Early pregnancy bleeding and clots: Vaginal Bleeding and Blood Clots During Pregnancy
‘Can Implantation Bleeding Be Heavy?’ & Other Questions
If you don’t know about implantation bleeding, it can come as a bit of a shock during early pregnancy.
Many women mistake it for a period, and some women don’t experience implantation bleeding at all. Most of the time, it is very light and has few symptoms, and the majority of the time it is nothing that you need to worry about.
Knowing the difference between your period, implantation bleeding, and other types of bleeding while you are pregnant will help you to work out what you need to do and when you need to seek medical help.
If you want to know more about your pregnancy, then why not take a look at this piece on what to expect at the 11 week ultrasound, and find out how many days after your period you can get pregnant.
What Is Implantation Bleeding?
Implantation bleeding is a symptom of early pregnancy that isn’t often talked about, so can come as a bit of a surprise.
It is a small amount of light bleeding caused by the fertilized egg becoming attached to the lining of the uterus. This will usually be experienced between 10 to 14 days after conception.
After ovulation, and once an egg has been successfully fertilized by a sperm, the fertilized egg will begin to grow inside the fallopian tube. It will quickly divide and grow into a blastocyst, which is a rapidly dividing cluster of cells that will become the embryo.
At the same time, the endometrium (the lining of the uterus) will start to thicken and mature to protect the growing embryo and give it the nutrients it needs. After around six days, the embryo will have moved into the uterus and will latch onto the uterus walls to take full advantage of the nutrients. Implantation bleeding is then caused by the bursting of blood vessels as the embryo makes its journey, which is why you only experience a very small amount of blood and occasionally some implantation cramping.
If you are wondering if your bleeding is caused by implantation or your period, you can take a pregnancy test to solve the mystery. It will measure the level of human chorionic gonadotropin (hCG) in your blood, which is created by the placenta to nourish a baby during pregnancy. This hCG is not actually produced until after the egg implants, so if you still think there’s a chance you could be pregnant after a negative result, wait around seven days and take a test again.
Implantation bleeding only happens in 15-25% of all pregnancies, so it is best to check with your doctor to be on the safe side if it does occur. If you find out you are pregnant after your implantation bleed, mention it to your medical provider so they can rule out any other issues.
It is also important to remember that there are a lot of other reasons why you might be bleeding during pregnancy in the first trimester, including ectopic pregnancy, miscarriage, a subchorionic hemorrhage, or molar pregnancy. If the bleeding you are experiencing is heavy (heavier than a period) or red in color, it’s a good idea to contact a medical professional to take a look. You should also contact your doctor if the bleeding you are experiencing is impacting your daily life.
What Does Implantation Bleeding Look Like?
So you know it exists, but how can you tell that your bleeding is implantation bleeding and not just your usual period? There are a few signs in the way that the implantation bleeding looks that can help you to differentiate.
With implantation bleeding during pregnancy, you won’t experience a heavy flow, and instead, it could be as little as some light spotting of just a couple of drops of blood, or slightly more.
The blood that you will see during implantation will usually be a dark brown color or even black. This is because the blood is older than your usual period blood, which will often start off a darker color and then lighten up over a couple of days. Sometimes your implantation bleed can be red or light pink in color too.
You might also be experiencing other signs and symptoms of early pregnancy around this time, like nausea, tender breasts, fatigue, and frequent urination.
How Long Does Implantation Bleeding Last?
If you are trying to tell the difference between normal vaginal bleeding from your menstrual cycle and implantation bleeding, then the length of time might be a factor that helps you work out what kind of vaginal bleeding you are experiencing.
Usually, implantation bleeding is much shorter than menstrual bleeding. It typically lasts no more than between 24 and 48 hours, as this is roughly how long it takes for the fertilized egg to become implanted into the uterine lining.
If you are monitoring your periods to find a sign of pregnancy, then the spotting that comes from the implanting egg will be a good factor to look out for. The timing of implantation will usually be a bit earlier than the time you would expect to have your period.
Implantation Bleeding vs Periods
Even though implantation bleeding is completely normal and nothing to worry about, it’s important that you let your doctor know about any bleeding you experience during pregnancy so that they can make sure everything is OK and offer any medical advice.
If you want to tell the difference between implantation bleeding during pregnancy and your menstrual period, then these are a few signs you can look out for.
The amount of bleeding you experience during your menstrual cycle is usually far heavier than the light bleed that most women experience during implantation. You will probably only experience some light spotting.
The color should be different. Implantation bleeding will usually be a light pink or brown color, whereas menstrual bleeding might start off a similar color but will usually turn bright red as your cycle gets heavier.
Length of flow time will be a lot shorter than a period, lasting anything between one and three days versus the average period of four to seven days.
If you experience any cramping during implantation bleeding, it will most likely be fleeting and much less intense than your usual period cramps.
Usually, a period will start light and get heavier over a few days. You will probably experience light spotting that is on and off with implantation bleeding.
Implantation bleeding will not produce any clots, so if you see clots in your blood then you are probably experiencing your period. Clots are formed by a mix of tissue and blood, whereas implantation bleeding is just blood.
There’s usually no treatment for implantation bleeding during pregnancy because it does not cause any problems and will go away on its own. If the bleeding you experience is more severe, is heavier than a period, or goes on for longer than expected, then it’s advisable to call your doctor.
If you found this article helpful, then why not take a look at whether having no morning sickness is something to worry about or if pregnant women can ever drink wine?
When Does It Start? How Long Does It Last?
Are you trying to get pregnant and have noticed a change in your bleeding? Are you unsure if it’s an early sign of pregnancy or your period starting? Telling the difference between period and implantation blood just takes a bit of expertise!
Every hopeful mom is eager to see the first sign of a new life growing, so it’s hard not to panic when your body behaves unexpectedly. If you’re feeling stressed out about a spot of blood when you suspect you’re pregnant, learning a bit more about implantation bleeding may put your mind to rest.
Is Implantation Blood Normal During Pregnancy?
As women, we have a pretty familiar relationship with blood, especially if comes from down there. It’s just part of life, and after a while, it stops being gross and scary and just becomes routine.
But there are lots of reasons why we may see of blood besides a period. From irritation to breastfeeding to hormonal changes, our bodies can expel blood for a variety of reasons. One of these is implantation bleeding during early pregnancy, and it’s perfectly normal!
What is Implantation Bleeding?
Light spotting during early pregnancy is usually the sign of the fertilized egg lodging itself into the uterus lining. As the egg moves down your fallopian tubes and into your womb, it nestles into the uterine lining, nice and snug. But this can cause enough irritation to produce light, harmless bleeding.
When Does Implantation Bleeding Occur?
Contrary to popular belief, this form of bleeding doesn’t happen right when the actual implantation does. Instead, it’s a bit of an “aftermath,” a sign it has happened instead of is happening.
You shouldn’t expect to see implantation bleeding until the deed is done. Bleeding won’t happen until at least five days after conception, but it can take up to 10 to notice any bleeding if it happens at all (1). In some cases, this coincides with the typical time of a woman’s period and she may not realize she is pregnant at all.
Does Every Woman Experience Implantation Bleeding?
Only around 30 percent of pregnant women experience implantation bleeding.
If you don’t see any sort of spotting in your early pregnancy, don’t freak out — you’re in the majority if you haven’t noticed it. And even if you did bleed a tiny amount, you could’ve missed it.
Relying on one clue to prove your pregnancy is never a good idea, so if you think you may be pregnant but haven’t noticed spotting, just look for other signs your body gives. Some women may also experience spotting with only one pregnancy if they’ve had multiple children. Each journey is different!
What Does Implantation Bleeding Look Like?
A lot of women get confused when they try to figure out if what they’re seeing is a sign of pregnancy or just the beginning of their period. They may also start to wonder if something is wrong, especially if a pregnancy wasn’t planned or expected.
Telling period bleeding from implantation bleeding is pretty simple if you have a good relationship with your cycle and know what to look for. Picture what a typical period looks like for you, and compare it to what you’re seeing now.
Some of the things you’ll notice with implantation bleeding:
- Amount: Implantation bleeding is nowhere near as heavy as a period. It shouldn’t be enough to fill up a pad, so if it’s less than what you’d see during a period, this is a great clue.
- Color: Every woman sees a different pattern with her cycle, but you should be familiar with what shade your blood usually is during your period. Implantation bleeding is almost always a different color than period blood, sometimes dark brown, other times almost pinkish.
- Thickness: Even women who experience a light flow usually can tell the difference between implantation bleeding and period blood. Unlike what you see once a month, this type of bleeding is thinner and won’t come out in thick clumps, but streaks or slight drops.
- Duration: The length of implantation bleeding differs between women, but the maximum amount is about three days of spotting. This is much shorter than a period, so if you see blood for a short time and it disappears, this is a good sign you’re pregnant and experiencing implantation bleeding.
- Timing: Implantation bleeding generally comes before you expect to get your period by a couple of days. If you experience light bleeding and it comes before your expected period, this is a good sign that it is implantation and not your period.
Even if you feel like what you’re seeing fits all four of these categories, don’t stress yet. You should never accept anything as definite until a doctor tests you, but it doesn’t hurt to keep paying attention to your body!
How Common is Heavy Implantation Bleeding?
Implantation bleeding is not all that common, and heavy implantation bleeding even less so. There’s little information out there about heavy or late bleeding that isn’t a period or a miscarriage. While there are a few success stories buried in various mommy forums and comment sections, it’s important to note that heavy bleeding is usually not a good sign.
The main reason heavy implantation bleeding occurs is because of something wrong with the initial implantation itself. If this happens, it may be because the egg has planted itself somewhere it shouldn’t, such as the cervix, fallopian tube, or abdomen.
This condition is called an ectopic pregnancy, meaning the egg is trying to grow somewhere it can’t (2). Unfortunately, these pregnancies almost always end in termination and may be life-threatening to you, so seek help immediately if you experience heavy implantation bleeding and you’re sure it isn’t your period.
How Common is Late Implantation Bleeding?
Implantation occurs after fertilization. It takes the fertilized egg some time to move from the fallopian tubes and down into the uterus, so there’s usually around 6 to 14 days from conception to the fertilized egg being fully implanted into the uterus.
You could see implantation bleeding anywhere from the fifth or sixth day after conception, but it can occur so late it coincides with your period due date.
Late implantation bleeding can be an alarming sight, and disappointing if you’re trying to conceive. But it doesn’t always indicate a miscarriage or the absence of a pregnancy! Some women have positive pregnancy tests after what they thought was their “period” because what they actually experienced was late implantation bleeding.
In some cases, implantation just happens later. Studies have shown, however, that the later the implantation, the more likely a miscarriage will occur (3). This is not written in stone, but if you’re worried, talk to your doctor.
Does Heavy Implantation Bleeding Mean Twins?
Once again, there isn’t a lot of reliable information out there about the connection between twins and heavy implantation bleeding. When you’re pregnant with twins, most signs of pregnancy are exaggerated, and some women have reported seeing more spotting for longer periods in their twin pregnancies.
But truthfully, these occurrences are rare on their own, and even more unlikely to happen all at once. On one hand, the body is put under more stress with twins, so you may be more likely to see implantation bleeding. On the other, many women experience implantation bleeding and go on to have singleton pregnancies.
Implantation bleeding is caused by damage to tiny blood vessels in the uterine lining, so it stands to reason if there are two eggs (like in a fraternal twin pregnancy), there would be twice as much bleeding! However, this explanation makes less sense for identical twins, and anecdotal evidence aside, there’s not much to say that implantation bleeding alone is a sign of twins.
Keep Your Doctor In The Loop
As always, if you notice anything unusual, contact your doctor first. Especially whenever it concerns spotting or heavy bleeding, since these could be early warning signs for something serious.
Is Implantation Bleeding a Miscarriage Sign?
It’s easy to tend to cling to an unusual sign or symptom as proof something negative is happening, especially if you’ve had bad experiences in the past with fertility. It’s also hard to see an unexplained change and stay positive, especially if your hopes are high.
But more often than not, light implantation bleeding is not a cause for concern. In fact, you can take it as a reassuring pat on the back!
Though miscarriages begin with spotting that may seem like implantation bleeding, they quickly become crampy, clotty, heavier and thicker. You won’t see the thin blood for long if it’s indeed a miscarriage, so your worries should be put to bed after 24 hours of noticing slight spotting.
Can Implantation Bleeding Include Clots?
Unlike period blood, implantation bleeding is very light and thin and doesn’t last long. Blood clots happen when a lot of blood pools up in the bottom of the uterus and can’t be expelled through typical contractions (aka our lovely friend cramps). There will never be enough blood to pool and thicken if you’re experiencing implantation bleeding, so this should never occur.
If you do see clots in blood that otherwise fits the bill for implantation bleeding, let your doctor know. Clots can be a sign of miscarriage, especially if your bleeding is light like it would be during implantation (4).
Other Symptoms of Implantation Bleeding
Both early pregnancy and the start of your period can manifest similar symptoms, which is frustrating for an eager mom waiting to take a pregnancy test.
You know your body, so you’ll know what’s normal and what isn’t, but there are a few key symptoms that make themselves present during implantation bleeding.
- Light cramping: As the egg arrives into its soft, cushiony new home, your endometrium is getting ready to be a gracious host for the next 9 months. All of this can result in some cramping.
- Lower back pain: Just like cramping, this is a sign your body’s hormones are working hard to create the perfect place to grow your baby.
- Headaches: As progesterone courses through your body and your womb kicks into action, the sudden change may cause you to experience headaches. This is normal.
- Mood swings: Your body is preparing to change drastically over the next few months and your hormones have kicked into high gear. This can cause some mood swings, similar to PMS.
You may notice these symptoms are suspiciously similar to those of your period. To avoid disappointment, it’s important not to rely on these symptoms alone; waiting until the moment you can take a pregnancy test is, unfortunately, the only way to know for sure.
Are Tampons Okay During Implantation Bleeding?
If there is any chance you’re pregnant, you should never use a tampon. It’s something I’ve talked about before, but it’s good to mention again.
Implantation bleeding shouldn’t be enough to warrant the use of a tampon anyway. You’ll be able to deal with it with little more than a thin panty liner. Typical implantation bleeding won’t be enough to even fill this, so if it does, you’re probably not pregnant and you’re starting your period.
Tampons can introduce bacteria into the vagina that can harm you and your baby in some cases. If you’re actively trying to become pregnant, always wait to use a tampon until you’re sure there is no chance of pregnancy.
What’s the deal with blood clots during pregnancy?
When Sandra Blitz was 22 weeks pregnant with her first child, she stood up from lying on the couch and was overcome by pain radiating down her leg, which was swollen and purplish. She phoned her husband, who was in surgical training at the time, and described her symptoms. He told her to go to hospital.
It turns out Blitz had developed a blood clot in a vein in her pelvis. The clot, called a deep vein thrombosis (DVT), in her groin, blocked blood from flowing into her left leg and she ended up staying in the hospital on blood thinners for two weeks. Though it was a frightening experience for the first-time mom, her main concern was for the health of her baby.
“Once I knew my baby was okay I was all right,” says the now mom-of-two in Kelowna, B.C. “The pain was substantial but when that started to subside I was fine.”
Blood clots during pregnancy are uncommon—there’s only a one in a thousand chance of developing one—but the even more rare risk of blood clots from the AstraZeneca vaccine has called attention to the fact that women can be at an increased risk of blood clots for many reasons throughout their lives.
Expecting mothers are at a higher risk of developing a blood clot during their nine months of pregnancy and also up to six weeks (and even 12 weeks in some cases) postpartum. Likewise, taking a combination birth control pill, with both estrogen and progestin, is associated with a risk of developing a blood clot about four times that of women not on a birth control pill, and that risk increases with age. (Higher doses of estrogen appear to increase clotting factors in the blood, which can lead to clot formation.)
Here’s what you need to know about these different types of blood clots.
Blood clots from the AstraZeneca vaccine
For unknown reasons, the AstraZeneca vaccine has triggered what hematologists call a “clotting storm” in a small number of people who have received it. Essentially, an abnormal immune reaction has caused their platelets — the blood cells that help blood clot after an injury — to be activated and cause abnormal clotting.
“With this clotting storm you get these very serious clots that can occur in unusual places like the brain, liver, gut, or even in the arteries,” says Shannon Bates, director of the division of hematology and thromboembolism at McMaster University in Hamilton, Ont.
Right now, this looks to be a rare event, says Bates. While the rate is still being confirmed, The World Health Organization currently pegs the risk of developing a blood clot from the AstraZeneca vaccine at somewhere between four to eight in one million while a German study showed it to be 1 in 100,000.
Blood clots during pregnancy
In contrast, the women who develop a blood clot during pregnancy or postpartum do so for very different reasons.
For one, expectant mothers experience decreased blood flow during pregnancy because a growing baby puts pressure on the veins in the pelvis, restricting blood flow. In addition to other natural changes in the body that occur due to pregnancy, that’s why most blood clots during pregnancy occur in the legs (most commonly the left leg) and pelvis (though sometimes a clot will show up in a lung, likely because it travelled there from the leg).
Also, the body’s way of stopping bleeding, sometimes called its “clotting system”, gets activated during pregnancy, which makes the blood more prone to coagulation. The reason for this normal change is to stop the bleeding after delivery, which is a good thing.
Nobody really understands why the higher risk of developing a blood clot extends into postpartum—it could be that the body takes time to readjust to its clotting baseline, says Bates. The risk is highest immediately following delivery and drops as the weeks go by.
If you’re wondering why you didn’t hear much about blood clots in pregnancy previously, it’s because the majority of women will sail through pregnancy and postpartum without any clotting problems. However, there are a few factors that elevate the risk of developing a blood clot, including smoking, obesity and age (the older the woman, the greater the risk). Even more concerning is a personal or family history of blood clots; in this case, the family doctor, midwife or obstetrician would discuss options, such as starting on preventative blood thinners that are safe to take during pregnancy and while breastfeeding. When Sandra Blitz found out she was pregnant with her second child, her doctor immediately put her on blood thinners because she’d experienced a DVT during her first pregnancy. She had no clotting issues the second time around.
Pregnancy blood clot warning signs
With Blitz’s blood clot, it was fairly obvious that something was wrong — her leg was extremely tender, in addition to being swollen and purple — but not all clots show up the same way. Some of the symptoms, such as leg swelling, occur regularly during pregnancy. But normal swelling appears in both legs and is lessened by elevating the feet, whereas a clot typically causes only one leg to swell and it doesn’t get better by resting. Even shortness of breath or chest tightness, which can be a sign of a blood clot in the lungs, is common later in pregnancy from the additional weight women are carrying around.
Obviously, women shouldn’t rush to the ER every time their ankles swell or they get winded going up the stairs—the real red flag, says Bates, is when there are symptoms in combination.
“If the swelling is getting worse rapidly, or there’s swelling, pain and redness—that probably signifies something more worrisome,” says Bates. “The typical pain that people describe with a (lung clot) is a sharp pain that gets worse when you breathe in, or coughing up blood, or a racing heart, or feeling light-headed… They need to go to the emergency room right away—COVID or not.”
Fortunately, most patients respond well to the standard treatment of blood thinners once they arrive in hospital. And data suggest that less than 10 percent of all blood clots are fatal, says Bates. (This data does not include blood clots from the AstraZeneca vaccine.)
COVID vaccine and blood clots in pregnant people
Though it’s been 14 years since her blood clot, Blitz wonders if her history puts her at a higher risk of developing a vaccine-related clot. But pregnant women and women with a history of blood clots needn’t worry that they have an increased risk of blood clots from the vaccine, say experts. (There is one caveat, according to Bates. People who have had a brain clot or a HITT reaction (Heparin induced thrombosis) are being advised not to get the vaccine.)
“The blood clots that are being identified as potentially associated with the [AstraZeneca] vaccine are driven by an immune response to the vaccine that causes clotting,” says Chelsea Elwood, a reproductive infectious diseases specialist and OB/GYN at BC Women’s Hospital and Health Centre. “Those are fundamentally different from the blood clots we see in pregnancy, as well as after delivery. They are both clots, but the reason for them is very different.”
That means there’s no reason to avoid getting a vaccine if you’ve had a history of blood clots. “Right now we’re advising our patients with a prior history of blood clots that we don’t think they’re at higher risk for the AZ-related clotting,” says Bates. “Get whatever vaccine is first available to you.”
Likewise, the Society of Obstetricians and Gynaecologists of Canada (SOGC), supports the use of all COVID-19 vaccines approved in Canada in any trimester of pregnancy and during breastfeeding.
“We’re getting a lot of questions asking for clarity, and we’re pretty clear about the importance of vaccinating pregnant women in the current pandemic,” says Elwood, who is also the co-chair of the SOGC infectious diseases committee. “The best vaccine is any COVID-19 vaccine, and the best time to get it when you’re pregnant is any time.”
My scan showed that I have a blood clot under the placenta. What does this mean?
The blood clot found during your scan may have been caused by a small bleed. It’s common to have light bleeding in the first three months of pregnancy. So if you’re in your first trimester, and your sonographer noticed the clot during your dating scan, it may be nothing to worry about.
This type of light bleeding may happen when your pregnancy steps up a gear. At about six weeks, the placenta is established enough to take over production of pregnancy hormones, a job your body previously did. This is thought to trigger light bleeding for some women, possibly leaving behind a clot under the placenta.
What exactly is the placenta?
If the area of bleeding under the placenta is small, the blood clot should be gradually absorbed, and it won’t affect your baby.
A larger clot, or more than one clot, may be more of a worry. The scan may show small pockets of clots under the placenta. This will appear on the scan as a dark, thickened area behind the placenta. Unfortunately, this may mean that you have an increased risk of miscarriage.
Your sonographer is likely to recommend that you come back for another scan in a week or so, to check that all is well.
Occasionally, blood clots under the placenta in your first trimester signal that problems may arise later in pregnancy. It may mean that you have a higher risk of having pregnancy complications, such as high blood pressure or pre-eclampsia.
These conditions affect how well the blood flows between the placenta and your baby, which can affect your baby’s growth.
Blood clots are more difficult to see on a scan later in your pregnancy, as the area of bleeding looks very similar to the placenta itself. In later pregnancy, you’re likely to be offered scans that check how well the placenta is working, and how well your baby is growing.
Bleeding from behind the placenta in later pregnancy may mean that you have a low-lying placenta, perhaps covering your cervix (placenta praevia). If this is the case, you’ll be under the care of an obstetrician, and you’ll have frequent scans to check where the placenta is lying, and how your baby’s doing.
Find out more about scans to check the placenta.
RACGP – Early pregnancy bleeding
Twenty to forty per cent of pregnant women will experience bleeding during the first trimester. Initial presentation is usually to the general practitioner. Complications of miscarriage, including threatened miscarriage and ectopic pregnancy, are the most common diagnoses. The failure to diagnose an ectopic pregnancy may have life-threatening consequences for a woman.
The aim of this article is to review the history, examination findings, investigations and management options for miscarriage and ectopic pregnancy.
Early pregnancy bleeding is a very distressing symptom for which a woman seeks reassurance that she has an ongoing pregnancy. It is not always possible to make a diagnosis at the first presentation. In some cases, the need for follow-up investigations or referral to a gynaecologist is required. As healthcare providers, we should continue to review and update our knowledge in the management of this common presentation in order to optimise our care of these patients.
Twenty to forty per cent of pregnant women will experience bleeding during the first trimester of pregnancy.1 The major causes are miscarriage (10–20% of clinical pregnancies) and ectopic pregnancy (1–2%).2 Bleeding in the very early weeks of pregnancy may be related to endometrial implantation. Rarer causes include cervical and vaginal lesions (eg malignancy, cervical ectropion, polyps, infection) and uterine infection. Gestational trophoblastic disease should always be considered, particularly in the setting of an abnormally raised serum human chorionic gonadotropin (hCG) or suggestive ultrasound findings. Establishing the site of the pregnancy is vital, as failure to correctly diagnose an ectopic can have potentially life-threatening consequences.
The initial assessment of a woman with vaginal bleeding in early pregnancy must first consider haemodynamic stability and the degree of pain or bleeding. Immediate transfer to the emergency department is necessary in a haemodynamically unstable patient. It is important to recognise that young women may suffer significant blood loss before any signs of haemodynamic instability are evident.
The most likely diagnoses of a haemodynamically unstable patient with early pregnancy bleeding are a ruptured ectopic pregnancy an incomplete miscarriage with ‘cervical shock’ (parasympathetic stimulation caused by products in the cervical os leading to hypotension and bradycardia) or massive haemorrhage secondary to miscarriage. A speculum examination must be performed and any products of conception (POC) removed from the cervical os. These patients may require urgent transfer to the operating theatre for a suction curettage, laparoscopy or laparotomy.
In the haemodynamically stable patient, a more detailed assessment can be undertaken in the community setting.
It is important to assess the likely gestational age of the pregnancy, the amount of blood loss and any associated pain symptoms. Syncope, chest pain and shortness of breath may point to anaemia from significant blood loss, and shoulder tip pain may be associated with intra-abdominal bleeding.
Risk factors for ectopic pregnancy include:1
- current use of an intrauterine device (IUD) or the minipill
- pregnancy as a result of assisted reproduction
- a past history of pelvic infection or sexually transmissible infections (STIs) or tubal surgery
- previous ectopic pregnancy.1
Cervical smear history is relevant, particularly if any abnormal bleeding has also been occurring outside of pregnancy. Certain medical conditions, such as poorly controlled diabetes and thyroid disease, are associated with an increased risk of miscarriage.3
Following initial assessment for any evidence of haemodynamic instability and anaemia, abdominal examination may reveal areas of tenderness, guarding or rigidity, and signs of distension. The fundus will be palpable above the symphysis pubis when the uterus reaches the size appropriate for a 12-week gestation. It may be palpable earlier than this in the case of a multiple pregnancy, gestational trophoblastic disease (GTD), or if other pelvic or uterine masses such as fibroids or ovarian cysts are present.
Speculum examination is performed to assess the amount and origin of ongoing bleeding. The vagina and cervix should be inspected for other causes of bleeding (eg polyps). Tissue present in the open cervical os must always be removed and should be sent for histopathological examination to confirm retained POC. Bimanual examination allows assessment of uterine size, dilatation of the cervical os, pelvic tenderness and cervical motion tenderness.
Pelvic and cervical motion tenderness need immediate further investigation and discussion with a specialist.
A combination of ultrasound assessment and measurement of serum hCG is required to determine the location and viability of an early pregnancy when the woman has presented with bleeding. Testing for maternal blood group and antibody status will determine the need for Rh D immunoglobulin administration.
|Figure 1. Gestational sac within uterine cavity on TVS|
Serum hCG levels rise exponentially up to six to seven weeks of gestation, increasing by at least 66% every 48 hours.4 Following repeat measurements separated by 48–72 hours, a falling hCG is consistent with a non-viable pregnancy, but does not indicate whether the pregnancy is a failed intrauterine pregnancy (IUP), or an involuting ectopic. Plateaued or very slow to rise levels of hCG (<50% in 48 hours) are suggestive of an ectopic or non-viable intrauterine pregnancy.3 However, it should be noted that an apparently appropriately rising hCG is found in 21% of ectopic pregnancies.3
Ultrasonography for pregnancy assessment in the first trimester should be performed transvaginally by an experienced sonographer. On transvaginal ultrasound (TVS), a gestational sac will usually be visible from four weeks and three days after the last menstrual period,5 assuming the dates are correct and menstrual cycle is regular (Figure 1).
A non-viable pregnancy is diagnosed on ultrasound under either or both of the following circumstances:
- no live fetus visible in a gestational sac where the mean sac diameter (MSD) is >25 mm
- visible fetal pole with a crown rump length (CRL) of >7 mm, with no fetal heart activity after a period of observation of at least 30 seconds.5
If there is any doubt regarding the viability of the fetus, a second opinion or a review scan in one week is recommended. If a gestational sac is not visible in the uterus, the adnexa should be carefully examined for evidence of an ectopic pregnancy (Figure 2). An adnexal mass is the most common ultrasound finding in ectopic pregnancies, present in >88% of cases.6
|Figure 2. Ectopic pregnancy on TVS|
The discriminatory zone is the serum hCG level above which a gestational sac should be visualised on TVS. In most institutions, this is set at 1500 or 2000 IU/L, although a number of variables, including skill of the sonographer and quality of the ultrasound, can alter the level. Below the hCG discriminatory zone, the diagnosis of a non-viable pregnancy can be made solely on the basis of an inappropriately rising hCG. Above the discriminatory zone, the diagnosis is based on the absence of evidence of an IUP on TVS. Table 1 gives examples of a discriminatory hCG of 2000 IU/L, with TVS findings and recommendations for management.
|hCG/TVS in clinically stable women||Interpretation/recommendation|
|hCG <2000 IU/L||Repeat TVS/hCG in 48–72 hours|
|hCG >2000 IU/L and TVS with no IUP, complex adnexal mass and/or free fluid||High probability of ectopic pregnancy|
|hCG >2000 IU/L and TVS with no IUP and no abnormal findings||Repeat TVS/ hCG in 48–72 hours|
|Declining or suboptimally rising hCG levels||Indicates a non-viable pregnancy (ectopic or IUP), appropriate follow-up to ensure adequate resolution of either diagnosis|
|hCG, human chorionic gonadotropin; TVS, transvaginal ultrasound; IVP, intrauterine pregnancy|
Pregnancy of unknown location
If there are no signs on a TVS of an intra- or extra-uterine pregnancy, and no obvious retained POC are seen, the pregnancy is defined as a pregnancy of unknown location (PUL). Under these circumstances, the three possible scenarios are:5
- intrauterine pregnancy
- ectopic pregnancy
- failed PUL.
When interpreting the scan result of a woman with a PUL, there is evidence that serum hCG levels at zero and 48 hours are helpful in diagnosis of the ectopic location.5
Until the location is determined, a woman with a PUL could have an ectopic pregnancy. It is therefore important to re assess the woman if symptoms change. Women who have a plateauing hCG, or new or worsening clinical symptoms, require referral for specialist assessment. Clinical symptoms may necessitate admission to hospital while further investigations are undertaken.
Management of miscarriage
|Miscarriage||Pregnancy loss before 20 weeks’ gestation or fetal weight <400 g|
|Threatened||Vaginal bleeding prior to 20 weeks’ gestation|
|Inevitable||Passage of POC of a non-viable IUP occurring or expected to occur imminently|
|Incomplete||Some retention of POC of a non-viable IUP|
|Missed||Ultrasound scans diagnosis of a non-viable IUP in the absence of vaginal bleeding|
|Septic||Miscarriage complicated by infection|
|Recurrent||Three or more consecutive miscarriages|
|Complete||Full expulsion of POC of an IUP|
|POC, products of conception; IVP, intrauterine pregnancy|
Several terms are used to describe clinical scenarios around the process of miscarriage. These are defined in Table 2.
Threatened miscarriage is treated expectantly. There is a 2.6 times increased risk of miscarriage later in the same pregnancy in cases of early threatened miscarriage, and 17% of women go on to have further complications in pregnancy (such as pre-term labour or intrauterine growth restriction).7 There is insufficient evidence to recommend progesterone administration in the setting of threatened miscarriage.8
For inevitable, incomplete and missed miscarriages, management options include expectant, medical and surgical treatments. Depending on the method chosen, follow-up will be required to ensure complete evacuation of the uterus. A complete miscarriage requires evaluation of any ongoing bleeding, with confirmation that the cervical os is closed, and, if necessary, a TVS to rule out retained POC.
Expectant management involves allowing the natural process of expulsion of uterine POC to occur without intervention. The woman must be informed regarding the expected length of the process, symptoms of pain and bleeding that she is likely to experience, and how to seek emergency medical assistance. For incomplete miscarriages, 60% of women experience complete expulsion of products in the ensuing two weeks and 90% by six to eight weeks.9 Missed miscarriages generally take longer to expel.
Ongoing review should occur at one to two weeks, and if pain and bleeding have ceased, a repeat serum hCG should be performed at three weeks. If this is positive, further assessment with serial hCG measurements, to ensure these fall to negative levels, or an ultrasound scan may be required to assess for retained POC.
If no bleeding or pain occurs within seven to 14 days of the initial consultation, repeat the ultrasound and further discuss all treatment options as appropriate.
Medical management involves the use of misoprostol (a prostaglandin E1 analogue), which has been shown to be highly effective for medical evacuation of the uterus given either vaginally or orally.10 Further research is required to determine the optimal dose and route of administration. Medical management should only be performed in a unit with experience in this form of management
Surgical evacuation is the treatment of choice for women with haemorrhage or sepsis. A woman may choose a surgical evacuation in order to avoid pain, bleeding and prolongation of the process. Medical management is contraindicated in some cases, such as for a woman on anticoagulant therapy. Complications of surgical evacuation include anaesthetic risks, haemorrhage, perforation, retained POC and endometritis.
The MIST trial,11 a large, randomised controlled trial, compared expectant, medical and surgical management options for the treatment of miscarriage. It showed comparable efficacy and no significant difference in infection rates (2–3%). The trial reported that unplanned hospital admissions were significantly increased in the expectant (49%) and medical (18%) groups, compared with the surgical group (8%). Surgical management was required in 44% of the expectant group and 13% of those given medication; 5% of the surgical group required a further surgical procedure.
Management of ectopic pregnancy
Ninety-five per cent of ectopic pregnancies are situated in the fallopian tube.12 Other, rarer sites include the cervix, ovary, other abdominal sites or in a caesarean section uterine scar. Rarely, an ectopic pregnancy may co-exist with an intrauterine pregnancy (heterotopic pregnancy).
Management options for tubal ectopic pregnancy include surgery (salpingectomy or salpingostomy), medical management with methotrexate, and possibly expectant management in a limited population of carefully selected cases, although no high-level evidence exists to recommend this approach.
Surgery is required for the haemodynamically unstable patient, those with evidence of rupture, after failed medical treatment and if contraindications to methotrexate therapy exist (including the possibility of non-compliance with follow-up). Some patients may choose surgery over medical management. Laparsocopic surgery should be performed whenever possible.13 A salpingectomy is usually performed unless the contralateral tube is damaged. A salpingostomy may result in a need for further treatment (4–15%)14 with methotrexate or a salpingectomy if follow-up hCG levels do not fall appropriately. In women who have had a salpingostomy, hCG levels should be measured weekly until negative due to the potential for retained pregnancy tissue in the affected tube. In the case of a salpingectomy, histological confirmation of a tubal pregnancy is usually all that is required.
About one-third of patients with ectopic pregnancy are suitable for medical management with methotrexate. These women should be haemodynamically stable, be able to comply with treatment and follow-up, ideally have an hCG <5000 IU/L (the greatest predictor of success)7,15 and an adnexal mass <3.5 cm with no fetal cardiac activity. Initial treatment is with a single intramuscular dose of methotrexate (50 mg/m2), with 14% of women requiring a further dose. Success rates are up to 85%, which is similar to salpingostomy.9 Up to 15% of women may require surgical intervention.
Ongoing fertility in the two to three years following surgical or medical treatment for ectopic pregnancy appears to be similar between methotrexate, salpingotomy and salpingectomy groups.15
Management of rhesus negative patients
Rh D immunoglobulin (RhIg) is indicated for the prevention of Rh D sensitisation in Rh D negative women. RhIg can be obtained through emergency departments or blood banks; 250 IU RhIg is required for a first trimester sensitising event such as miscarriage, ectopic pregnancy, termination of pregnancy and chorionic villous sampling. This should be given within 72 hours of the sensitising event, though administration of RhIg up to nine to 10 days later may provide some protection.1
Early pregnancy bleeding can cause great anxiety and distress for a woman, her partner and family, especially where a diagnosis of a non-viable pregnancy is made. It is important that the situation is dealt with both safely and sensitively and that the woman and her family are well supported throughout this time. Most tertiary and many regional hospitals now run early pregnancy assessment clinics that can assist GPs in the management of complications in the first trimester.
Carol Breeze MBChB, FRANZCOG, Staff Specialist, Obstetrics and Gynaecology, Cairns Hospital, Lecturer, Obstetrics and Gynaecology, James Cook University, Townsville, QLD. [email protected]
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
Vaginal Bleeding During Pregnancy | CS Mott Children’s Hospital
The following guidelines will help you determine the severity of your vaginal bleeding.
- Severe bleeding means you are soaking through your usual pads or tampons each hour for 2 or more hours. For most women, soaking through their usual pads or tampons every hour for 2 or more hours is not normal and is considered severe. If you are pregnant: You may have a gush of blood or pass a clot, but if the bleeding stops, it is not considered severe.
- Moderate bleeding means that you are soaking more than 1 pad or tampon in 3 hours.
- Mild bleeding means that you are soaking less than 1 pad or tampon in more than 3 hours.
- Minimal bleeding means “spotting” or a few drops of blood.
Vaginal bleeding can be a sign of miscarriage or preterm labor during pregnancy in the first trimester. During the first trimester of pregnancy:
- Up to 25% of pregnant women have some spotting or light vaginal bleeding. Of these women, about 50% do not have a miscarriage. Vaginal bleeding during pregnancy is more common among women who have been pregnant before than in women who are pregnant for the first time.
- Very early spotting sometimes occurs when the fertilized egg implants in the uterus. Implantation takes place 6 to 10 days after fertilization.
Bleeding in the second or third trimester of pregnancy may mean a problem is present, such as:
- Placenta previa. Normally, the placenta is attached to the top portion of the uterus. In placenta previa, the placenta has attached low in the uterus, and partially or completely covers or blocks the cervix.
- Placenta abruptio. Normally, the placenta is firmly attached to the uterine wall until birth. If the placenta separates from the uterus before the baby is delivered, this is called placenta abruptio or abruptio placenta or placental abruption. Placenta abruptio usually occurs in the third trimester of pregnancy, but it can occur any time after the 20th week.
Current as of:
October 8, 2020
Author: Healthwise Staff
William H. Blahd Jr. MD, FACEP – Emergency Medicine
Kathleen Romito MD – Family Medicine
Adam Husney MD – Family Medicine
Elizabeth T. Russo MD – Internal Medicine
Kirtly Jones MD – Obstetrics and Gynecology
Current as of: October 8, 2020
Medical Review:William H. Blahd Jr. MD, FACEP – Emergency Medicine & Kathleen Romito MD – Family Medicine & Adam Husney MD – Family Medicine & Elizabeth T. Russo MD – Internal Medicine & Kirtly Jones MD – Obstetrics and Gynecology
Bleeding & Cramping – Pomegranate Midwives
Bleeding in Pregnancy
What are the possible causes of bleeding or spotting?
- Cervical friability (i.e. cervix that bleeds easily for benign reasons)
- Growth spurt (common around 12 weeks, again around 20 weeks – often with cramping)
- Irritation or trauma, especially if infection, cervical cyst or polyp present
- Unknown cause
- Implantation spotting (i.e. as the fertilized egg attaches itself to the uterus it may cause some irritation and bleeding)
- Ectopic pregnancy (i.e. the embryo is growing outside the uterus)
- Cervical dilation
- Early labor “show” (a sign of cervical dilation starting to happen)
SECOND & THIRD TRIMESTERS
When should I worry about miscarriage?
Obviously miscarriage is what everyone worries about whenever they see spotting.
THE GOOD NEWS
One in three women experience spotting or bleeding in pregnancy. Only 50% of these go on to have miscarriages, the majority in the first trimester.
While 40% of pregnancies end up in miscarriage, most of these are before 4 weeks of pregnancy (i.e. 2 weeks post conception, when you would miss your period). After 4 weeks, the miscarriage rate goes down to 15%. In addition, once your baby’s heartbeat has been heard, the chance of miscarriage goes down to 5%.
Part of the reason that so many pregnant women experience spotting is that there is a tremendous increase in blood volume, which means that capillaries in the cervix are easily disturbed causing bleeding. This is the equivalent of having your gums bleed after brushing or starting a nosebleed by blowing your nose – both things that many pregnant women also experience for the same reason. An average non-pregnant woman has about 4 litres of blood. The same woman when pregnant will increase her blood volume to over 6 litres! With this large increase, some of it may “leak” out sometimes.
THE BAD NEWS
Miscarriage cannot be predicted, only diagnosed. If you are having signs of a threatened miscarriage, your midwife may be able to send you for some testing:
- Ultrasound will be able to determine if the embryo is implanted inside the uterus, and once you are past 6-7 weeks, if there is a heartbeat.
- Early in the first trimester, bloodwork that is repeated every 48 hours will be able to demonstrate whether your pregnancy hormones are increasing at an expected rate.
- If you are beyond 10-12 weeks gestation, your midwife may be able to find your baby’s heartbeat in the clinic with a Doppler.
In any case, by the time the bloodwork results are returned or an ultrasound appointment can be made, the situation will often have made itself obvious (i.e. either the bleeding stops, or becomes heavier and clearly a miscarriage).
Can I prevent miscarriage?
- Miscarriage cannot be prevented if it is meant to happen.
- The same is true about causing miscarriage: nothing will induce miscarriage (except a medical abortion), if the pregnancy is meant to continue
Self-care is never a bad idea, if you are having some spotting, bleeding or cramping. Stay well hydrated, keep your bladder empty to prevent uterine irritation, rest and relax – these will often help settle any bleeding that is not caused by an impending miscarriage.
What can I expect if I do have a miscarriage?
What to expect depends on how far along you are, and how the miscarriage is diagnosed. Generally, the later your gestation, the more physically intense the experience.
Typically, the first sign may be spotting that progresses from brown to red over a few hours or days, then has a few hours of very intense cramping and heavy bleeding, subsiding into regular bleeding like a normal period. You may pass some clots or tissue.
Or the (impending) miscarriage may be diagnosed during an ultrasound. If this is the case, you have two options:
- EXPECTANT MANAGEMENT i.e. waiting for your body to complete the miscarriage on its own. Sometimes this happens immediately. Sometimes it takes days to weeks. Acupuncture and/or certain herbs are safe to use to hasten this process – if you are interested, the herbalists at Gaia Gardens Herbal Pharmacy can help.
- MEDICAL MANAGEMENT i.e. inducing the miscarriage. A medically-induced miscarriage may include using medication to cause the uterus to contract and expel its contents; or it may include dilating your cervix and evacuating the uterus with instruments, under either local or general anesthetic. This latter procedure is occasionally necessary when miscarriages don’t complete on their own.
What if I am past the first trimester?
Once you are past the first trimester, it is unlikely you are losing the pregnancy. As in the first trimester, most causes of second and third trimester bleeding are benign, but at the same time should still be monitored.
When should I contact my care provider?
Does not need immediate assessment unless further symptoms develop:
- Brown or pink spotting
- Small amount of fresh red spotting, less than 1 tablespoon (i.e. less than a panty liner)
Care provider should be aware. Further assessment may or may not be necessary.
- Red bleeding, more than 1 tablespoon (i.e. more than a panty liner)
- Vaginal discharge has noticeably increased recently, has a bad smell, or is causing itchiness/irritation.
- Ongoing spotting over a period of days or weeks
- Rh negative bloodtype
Page care provider right away. Further assessment will likely be necessary.
- Fully soaking >1 large maxi pad in an hour
- Spotting or bleeding with any of the following:
- Nausea or vomiting
- Foul discharge
- Shock symptoms … cold, clammy, shivery, dizziness, mental fog
- Bleeding heavier than a period >24 hours
- Severe abdominal pain
- Pain during intercourse, especially if <9 weeks pregnant
- Pain during urination
- Known placenta previa
- Preterm labor symptoms
- Contractions increasing in intensity, frequency and duration
- Gush of fluid from vagina
- Lower back pain, especially if rhythmic and progressive
- Noticeable increase in pelvic pressure
90,000 How does blood clotting affect pregnancy?
How does blood clotting affect pregnancy?
23 April 2019
How does blood clotting affect pregnancy?
Disorders of hemostasis increase the risk of severe bleeding during childbirth and caesarean section. Hemostasis is a biological system that preserves the liquid state of the blood, prevents or inhibits blood loss by maintaining the integrity of the vascular wall and the formation of blood clots at the sites of vascular damage.
In obstetric practice, the most dangerous are hidden defects of hemostasis, which, if undiagnosed, may well cause an unfavorable outcome of gestation.
Pregnancy in women with hereditary defects of hemostasis can proceed without pronounced disturbances. One of the mandatory stages of examination during pregnancy is hemostasiological examination.
Interpretation of laboratory tests taking into account the gestational period underlies the timely diagnosis and adequate therapeutic correction of obstetric complications, the interpretation of the research results is carried out by the obstetrician-gynecologist in the antenatal clinic together with a related specialist – hematologist.
Changes in the hemostatic system during pregnancy are physiological and are associated with the appearance of the uteroplacental circle of blood circulation. As gestation progresses, changes occur in all links of the blood coagulation system aimed at maintaining balance in the hemostatic system.
This process is due to various factors and is an adaptive response of the pregnant woman’s body to reimbursement of costs in connection with the development of the fetus. In pregnant women with gestational age, the potential for blood coagulation increases, which contributes to the quality preparation of a woman for possible violations of the hemostasis system during pregnancy, childbirth and the early postpartum period.
Monitoring of the hemostasis system in pregnant women is carried out at least 2 times in a antenatal clinic.
90,000 Russian scientists have created an effective way to deal with blood clots
Scientists from the Moscow Institute of Physics and Technology and the National Medical Research Center of Hematology of the Ministry of Health of the Russian Federation have developed a new method for dealing with various types of thrombosis.A paper describing the use of ultrasound to record early stages of blood coagulation was published in PLOS ONE .
Thrombosis is the formation of blood clots (blood clots). When injured, this process is helpful as it stops the bleeding. However, today thrombosis often occurs due to problems of the cardiovascular system, and in these cases it can lead to complete blockage of blood vessels and cell death.
This can be prevented with the help of thrombolysis – the introduction into the blood of special drugs that dissolve blood clots. Since there is a risk of acute bleeding and large blood loss, this procedure is carried out only if there is a direct threat to the patient’s life.
This disease is difficult to identify, since the external symptoms of thrombosis appear only when the blood clot becomes very large. In addition, sometimes thrombosis is the result of rapidly developing processes (for example, heart attack or stroke), and requires urgent measures.Therefore, early diagnosis of thrombosis is an extremely urgent task: its solution will allow you to quickly and safely remove the blockage of blood vessels.
Scientists from the Moscow Institute of Physics and Technology and the National Medical Research Center of Hematology of the Ministry of Health of the Russian Federation have established that it is possible to track the development of thrombosis in real time using ultrasound.
They studied large and deep-lying blood vessels, which are the most dangerous for thrombus formation.During the experiment, the researchers continuously measured the blood clotting rate using high-resolution ultrasound. Based on the data of this monitoring, the optimal time for the automatic administration of the thrombolytic agent was determined.
It turned out that ultrasound allows you to register clotting at those stages when the thrombus has not yet formed completely and can be effectively dissolved with the help of medication. The authors of the study note that the new technique opens up the prospect of creating a compact device that will provide prompt assistance to patients with a high risk of blood clots.
Acute ileofemoral venous thrombosis
Acute ileofemoral venous thrombosis (IPVT) is one of the most common vascular pathologies, the frequency of which, according to some data, is 1-2 cases per 1000 population in the general population per year [1-3].
One of the most dangerous of its fatal complications is pulmonary embolism (PE), in which the mortality rate reaches 15.7-21.3% [1, 4]. According to the literature , the incidence of IPVT and its thromboembolic complications increases every year.
However, diagnostic and tactical errors are still frequently encountered in the recognition and treatment of IPVT .
In the development of IPVT, a certain role belongs to such factors as increased blood coagulation properties, prolonged immobilization and trauma of the limb, advanced age, pregnancy and the postpartum period, obesity, the use of hormonal and contraceptive drugs, the presence of neoplastic processes and thrombophilia [2, 4].
At the same time, there are not enough reports in the literature on the significance and influence of high altitude conditions, starvation and dehydration of the body, the role of infectious diseases in the development of venous thrombosis.
Despite the development and use of modern drugs, 45-100% of patients who underwent IPVT develop a complex of pathological symptoms known as post-thrombotic disease, in which the incidence of disability reaches 32% [5, 7].
Untimely and inadequate treatment of the disease, the use of outdated methods of conservative therapy for acute thrombosis, the lack of outpatient monitoring and clinical examination of patients, as well as the determination of the coagulation properties of their blood lead to a worsening of the course of the disease, and often – to rethrombosis of the affected segment [6-8] …
There are no publications on the features of the course and treatment of vascular thrombosis in patients living in countries with hot climates. The incidence of IPVT during fasting during the Ramadan fast and the peculiarities of the course and treatment of patients with IPVT, which developed due to infectious diseases of the abdominal organs, also remain unexplored.
Purpose of the study – to study the influence of poorly studied factors in the development, course and treatment of acute IPVT NK.
Material and Methods
The work is based on the results of complex diagnostics and treatment of 432 patients with acute IPVT NK who were in the department of vascular surgery of the Republican Scientific Center of Cardiovascular Surgery over the past 8 years (2007-2014).Among those observed were 289 (66.9%) women and 143 (33.1%) men aged 19 to 84 years (mean age 51.71 ± 2.2 years).
The predominance of females among patients ( n = 289) can be explained by the use of hormonal contraceptives, frequent pregnancies and childbirth, typical for women in the Republic of Tajikistan. The increased weight and low mobility of the patients were of no small importance. Most (68.75%) patients with IPVT were in the middle and older age groups.
It should be noted that among patients living in rural areas, there were 319 (73.8%), urban – 113 (26.2%) residents. 57 (17.9%) of the rural population lived in the high mountain valleys of the Pamirs.
The diagnosis was established on the basis of the clinical manifestations of the disease and the results of ultrasound duplex angioscanning (UZDAS).
UZDAS was carried out by the ultrasound diagnostic systems PHILIPS SD 800 (USA, 2005) and DC-3 Mindray (China, 2012), equipped with transducers with a frequency of 3.5-10 MHz, using B-mode and color Doppler blood flow mapping.
The state of the hemostasis system was assessed by determining the level of activated partial thromboplastin time (APTT), prothrombin time (PTT), prothrombin index (PTI), international normalized ratio (INR), thrombin time, fibrinogen, platelet count, Lee-White CCT and kaolin time.
The main objective of such a study was an attempt to establish a connection between changes in the hemostatic system and the development of IPVT, as well as the need to influence this system in the process of treating patients.
All data obtained as a result of the study were processed using Microsoft Office Excel 2007. Parametric descriptive statistics were calculated: mean ( M ), standard deviation (σ), root-mean-square error ( m ). The statistical significance of the difference in indicators was carried out according to the t -Student’s criterion. Differences between indicators were considered statistically significant at p <0.05.
Results and Discussion
Timely hospitalization of patients from rural areas largely depended on the competence of the primary care physician, since most patients were initially treated for other pathologies.
The distribution of patients depending on the age of admission to the hospital is presented in table. 1.
Table 1. Distribution of patients depending on the admission date
About 70% of patients were hospitalized within 5 days from the onset of the disease. Patients admitted in the acute period of the disease were either self-medicated, or were treated in non-core institutions, or not for thrombosis.
Studying the influence of seasonal cyclicity in the development of pathology, we found that the largest number of visits ( n = 270) was observed in the summer period – June-August (Fig.1).
Rice. 1. Seasonal frequency of development of IFCT.
The obtained data confirm the presence of the influence of a hot climate in the development of the disease, which is caused by increased sweating and dehydration, accompanied by hypercoagulation in the coagulation system.
It should be noted that among all the patients observed during this period, 107 observed fasting in the Muslim holy month of Ramadan, during which they did not take liquid and food for 13-16 hours. In the last 8 years (2007-2014), this post has coincided with the hot season.This confirms our assumptions about the significant influence of these factors on the origin of acute thrombosis.
Profuse sweating against the background of high ambient temperatures (from June to September, the average temperature, according to the hydrometeorology of the Republic of Tajikistan, is 31.2-39.6 ° C, reaching 42 ° C in some regions), dehydration and starvation in such conditions led to hypovolemia and profound changes in the hemostatic system.
Thus, the revealed by us some regularity of the development of acute IPVT in the hot period of the year and in the month of Ramadan may be the basis for taking preventive measures during these periods in patients at risk.
On the basis of UZDAS, the occlusive form of IPVT was detected in 345 (79.9%) patients, parietal thrombosis – in 51 (11.8%) and floating thrombosis – in 36 (8.3%).
When studying the history of the disease in most patients, some factors were identified that contribute to the development of IPVT, the data on which are given in table. 2.
Table 2. Etiological factors of acute ileofemoral venous thrombosis
In 296 (68.5%) patients, factors for the development of IPVT were identified, which, in our opinion, could contribute to the formation of a venous thrombus.Among them, the most important, from our point of view, are fasting during the holy month of Ramadan, complicated childbirth and the postpartum period, severe typhoid fever, and operations on the abdominal and pelvic organs.
It should be noted that when observing the fasting of Ramadan, patients do not take food and water during the day, which leads to hypovolemia. Against the background of starvation and profuse sweating, the existing hypovolemia and hypercoagulation significantly deteriorate, especially among elderly patients.
Complicated labor with an average or large volume of blood loss, infection in the postpartum period, possibly led to the development of pelvic vein thrombosis, which subsequently passed downward into the iliac veins. It should be noted that this could also be facilitated by natural hypercoagulation in parturient women after childbirth.
Severe typhoid fever with hectic fever led to increased sweating, and limited fluid intake contributed to the development of hypovolemia and hypercoagulation with the development of a thrombotic process in the veins of the NK.
A history of various surgical interventions on the abdominal and pelvic organs was found in 18 patients with IPVT. The cause of thrombosis in such cases, most likely, were: surgical trauma, retroperitoneal and pelvic hematomas and an inflammatory process in the paravasal tissues.
As can be seen from the presented table. 2, other factors leading to the development of IPVT were found in fewer cases, and in 136 patients they were not established at all.
Thus, in the pathogenesis of the development of acute IPVT, in addition to the infectious principle, contributing factors, which were stated above, were of no small importance.Patients always had one of the factors of the Virchow triad of thrombus formation. The identified risk factors could by themselves and, to a greater extent, in combination with other factors, increase the risk of thrombosis.
The dynamics of indicators of the blood coagulation system during hospitalization, during treatment and before discharge of patients is given in table. 3.
Table 3. Indices of the blood coagulation system during hospitalization, during treatment and at discharge. Note.* – p <0.05; ** - p <0.01; *** - p <0.001 in comparison with the indicators on admission.
As can be seen from the indicators of the table. 3, during hospitalization of patients in all cases, there was a violation of the blood coagulation system in the direction of hypercoagulation. The conducted complex conservative therapy, with the use of modern direct and indirect anticoagulants, led to the normalization of existing disorders in the treatment process and the state of hypocoagulation upon discharge from the hospital.
UZDAS was performed in all patients before and after treatment in B-mode, which made it possible to visualize changes in the vein wall, determine the presence of blood clots, and assess the nature of recanalization of the vein lumen.
At UZDAS, attention was paid to the following indicators: the diameter of the vein, the state of its wall, localization and echo structure of the thrombus, the shape of the proximal part of the thrombus, the nature of the blood flow in the affected area. The examination was carried out on both NCs.
In the case of the occlusive form of IPVT, the lumen of the vessel was filled with masses of heterogeneous structure, blood flow in this zone was not recorded.In the parietal form, thrombotic masses were visualized in the lumen of the vein, which had a dense character, while the monophasic nature of venous blood flow was recorded due to the rigidity and thickening of the vessel wall.
In the early stages of the disease (up to 4 days), the thrombus had low echogenicity, the response of the vein to compression was partially preserved, which indicated that the thrombus was loose, its weak fixation to the vein wall, and a high probability of separation. The diameter of the vein at the sites of thrombus formation was increased due to the edema of its wall.
When the disease was 5 to 10 days old, the thrombus was more tightly fixed to the vein wall, its echogenicity was low, the lumen of the affected vein area was moderately enlarged.
In terms of more than 10 days, the echogenicity of the thrombus was increased, while it was tightly fixed to the vein wall with partial elements of organization. The diameter of the affected area of the vein approached normal values.
When examining patients, great importance was attached to the prevalence and nature of the thrombus in its proximal part, in which the length of the thrombus in all cases covered two segments of the deep veins of the NK (the proximal part of the common femoral and distal part of the external iliac veins).
Duplex scanning data on the nature of the deep vein thrombus were essential in determining the treatment tactics.
So, when a floating end of a thrombus was detected, patients were recommended to bed rest for a long time (at least 10 days) because of the danger of thromboembolic complications. The occlusive form of a thrombus was considered safer, which made it possible to activate patients early (5-7 days).
Thus, the widespread use of UZDAS in patients with any manifestations of IPVT made it possible to correctly diagnose, determine the nature of the apical part of the thrombus, and choose rational treatment tactics.By studying the echo structure of a thrombus, it is possible to determine the age of its formation and nature, as well as the state of the vein wall, vessel lumen and venous blood flow.
All patients underwent complex conservative therapy taking into account predisposing factors. The duration of inpatient treatment in our observations was 8-14 days.
The main component of conservative therapy was direct and indirect anticoagulants. Heparin (450-500 U / kg), fondoparinux sodium and enoxaparin sodium were used as direct anticoagulants.In patients with typhoid fever ( n = 41) and pregnant women ( n = 16), anticoagulants were prescribed in minimal dosages.
The first dose of heparin was injected intravenously as part of latrene or a mixture of rheopolyglucin + trental, then the drug was injected subcutaneously in the navel. The duration of administration of direct anticoagulants was 5-7 days with a gradual decrease in the dose of the drug. Starting from the 3rd day, the patients were prescribed warfarin at a dose of 2.5-5 mg / day.
Complex therapy included latren (200.0 ml intravenously once a day for 5-7 days) or rheopolyglucin + trental + heparin, phlebotonics (Detralex, Phlebodia 600, Flavovain), non-steroidal anti-inflammatory drugs (Diclofenac 3.0 (75 mg) intramuscularly for 5-10 days), aspirin or thrombotic ACC, compresses along the neurovascular bundle with heparin ointments, Lioton 1000, indomethacin.
Patients who developed thrombosis against the background of polycythemic hypovolemia and dehydration were prescribed intravenous infusion of colloidal and crystalloid solutions in a volume of up to 2.5-3 liters per day and drinking plenty of fluids.
It should be emphasized that with polycythemic hypovolemia, there is a decrease in the total blood volume in the body due to a decrease in plasma volume, and the hematocrit values in this state are above the normal range. In some patients, the hematocrit was higher than the norm, and in some it was lower, our data do not reflect severe hypovolemia in the general cohort of patients.
Compression therapy by elastic bandaging of the limb with giving it an elevated position was an obligatory component of the treatment.
It should be noted that 2 patients after suffering typhoid fever on the 5-7th day from the start of anticoagulant therapy had intestinal bleeding. Severe hypovolemia, exhaustion due to the transferred intoxication and associated bleeding became the causes of death in both cases.
In 9 out of 432 patients, at different times after discharge from the hospital, repeated thrombosis developed, for which they were again hospitalized.In some cases, the cause of the relapse was errors in the implementation of the recommendations.
During inpatient treatment, 11 patients had a clinical picture of thromboembolic complications, which was confirmed by X-ray examination. Death from PE occurred in 5 (1.2%), among whom three were drug addicts.
After discharge, the patients continued taking warfarin for 6 months, carried out compression therapy, observing the exercise regimen. The effectiveness of subsequent anticoagulant therapy was monitored by control studies of the INR value, which in our observations varied from 1.6 to 2.5, while in patients where the INR level was below 2.0, the dose of warfarin was adjusted.
Outpatient treatment, in addition to warfarin at a dose of 2.5-5 mg, included taking pentoxifylline 1 (100 mg) tablet 3 times a day for 20 days; flavovein or phlebodia 600 mg 1 time per day for 1 month, aspirin 100 mg per day continuously.
The effectiveness of conservative therapy in the course of treatment was studied on the basis of regression of the main clinical symptoms of the disease, changes in coagulogram indices, the degree of recanalization of thrombosed veins using UZDAS.
Immediate results of treatment were assessed on a 3-point system: good, satisfactory, unsatisfactory.
Good results were considered when the patient had no pain at all, the edema disappeared or significantly decreased, the function of the limb was restored in the same volume. Duplex scanning in the early period showed signs of incipient recanalization or good collateral outflow along the suprapubic veins and groin. When followed for more than 6 months, the degree of recanalization was more than 35%. These were patients who were hospitalized in the early stages of the disease – up to 24-48 hours from the onset of the disease.
A satisfactory result was considered when there was no pain syndrome and swelling decreased slightly, but increased when walking. With UZDAS, insignificant recanalization of the affected veins was noted – up to 30%.
The result was considered unsatisfactory when the main symptoms of the disease persisted: pain, although their intensity decreased, edema remained at the initial level, or an exacerbation of thrombosis was noted during treatment, and the area affected by thrombophlebitis expanded.With duplex scanning, the worst degree of recanalization of the ilio-femoral segment was noted, i.e., up to 10%.
Unsatisfactory results were more often observed in patients with severe background diseases hospitalized at a later stage of the disease.
The immediate results of conservative therapy are shown in Fig. 2.
Rice. 2. Immediate results of treatment.
As seen from fig. 2, in the process of inpatient conservative treatment, good results were obtained in 372 (86.1%) patients, satisfactory – in 31 (7.2%) and unsatisfactory – in 24 (5.5%) patients.PE with a fatal outcome was observed in 5 (1.2%) patients. Another 2 patients died from acute intestinal bleeding, which developed against the background of typhoid fever. Bleeding in these patients is not caused by hypocoagulation, but by the development of typhoid ulcers as a result of sequestration and rejection of necrotic masses in the small intestine.
Thus, acute IPVT, being a fairly frequent vascular pathology, is more common in the presence of background diseases that are predisposing factors.These include pregnancy, childbirth and the postpartum period, operations on the abdominal and pelvic organs, trauma to the limb, drug injection into the groin area, severe infectious diseases, prolonged immobilization of the limb, and the use of hormonal drugs.
At the same time, high temperatures in countries with hot climates are important, contributing to profuse sweating, thickening of the blood, hypovolemia and disorders in the hemostasis system, especially during the Ramadan fast.
There is no conflict of interest.
90,000 Frozen pregnancy: causes, symptoms, diagnosis, prevention
Freezing early pregnancy is the death of the fetus in the womb. It stops developing and dies within 28 weeks. Symptoms may be mild, increasing the risk of maternal toxicity.If during pregnancy the fetus froze and stopped its development, an urgent visit to an obstetrician-gynecologist is necessary.
Symptoms and signs of a frozen pregnancy
A frozen pregnancy in an early period proceeds absolutely imperceptibly, it can last for 1-2 weeks.This is the danger of the situation.
After 10-12 days, the woman develops the first symptoms of a frozen pregnancy:
- discharge with blood;
- severe pain in the lower abdomen;
- after 18 weeks, the cessation of fetal movement can be traced.
There are no symptoms of a frozen pregnancy in the first trimester. Sometimes spotting bloody discharge appears, a pulling feeling appears below the navel.
The second missed pregnancy indicates the presence of a pathology that requires careful study.
Do you have symptoms of a frozen pregnancy ??
Only a doctor can accurately diagnose the disease.
Do not delay the consultation – call
+7 (495) 775-73-60
Reasons for the development of
Unfortunately, the first missed pregnancy is more common.This is due to the lack of preparation of your own body. This can happen to any woman.
- genetic and chromosomal abnormalities cause the development of abnormalities that are incompatible with the life of the fetus;
- the fetus was infected with infections and sexually transmitted viruses – even before pregnancy, the risk of the presence or development of such diseases must be excluded;
- hormonal imbalance increases the risk of miscarriage, during gestation, progesterone levels should be monitored;
- the problem of blood clotting provokes the formation of blood clots, they do not allow the delivery of a sufficient amount of oxygen to the child;
- Rh-conflict causes the production of antibodies that provoke oxygen starvation of the fetus.
To accurately answer the question “Why does pregnancy freeze?” pretty hard.
Let’s consider the most common factors:
- viral diseases can affect the development of the fetus;
- the main reason is hormonal imbalance;
- non-compliance with the doctor’s recommendations;
- severe stress;
- overheating or severe freezing is prohibited while carrying a child;
- smoking and alcohol;
- Very tight clothing can harm the pregnancy;
- self-medication and taking drugs not prescribed by a doctor should be abandoned, the chemical processes of the body are closely interrelated with each other, the effect may be unpredictable.
Signs of a frozen pregnancy cause the following complications:
- depression. Requires drug treatment, psychiatric visits;
- fetal mummification, occurs with a prolonged frozen pregnancy, mummification occurs due to calcium salts, requires surgical intervention;
- infection of the mother’s body.The toxins that are formed due to the decomposition of the fetus quickly enter the woman’s bloodstream. There is sepsis, intoxication, the correct blood clotting is impaired;
- Lithopedion is a fossilized fetus that has been calcified in the body. At the same time, a woman may not feel painful symptoms.
When to see a doctor
The gynecologist must observe his patients throughout the entire period of pregnancy.If there is a risk of a frozen pregnancy, the duration of which does not exceed 12 weeks, you should immediately consult a doctor. He will determine the condition of the fetus and prescribe further examinations and treatment.
Preparing to visit a gynecologist
- You must shower before visiting your doctor.
- It is better to visit the doctor with an empty bladder so as not to interfere with palpation.
- Do not take medications that may affect the microflora or the general condition of the body; this will prevent the doctor from collecting an accurate medical history.
Symptoms of a frozen pregnancy may not appear at all. To avoid intoxication of the body, you should regularly visit a gynecologist.
Diagnostics of a frozen pregnancy
Diagnostics is carried out in 2 ways: blood test and ultrasound.If ultrasound diagnostics reveals fetal cardiac arrest, the patient is referred to a gynecologist for further procedures.
The patient can make an appointment and get a consultation at a convenient time for him. The pregnancy management program fully complies with clinical guidelines and the latest standards.
JSC “Medicine” (the clinic of Academician Roitberg) is located in the Central Administrative District of Moscow, not far from m Mayakovskaya, m Belorusskaya, m Novoslobodskaya, m Tverskaya, m Chekhovskaya.At the address: 2nd Tverskoy-Yamskaya lane, 10.
Treatment takes place in 3 ways:
- artificial childbirth.
Curettage – curettage of the uterine cavity.Cleaning after a frozen pregnancy is carried out for a period of 5 weeks.
Aspiration – pumping out the remains of the ovum. It is carried out in the early stages up to 5 weeks.
Curettage and aspiration are performed under general anesthesia. The procedure takes about 30 minutes. After the operation, a course of antibiotics must be prescribed. The patient then visits the doctor every week. If complications do not appear, and the causes of the frozen pregnancy are eliminated, the woman can continue life in her usual rhythm.
After the loss of the embryo, many women are depressed, they begin to blame themselves that they could have done something wrong. This is an absolute mistake that can lead to depression. To alleviate your condition, you should contact a psychologist, as well as a gynecologist and other specialists who will help prepare the body for pregnancy.
After treatment, a woman can plan a pregnancy after a frozen pregnancy in six months.
Treatment of a frozen pregnancy, the duration of which has exceeded 12 weeks, implies surgery. At home, the restoration of the body is impossible. For a successful recovery, it is necessary to pass a large number of tests and a long recovery, associated with taking antibiotics.At home, it is possible to raise the general tone of the body.
Important! During gestation, any medication should be taken as directed by a doctor. Many decoctions and herbs have a negative effect on the fetus and can even provoke early childbirth or miscarriage.
To increase your progesterone levels, you need to:
- Include fermented milk products, cheeses, cottage cheese, milk, cream in the diet;
- eat fatty fish;
- do not forget about nuts, berries, fruits and vegetables;
- drink a decoction of plantain seeds, borax uterus, raspberry leaves.
It is better to use decoctions in the second half of the cycle. Drink a drink in a volume of 200 ml, no more than 2 times a day.
Important! Broths that increase progesterone should not be drunk at the same time as hormonal drugs.
To prepare for pregnancy, you need:
- replace coffee with chamomile, mint, rosehip and oregano tea;
- replace sugar and sweeteners with natural honey;
- drink more clean water;
- to be treated for genital infections and maintain health with the help of a decoction of a red brush, borax uterus, coltsfoot.
Prevention is a thorough preparation for the new bearing of the fetus. For this, it is necessary to study the problem of the previous arrest of the development of the embryo.
To exclude signs of a frozen pregnancy, you need:
- visit a geneticist who will advise a man and a woman.He will calculate the probability of a frozen pregnancy;
- both partners need to be screened for genital infections. If they are present, do not start conceiving until the body is fully restored;
- before conception, you need to know the Rh factor and blood group. If Rh is negative, the woman should be monitored by a doctor who will monitor dynamic observation and monitor the antibody titer;
- Controlling the hormone progesterone will reduce the risk of miscarriage and developmental arrest.If the level is too low, the woman is prescribed special drugs.
It also makes sense to stop smoking and drinking pleasure drinks. It is necessary to do this not only for a woman, but also for a man.
How to make an appointment with an obstetrician-gynecologist?
You can make an appointment with a doctor by filling out a simple form on the website or by calling the phone number +7 (495) 775-73-60.You can call around the clock. The causes of a frozen pregnancy cannot be detected independently; consultation of several specialists is required.
We are located near the Mayakovskaya metro station and the Belorusskaya metro station.
Diagnosis of hereditary diseases using high-throughput sequencing
In accordance with the peculiarities of the methods and the specifics of practical and scientific problems, 3 directions of clinical diagnostics are organized in the laboratory:
Appointments are made through the paid services department: 437-11-00, + 7-911-766-97-70 on weekdays from 09-00 to 17-00.
Diagnosis of hereditary diseases by high-throughput sequencing
Hereditary diseases are an urgent problem of modern healthcare. According to the WHO, the estimated number of hereditary diseases can reach 10,000, and the number of patients is 10% of the total population of the world.
The primary task facing the attending physician is to exclude or confirm the genetic nature of the disease, which makes it possible to determine the tactics of treatment, to predict the life and health of the patient and his relatives.
Clinical diagnosis of a rare disease is often difficult, especially in newborns. In such cases, molecular diagnostics is of decisive importance.
Depending on the specific clinical task, it is required to study genome regions of different sizes – from one nucleotide to the entire genome. The decision on the amount of genetic testing to be performed is made individually for each patient and requires an integrated approach.
In the genetic laboratory of St. Petersburg GBUZ GB No. 40, it is possible to carry out molecular genetic testing by high-throughput sequencing on the MiSeq Illumina device.This method makes it possible to determine the nucleotide sequence of both individual genes and the entire exome (all coding sequences) or genome.
Consultation with a geneticist before molecular genetic testing allows you to clarify the indications for the test and the scope of the study. Based on the results of the analysis, a written conclusion with a detailed interpretation is issued. Recommendations and clarifications on the results can be obtained from a geneticist or attending physician.
In the future, the genetic passport will become the most reliable carrier of all personal data of a person.Now St. Petersburg scientists have already developed a method for determining genetic opportunities and risks based on DNA.
The technology of this process is simple. A molecule is isolated from almost any biomaterial (scraping from a cheek or a drop of blood). It contains, according to the latest data, 22 thousand genes. However, for the most accurate analysis, about 100 genes are used. Each of them carries its own information, which assesses both your predisposition to diseases, for example, pathology of the heart and blood vessels, and to other indicators: stamina, obesity, aggression, intolerance to milk, cereals or alcohol.
Then it is enough for a specialist to look at the “picture” and say what dangers lie ahead, to issue certain recommendations on lifestyle and nutrition. For example: if diabetes is likely to occur, reduce sugar and fat intake; to reduce the risk of heart attack or stroke – to strengthen weak blood vessels. That is, even with a genetic predisposition to a particular disease, you can prevent its development or reduce the risk of severe complications.
Another plus – your genes will “prompt” the most effective treatment for an illness.Usually, for a doctor, a person who comes for treatment is an average patient, and in case of illness, he recommends a standard medicine for you. But for someone it will work well, but for someone it will not help much – it all depends on the genes. If the doctor looks at the genetic passport, he will be able to choose a treatment based on your characteristics – the most effective for your body.
In addition, it is possible to predict whether a particular person will turn out to be a good athlete, even a sport, a brilliant scientist or a musician.
So far, the main consumers of the “genetic passport” are expectant mothers who want to give birth and give birth to a healthy baby. For them, special genetic programs have been developed for planning pregnancy, preventing complications of pregnancy, reducing complications during childbirth, etc.
Genetic testing before conception and during pregnancy
- Every fifth married couple in Russia is infertile and more than 30% of women have serious disorders during pregnancy, with a high risk of serious complications for the mother and unborn child
- One of the reasons for miscarriage and infertility may be the presence of balanced chromosomal rearrangements in the spouses, which in no way affect the health of the carrier.Chromosomal rearrangements in the karyotype of one of the parents can lead to the appearance of an unbalanced karyotype in the fetus, which is the reason for stopping the development of pregnancy and the formation of defects. Standard karyotyping carried out in the laboratory makes it possible to identify carriers of chromosomal rearrangements, which will make it possible to choose the correct and optimal tactics for planning and managing pregnancy.
- A significant part of the disorders is associated with a woman’s hereditary predisposition to such frequent diseases as endometriosis, gestosis, recurrent miscarriage, diabetes, bronchial asthma, thrombophilia, etc.
The “Genetic Map of Reproductive Health” developed by the Laboratory staff allows to identify women at high risk of these diseases even before pregnancy and to start their timely prevention. It also provides for genetic counseling of a family planning to have a child, analysis of the karyotype of spouses and genetic testing of parents to exclude the carriage of mutations leading to severe hereditary diseases (cystic fibrosis, phenylketonuria, spinal muscular dystrophy, adreno-genital syndrome, etc.).
To carry out a complete or selective genetic examination for a hereditary predisposition to these diseases, for the latent carriage of mutations and chromosomal aberrations in the parents of the unborn child, you should:
- at an appointment with a laboratory geneticist to receive a referral for an examination that is necessary for your family;
- donate blood for genetic testing;
- Based on the results of genetic testing, obtain a specialist opinion and a recommendation from a geneticist.
Genetic tests and recommendations
Genetic and DNA tests are essential when planning a pregnancy
Genetic analysis of susceptibility to many multifactorial diseases has now become available. Various genetic centers and laboratories offer either an analysis for a number of diseases on the recommendation of a geneticist, or DNA analysis for all markers of multifactorial diseases available to the laboratory, followed by drawing up a genetic passport.In addition to information about the predisposition to multifactorial diseases, such a genetic passport may contain data on the carriage of hereditary diseases, recommendations for correcting the lifestyle and prevention of those multifactorial diseases to which a predisposition was found.
Hereditary thrombophilia and during pregnancy (a pathological condition that causes an increased tendency to intravascular thrombosis).
It is recommended to conduct an analysis for a predisposition to thrombophilia for all women planning a pregnancy (WHO recommendation dated December 8, 2005), especially if there were complications in previous pregnancies (both thrombosis and obstetric bleeding, the causes of which were coagulopathy).The analysis is also recommended for women with infertility and women with close relatives with thrombophilia.
What information can a thrombophilia predisposition test provide? This analysis can reveal the genetic causes of infertility, identify an increased risk of complications during pregnancy (gestosis, recurrent miscarriage, intrauterine fetal death, intrauterine growth retardation, premature placental abruption, repeated IVF failures, obstetric bleeding, thrombosis of the pelvic vessels, varicose veins, etc. T.etc.).
What can your doctor recommend if you have a predisposition to thrombophilia? Drug prevention of thrombosis and coagulopathy in order to prevent complications during pregnancy. Correction of the tactics of infertility treatment.
Varicose veins (pathological process of venous lesions, which is characterized by an increase in the diameter of the lumen, thinning of the venous wall, the formation of “nodes” and impaired venous blood flow).
It is recommended to conduct an analysis of the predisposition to varicose veins for all women planning pregnancy, especially if there are cases of this disease in close relatives (especially in the mother).
What information can be obtained from the analysis of the susceptibility to varicose veins? This analysis reveals an increased risk of developing varicose veins (varicose veins of the lower extremities and hemorrhoids). Pregnancy is a predisposing factor for the development of varicose veins, therefore, in the presence of a genetic predisposition to this disease, special attention should be paid to its prevention.
What can your doctor recommend if you have a predisposition to varicose veins? A set of measures to prevent this disease during pregnancy.
Endometriosis (a gynecological disease in which the cells of the endometrium (the inner layer of the wall of the uterus) grow outside the uterus. Since the endometrioid tissue has receptors for hormones, the same changes occur in it as in the normal endometrium, manifested by monthly bleeding, soreness, leading to inflammation of the surrounding tissues ).
It is recommended to conduct an endometriosis susceptibility test for women with infertility diagnosed with endometriosis, in cases of close relatives with endometriosis.
What information can the endometriosis susceptibility test provide? This analysis allows you to identify a possible cause of infertility. In the case of diagnosed endometriosis, the presence of a genetic predisposition to this disease may require correction of the therapy.
What can your doctor recommend if you have a predisposition to endometriosis? Correction of ongoing therapy for already diagnosed endometriosis. Laparoscopy to confirm or exclude endometriosis as a cause of infertility.Preventive measures to prevent the development of this disease (preventive examinations, treatment of chronic foci of infection of the genitourinary system, control of hormonal levels).
Habitual miscarriage (pregnancy pathology, characterized by repeated spontaneous termination of pregnancy).
It is recommended to conduct an analysis for the predisposition to recurrent miscarriage of women planning pregnancy, especially those who have had cases of miscarriage, as well as those who have close relatives with recurrent miscarriage.
What information can an analysis of the predisposition to recurrent miscarriage give? This analysis allows you to identify a genetically determined risk of miscarriage, to identify probable genetic causes in cases of diagnosed recurrent miscarriage.
What can your doctor recommend if you have a predisposition to miscarriage? A number of preventive measures to prevent termination of pregnancy, taking into account the genetic characteristics of the patient.
Gestosis (complication of the second half of pregnancy, characterized by increased blood pressure, edema, the presence of protein in the urine, with an unfavorable course leads to the development of multiple organ failure).
It is recommended to analyze the predisposition to preeclampsia for all women planning pregnancy, especially those who have close relatives with cases of this complication of pregnancy, as well as with existing somatic diseases (Diabetes mellitus type 1 and 2, hypertension, kidney disease, thyroid disease glands).
What information can be given by the analysis for predisposition to preeclampsia? This analysis allows you to identify a genetically determined risk of gestosis in order to prevent it during pregnancy.
What can your doctor recommend if you have a predisposition to preeclampsia? A set of measures for the prevention of gestosis during pregnancy, increased attention to the pregnant woman.
Hypertension (a disease of the cardiovascular system, the main manifestation of which is an increase in blood pressure) .
It is recommended to conduct an analysis of susceptibility to hypertension for all women planning pregnancy, especially those who have close relatives with hypertension.
What information can an analysis of susceptibility to hypertension give? Genetic predisposition to hypertension is associated with an increased risk of developing preeclampsia during pregnancy.
What can your doctor recommend if you have a predisposition to hypertension? A set of measures for the prevention of preeclampsia and hypertension during pregnancy.
Breast and ovarian cancer.
It is recommended to carry out a test for susceptibility to breast and ovarian cancer for all women, especially those with close relatives with such diseases.
What information can a breast and ovarian cancer susceptibility test provide? The lifetime risk of developing breast or ovarian cancer for women with a genetic predisposition to these diseases reaches 80-90%.At the same time, the risk of getting sick at a young age (up to 30 years) reaches 10%. For the successful treatment of cancer, it is very important to detect the tumor at an early stage, even before the onset of symptoms. Therefore, the presence of a genetic predisposition to breast and ovarian cancer is a very serious indication for regular examination (every six months, at least once a year) in order to detect the disease at an early stage.
What can your doctor recommend if you have a predisposition to breast and ovarian cancer? Routine examinations, which usually include a blood test for tumor markers, pelvic ultrasound, breast ultrasound, or mammography.
Predisposition to neural tube non-overgrowth and Down syndrome in the fetus.
It is recommended to test for susceptibility to neural tube obstruction and Down syndrome in the fetus for all women planning a pregnancy.
What information can the analysis provide? Some genetically determined features of homocysteine metabolism in a woman are capable of provoking congenital developmental pathologies in an unborn child. Analysis of the predisposition to neural tube non-overgrowth and Down syndrome in the fetus reveals the presence of these features.
What can your doctor recommend if you have a predisposition to neural tube obstruction and Down syndrome in the fetus? Taking high doses of folic acid and B vitamins during pregnancy planning significantly reduce the risks of congenital abnormalities in the fetus.
Carriage of monogenic hereditary diseases (cystic fibrosis, phenylketonuria, spinal amyotrophy, sensorineural hearing loss and others).
It is recommended to conduct the analysis for all married couples planning a child, especially those in whose families there were cases of genetic diseases.
What information can the analysis provide? The analysis reveals the carriage of monogenic diseases in future parents. In case of detection of a carrier of the disease in both spouses, a geneticist’s consultation is required before the onset or at the earliest stages of pregnancy.
What can a geneticist recommend when both spouses have a carriage of the disease? Prenatal diagnosis of the fetus for the presence of the disease.
It was recommended that both spouses be tested in case of miscarriage.
What information does the analysis provide? The analysis allows you to identify balanced chromosomal rearrangements that can cause miscarriage.
What can your doctor recommend if you have balanced chromosomal rearrangements? Prenatal karyotyping of the fetus in the first trimester of pregnancy for the correction of pregnancy management tactics.
General concepts of multifactorial diseases
Genetic information combined with the influence of the external environment determine the uniqueness of each person.Under the “external environment” we here mean the totality of many factors affecting human life, such as bad habits, education, professional activity, physical activity and many, many others.
Genetic information + External environment = Unique person
Genetic (or hereditary) information is contained in the nucleotide sequence of DNA. The DNA strand is tightly packed (twisted) into chromosomes. Each cell of the human body contains 23 pairs of chromosomes.Each pair has one chromosome from the mother, one from the father. The exception is the sex cells (eggs and sperm), which contain one chromosome from each pair. After fertilization of an egg with a sperm, an embryo is obtained with 23 pairs of chromosomes, from which a person develops with a full amount of genetic information.
A DNA molecule is a sequence of nucleotides (“letters”). This nucleotide sequence encodes hereditary information. As a result of the international program “Human Genome” in 2003, such a sequence was deciphered for all human chromosomes (with the exception of a number of regions, which are difficult to decipher due to their structural features).
Deciphering of the human genome showed that the genetic information of two people who are not related by kinship coincides only by 99%. The remaining 1%, together with the “external environment”, is responsible for the diversity of appearance, abilities, character, for all the differences between people from each other.
In addition to appearance, character or abilities, a person also inherits the characteristics of his health – resistance to stress, the ability to endure physical activity, metabolic characteristics, and tolerance of medications.The uniqueness of hereditary information is manifested in the peculiarities of the functioning of the organism at the molecular level. For example, in one person, a certain enzyme may be more active than in another, and in a third, this enzyme may be completely absent. Such variations can lead to various diseases, and these diseases are divided into hereditary and multifactorial.
In the case of hereditary diseases, changes in the genome (mutations) directly lead to the development of the disease.That is, if the mutation was passed on by one of the parents, then the person becomes a carrier of the disease, if the mutation was passed on by both parents, then the person will get sick. The most common genetic (or hereditary) diseases include cystic fibrosis, phenylketonuria, hemophilia, color blindness, and others.
Hereditary diseases are quite rare, mainly variations in the genome are associated with multifactorial diseases.
Multifactorial diseases are diseases arising from an unfavorable combination of a number of factors: genetic characteristics (genetic predisposition) and the influence of the “external environment” – bad habits, lifestyle, professional activity and others.The so-called SNPs (single nucleotide polymorphism – single nucleotide polymorphisms or substitutions) are most often responsible for the genetic predisposition. That is, replacing one letter in a DNA strand with another.
In the case of hereditary diseases, we used the term “mutation”, and in the case of multifactorial diseases, “polymorphism”. From a molecular point of view, they are one and the same: quantitative and qualitative changes in the structure of DNA. Their main differences are in the frequency of occurrence and consequences for the organism.Within the population, a certain mutation occurs with a frequency of 1-2%. They are either incompatible with life or necessarily lead to the development of the disease. Polymorphisms occur with a frequency of more than 1-2%. They can be neutral (do not affect the body in any way), predispose to diseases under certain conditions, or, conversely, to some extent protect against the development of the disease.
That is, the very presence of a genetic predisposition to a disease does not necessarily lead to the development of this disease.However, in the presence of unfavorable factors of the “external environment”, a person with a hereditary predisposition is significantly more likely to get sick than people who do not have such a predisposition.
As an illustrative example, we can cite a predisposition to lung cancer and such a factor of the “external environment” as smoking. Everyone knows about the dangers of smoking and the fact that this bad habit can lead to cancer. However, from smokers, as a denial of the harm of smoking, you can often hear stories about how someone smoked two packs of cigarettes a day all his life and lived to be 90 years old.Yes, this happens, only this does not refute the harm of smoking, it suggests that some people are genetically predisposed to the development of lung cancer, while others are not. And in combination with such an environmental factor as smoking, a hereditary predisposition is likely to lead to the development of cancer.
What can be given to us by the knowledge that we are genetically predisposed to any disease?
You can often hear the opinion that it is better not to know about your predisposition to various diseases – all the same, after all, nothing can be changed, just another reason to get nervous.But this is not the case!
First, let’s remember that a disease occurs when there are unfavorable environmental factors. The influence of these factors in many cases can be excluded. For example, having a predisposition to lung cancer is a strong argument in favor of quitting this bad habit.
Secondly, in a number of cases there are effective methods of preventing a disease to which there is a genetic predisposition. For example, if you have a predisposition to thromboembolism, regular use of low doses of aspirin significantly reduces the risk of thrombosis.
Third, it is much easier to treat diseases at an early stage. But at this time, the disease is often asymptomatic. Few people have the desire, time and financial resources for a regular full examination of their body. If we know the characteristics of our genome, we know a specific list of diseases to which we are predisposed, it will be easier for us to track these diseases at an early stage.
Fourth, the presence of a genetic predisposition to a particular disease may affect the treatment regimen for this disease.For example, the regulation of blood pressure is a rather complex process, for which a large number of genes are responsible. Depending on the change in which particular gene leads to the development of arterial hypertension, the doctor may prescribe the most effective treatment.
Establishment (determination) of paternity, relationship and personal identification
Genetic examination to determine paternity has always been and remains an expensive, troublesome and psychologically traumatic procedure: you need to go to court, obtain a court decision on the appointment of an examination, all family members appear at a court-appointed medical genetic center, donate blood in compliance with legal procedures, and usually enough wait a long time for the result.
We offer you, using our capabilities (based on the achievements of scientific and technological progress in the field of medicine and laboratory diagnostics), to conduct a genetic study to establish paternity and biological relationship.
Technologically, the procedure for performing the research, and, accordingly, the results obtained are identical to the examination of the determination of paternity. However, using the fact that cells of any human tissue contain absolutely identical DNA with blood cells, we are able to simplify the procedure for taking the material without losing the reliability of the study.
For this, it is only necessary to select material (scraping of the epithelium from the inner surface of the cheek) for research in the child and the alleged father in strict accordance with the instructions (saliva collection, blood sampling), that is, observe the rules for taking material, labeling procedure, storage conditions and delivery to the hospital laboratory registry.
The laboratory carries out a comparative analysis of DNA from the samples received from the customer. The customer is issued a conclusion containing a description of the methods and test systems used in the study, a list of the studied DNA sections (loci), genotypes (“genetic portraits”) of the child and the parent, all calculations for comparing these genotypes, that is, reliable objective information that can be reproduced (verified) in any equipped specialized laboratory with an identical result.The accuracy of the negative conclusion (“is not a father”) is 100%, the accuracy of the positive (“is the father”) is not less than 99.99%.
Sports Genetics and Genetic Passport
Analyzing the results of the last major world competitions, including the Olympic Games in Beijing, it becomes obvious that the success of sports science and practice is largely related to the use of modern scientific achievements of genetics.
Sports genetics and associated genetic testing are absolutely safe, unlike doping, and take into account the individual characteristics of the human body better than any other existing methods.Moreover, genetic testing at any stage of sports training can provide primary information to coaches for selection in sports sections and the choice of an individual approach to training when “doing for yourself”. On the other hand, an individual approach to recovery procedures is equally important. It is known that different people perceive training loads in different ways and at different rates. Some people tend to adapt quickly, others recover more slowly. Most of these processes, one way or another, are caused by genetic mechanisms, these processes are studied in the section sports genetics
An illustrative example of a clear dependence of the level of blood pressure on the work of some genes.If a person with the “high blood pressure” gene receives a high dose of exercise after a break, then the likelihood of myocardial infarction increases dramatically. On the other hand, such people recover faster with light and regular exercise. Building muscle mass is also directly dependent on genes – some of us need a few workouts to “pump up muscles”, others need to train a lot and for a long time. All of this is due to your genetics.
Recently, among the world Sports community and in various sports (football, weightlifting, tennis, boxing, etc.)there is a clear interest in sports genetics, and in particular in the use of molecular genetic methods and technologies in the practice of training athletes. At the same time, genetic technologies are used both for the selection of the most promising candidates in terms of hereditary qualities, and for the purpose of individualization and increasing the adequacy of the training process, in general, contributing to an increase in the effectiveness of the athlete himself and the sport in general.
Today, many football players and tennis players of the Russian national team, professional boxers and other famous and respected athletes already have the athlete’s genetic passport.
Orphan diseases in Russia
In Russia, it is proposed to consider as rare diseases with a “prevalence of no more than 10 cases per 100,000 people.”
In 2012, the specialists of the Ministry of Health and Social Development of the Russian Federation added 230 names to the list of orphan diseases, but in case of detection of new diseases, the list will be replenished. According to the Formulary Committee of the Russian Academy of Medical Sciences (RAMS), there are about 300 thousand Russians with these diseases.
Orphan, or “orphan”, diseases are a group of rare diseases. At the moment, about 7,000 of their varieties have been described.
Orphan diseases occur in a small part of the population, their prevalence is about 1: 2000 and less often. This statistics is rather arbitrary, since the same disease can be rare in one region and frequent in another. For example, leprosy is common in India but rare in Europe.
Where do orphan diseases come from?
Approximately half of orphan diseases are caused by genetic abnormalities.Symptoms may be obvious from birth or appear during childhood. At the same time, more than 50% of rare diseases manifest themselves already in adulthood.
Toxic, infectious or autoimmune orphan diseases are less common. The reasons for their development can be heredity, weakening of immunity, poor ecology, high radiation background, viral infections in the mother and in the children themselves at an early age.
Most orphan diseases are chronic. They significantly impair the quality of human life and can be fatal.There is no effective treatment for most of these diseases. The basis of therapy for such patients is to improve the quality and increase the life expectancy of patients.
Currently, orphan diseases are being actively studied in developed countries. It is hampered by the small number of patients, insufficient to conduct a full-fledged study. However, on the basis of scientific research, new drugs are synthesized and treatment regimens for patients are built.
Diagnosis of orphan diseases
The only way to find the causes of rare diseases today is DNA diagnostics.If the disease is well studied, then its diagnosis is carried out according to the developed protocols by conventional genetic methods, if the nature of the disease is not clear, or there are no major (frequent) mutations, then the diagnosis in such families is carried out by the method of whole genome sequencing with subsequent verification by other methods.