100. Bleeding in Early Pregnancy

Question 1

What is meant in bleeding in early pregnancy?

Answer 1

Bleeding within the first two trimesters:

0-12 weeks (1st trimester most common)
12-24 weeks

Question 2

What are the main causes for bleeding in early pregnancy?

Answer 2

Miscarriage,
Molar pregnancy,
Ectopic pregnancy
Cervical Lesions

Question 3

When is the most common time for a miscarriage?

Answer 3

Between 7 and 13 weeks

Question 4

What are the different types of miscarriage? (7)

Answer 4

Threatened
Inevitable
Complete
Incomplete
Missed
Septic 
Recurrent

Question 5

What is meant by a threatened miscarriage?

Answer 5

Bleeding but the cervix is closed

Typically light bleeding

Question 6

How do you treat a threatened miscarriage?

Answer 6

See in pre pregnancy clinic (If possible)

USS to see if a pregnancy is viable

If pregnancy is viable go away and come back with safety netting

Question 7

What is meant by a viable pregnancy?

Answer 7

A gestation sac with a fetal pole and a fetal heartbeat

Seen by 5 weeks transvaginal scan
Seen by 6 weeks USS scan

Question 8

What is meant by a inevitable miscarriage?

Answer 8

There is bleeding and the cervix is open

Heavier bleeding accompanied by painful uterine contractions

Question 9

What should you look out for in an inevitable miscarriage?

Answer 9

The patient becoming heamodynamically unstable:

Prolonged bleeding
Increased HR
Falling blood pressure
Reduced perfusion (cap refill time)

Question 10

How should you treat an inevitable miscarriage?

Answer 10

ERPC (Evacuation of retained products of conception)

Need anti D injection too

Question 11

What is a complete miscarriage?

Answer 11

Feotal sac is expelled, confirmed on ultrasound

Question 12

What is an incomplete miscarriage?

Answer 12

Some of the foetal products remain e.g. palcenta, chorionic sac,

This encourages further bleeding, sepsis and shock

Question 13

How do you treat an incomplete miscarriage?

Answer 13

Medical management- prostaglandin, mesoprostyl (encourages uterine cotnractions

Surgical- Local (MVA) or general (ERPC)

Question 14

What is a missed miscarriage?

Answer 14

Loss of pregnancy but products are not expelled

USS confirms this

Question 15

Discuss the ultrasound parameters of a non-viable pregnancy?

Answer 15

Transvaginal ultrasound that shows a fetal pole of >6mm with no fetal heartbeat (if <6mm repeat scan in one week. Fetal pole will not have grown)

A gestation sac of greater than 20mm is non viable

Question 16

How do you manage a missed miscarriage?

Answer 16

Expectant- wait for products to be naturally expelled

Medical Management- prostaglandin induces contractions

Surgical- MVA, ERPC

Question 17

What is the presentation of septic miscarriage?

Answer 17

Patient with fever with pain over the lower abdomen
Bleeding and vaginal discharge
May lead to sepsis, shock and DIC

Question 18

How do you investigate a septic miscarriage

Answer 18

Blood and urine samples
endocervical swabs
Cross match blood test (pre-emptive)

Question 19

How do you treat a septic miscarriage?

Answer 19

Fluid resuscitation
Broad spectrum antibiotics (co-amoxiclav)
Evacuate uterus ASAP

Question 20

What are the causes of

Answer 20

Endocrine
Infections
Thromboembolic disorders
Genetics
Anatomical problems
Environmental factors e.g. smoking

Question 21

What is the commonest site of ectopic implantation?

Answer 21

Ampulla (fallopian tubes)

Question 22

When do ectopic pregnancies present?

Answer 22

Within the first trimester, don’t usually survive longer than 8 weeks

Question 23

How do you investigate an ectopic?

Answer 23

History

Take a paired set of BHCG levels 48 hours apart (will slowly rise, less than normal pregnancy)

Question 24

What is a molar pregnancy

Answer 24

An abnormal fertilisation occurs leading to a grape like lesion, having the potential to turn into a carcinoma

Question 25

What are cervical lesions?

Answer 25

Mainly vaginal erosions due to high oestrogen levels in

Question 26

How should you investigate cervical lesions?

Answer 26

Do a cervical smear to rule out cervical cancer