LOC

Threatened abortion

Little vaginal bleeding
No or moderate lower abdominal pain
Uterus is of expected size by date
Cervix is closed
Pregnancy may still continue
  • Medical treatment is usually not necessary (hormones and tocolytics will not prevent a miscarriage)
  • Observe for 4-6 hours
  • Paracetamol 1 g every 6-8 hours prn for 5 days

If bleeding stops:

  • Avoid strenuous activity and ab- stain from sex for at least 14 days
  • Follow up in 2 days in ANC clinic

If bleeding persists, refer to HC3

HC2

 

 

 

HC3

HC4
Inevitable abortion
Process irreversible
Products of conception not yet expelled but painful contractions (pain similar to labour pains) and bleeding
Cervix proceeds to open
  • Bed rest
  • If there are signs of infection, give antibiotics
  • Observe for continued bleeding

If patient in shock:

  • Resuscitate with IV fluids (Nor- mal Saline

If anaemic:

  • Refer to HC4 for replacement of blood lost
  • Establish IV access before referral
  • Give stat dose of antibiotics before referral

HC2

HC3

HC4

 

 

 

 

 
Incomplete abortion
Uterine contents not completely passed out
Bleeding sometimes with clots from
the vagina (may be severe) or
Severe lower abdominal cramps
Cervix open
Products of conception (POC) may be felt in the cervical canal
  • If evacuation of uterus is not immediately possible
    Give oral misoprostol 600 microgram sublingual stat (repeat once after 4 hours if necessary)
  • If at HC2, refer to HC3 after misoprostol
  • Use fingers to remove POC protruding through the cervix
  • Evacuate the uterus by Manual Vacuum
    Aspiration (if pregnancy<16 weeks) or Dilation and Curettage
  • Ensure follow up
  • Give stat dose of antibiotics before referral
  • Treat anaemia

If signs of infection (fever, foul smelling blood)

  • Give a stat dose of IV Ceftriax one 2 g and IV metronidazole 500 mg
  • Amoxicillin 500 mg orally every 6 hours for 7 days
  • Plus metronidazole 400 mg orally every 8 hours for 7 days

HC2

HC3

HC4

 

 

 

Complete abortion

All uterine contents have been passed out
Bleeding is decreasing Cervix closed
Uterus empty and reduced in size
  • Examine to make sure that all products have been passed
  • Follow up for continuous bleeding (it should stop in a few days)
 HC3

Septic abortion

Incomplete abortion with infection (may follow induced abortion)

Fever

Offensive vaginal discharge

Lower abdominal pain

Tenderness on palpating the abdomen
  • Give 7-day course of antibiotics as in incomplete abortion (above)
  • Evacuate the uterus
 HC4
Post-abortal Sepsis
Patient has signs and symptoms of sepsis following an abortion, but there are no products of conception in the uterus
  • Give IV antibiotics ceftriaxone 2 g + metronidazole 500mg IV 8 hourly for 48 hours, until fever has disappeared, then switch to oral treatment as for septic abortion
 HC4

Missed abortion

Foetus died

Contents of the uterus not expelled

May be dark blood drops (spotting) from the vagina

Uterus smaller than expected by dates/not growing		 Refer to hospital for evacuation H

Molar abortion

Abnormal placenta, no foetus, vaginal bleeding, and passing of red material like ripe coffee berries/ white (translucent) grape like material; uterus much bigger than expected; mother feels no foetal movements even after five months
  • Resuscitate and refer the patient
  • Do not attempt to evacuate the uterus unless you have facilities for blood transfusion and oxytocin
  • Refer to hospital for further management
 H