Abstract: Cyclical menstrual like bleeding during pregnancy is uncommon, particularly during second and third trimester. Here, we present management of a case of repeated bleeding in a pregnant woman with bicornuate uterus who continued to have repeated bleeding up to late second trimester.
INTRODUCTION
Cyclical menstrual like bleeding during pregnancy is not very common. Bleeding during pregnancy is often reported up to first trimester. The reported occurrence of single as well as repeated bleeding during pregnancy is 3.75% while that of menstrual like bleeding of normal intensity and duration is 1.05% of pregnant women (Wessel and Endrikat, 2005). Exact incidence of cyclical bleeding in pregnancy with uterine malformation is not well documented in the literature. Here, we present a rare case of repeated bleeding up to second trimester in a pregnant patient with bicornuate uterus.
Case Report
A 28 years old woman, G 4 P 2 0 1 2, first reported with a history of 9
weeks’ amenorrhea for regular antenatal checkup at the Outpatient Department
of Obstetrical services at Gian Sagar Medical College and Hospital, Banur. She
was a diagnosed case of bicornuate uterus. She had previous lower segment cesarean
sections twice-- 4½ years and 2 years back. Both times she delivered
a good sized male babies with uneventful antenatal period. One year back, she
had MTP at 6 weeks amenorrhea by medical method. During her present pregnancy,
she had an excellent dating confirmed on ultrasonography. She gave history of
spotting per vaginum at 6 weeks of gestation. Routine antenatal checkup was
done and she was given treatment in the form of folic acid. Micronized progesterone
was started in view of her high-risk pregnancy. At 16 weeks period of gestation,
she reported with history of bleeding per vaginum and pain on the left side
of abdomen. On ultrasonography a single live baby was seen in the right horn
of the uterus with parameters corresponding to the period of amenorrhea. Placenta
was fundal and there was no retroplacental clot. Left horn of the uterus was
well developed and the endometrium was thickened. There was no seedling of fibroid
in any of the horns. There was no free fluid in the intraperitoneal cavity.
Scar thickness was normal and there was no evidence of cervical insufficiency.
On per speculum examination, the cervix was healthy, closed and uneffaced. Routine
biochemical tests and coagulation profile were within normal limits. She was
managed conservatively with bed rest, oral iron, calcium, folic acid and progesterone.
Bleeding persisted for four days and she had soaked 1-2 pads day-1.
She was discharged after one week with all medications. At 20 weeks period of
gestation, she again complained of bleeding per vaginum with pain on the left
side of abdomen. Her vitals were normal. On per abdominal examination, height
of the uterus was corresponding to period of amenorrhea. On ultrasonography,
the parameters corresponded to the period of gestation and baby was moving well.
Since she refused admission this time, she was managed conservatively with same
medications at home. She had bleeding for 3-4 days and soaked 1-2 pads day-1.
Bleeding stopped after 4 days. At 24 weeks, she again complained of bleeding
for 3-4 days and was managed conservatively at home. She had no further episode
of bleeding per vaginum after 24 weeks. She had been administered 2 doses of
tetanus toxoid. She was kept on progesterone support up to 34 weeks. At 36 weeks
period of gestation, she went into labor and emergency Lower Segment Cesarean
Section (LSCS) was done along with bilateral tubal ligation. Pregnancy was in
the right horn of the uterus. Previous scar was intact. Left horn of the uterus
was well developed and enlarged to 16 wks pregnant uterus size. She delivered
a live male baby of 3.1 kg with good Apgar score of 8 and 9. Her postoperative
period was uneventful.
RESULTS AND DISCUSSION
Bleeding during pregnancy in malformed uterus up to start of 2nd trimester is reported in the literature (Krause and Graves, 1999). However, bleeding up to late 2nd trimester in bicornuate uterine malformation as in the present case has not been reported (Fig. 1). Majority of these pregnancies end into miscarriage or preterm labor. In the indexed case, exact reason for bleeding was not clear but some hormonal factor or unstable endometrium could be the possible reason.
| Fig. 1: | Bicornuate uterus showing right (pregnant) and left uterine horns post-LSCS |
During pregnancy, ovulation ceases and maturation of new follicles is suspended due to persistently high levels of estrogen and progesterone. Incidence of vaginal bleeding in first trimester is up to 20%, out of which 15-20% end in miscarriages (Krause and Graves, 1999; Zinaman et al., 1996). Cyclical bleeding may occur up to 12 weeks of pregnancy until the decidual space is obliterated by fusion of decidua vera and capsularis. Cyclical bleeding during pregnancy up to 3rd trimester has been reported in the literature as denial of pregnancy. Brezinka et al. (1994) and Wessel et al. (2002) have published larger studies providing a rough incidence of denied pregnancy as 1 in 300-600 deliveries. In women with denied pregnancy, cyclical menstruation like bleeding has been given as the main reason for not recognizing pregnancy up to 3rd trimester. Unstable cervical endometrium and pseudomensturation from the decidua have also been reported as possible cause for late trimester bleeding (Wessel and Endrikat, 2005).
In conclusion, menstrual-like cyclical bleeding may sometimes occur up to late second trimester of pregnancy but its occurrence is still rarer in bicornuate uterus as in the present case. Knowledge of this occurrence and balanced approach for its management are the key to successful outcome.