bleeding in early pregnancy Flashcards
Hx Q to ask and exam
LMP Pregnancy test Hx of bleeding/tissue passed Pregnancy symptoms Hx of trauma Abdominal pain Fainting/shoulder pain/dizziness Bladder and bowel symptoms Gynae Hx - PID, Contraception Obstetric Hx PmHx PsHx - pelvic surgery Med Allergies SoHx Ex - GI, abdo, pelvic - speculum, bimanual.
Ix for bleeding in early pregnancy
Bloods - FBC, B HCG Blood group MSU USS - TV 4.5 wk, gestational sac, greater then 1500, Transabdominal 6500, Yolk sac 5.5 wks onwards Urine B hCG
DDX
Miscarriage Ectopic pregnancy Molar pregnancy trauma Cervical polyp Cervical cancer Vulval varicosities Hematuria Haemorrhoids
General Mx Miscarriage
Mx - Expectant - Medical - misoprostol - Surgical D and C Check Anti D and give within 72 hr
Causes Ectopic pregnancy
1%
Cause - 50% due to damage of fallopian tube cilia due to PID
Site - commonly in fallopian tube.
RF - Previous Hx, PID, Tubal surgery, IUCDs, infertility tx.
Molar pregnancy
1/1700 pregnancies
Types 80% present as a benign hydatidform mole, 15% invasive mole, 5% choriocarcinoma
Presentation - vaginal bleeding, Uterus large for dates, severe hyperemesis, early preeclampsia, Markedly elevated serum HCG level.
Mx - Surgical removal, D and C or hysterectomy, treat presentation. e.g. if hyperemesis - antiemetic or H2 antagonist, active bleeding give blood product, Thyrotoxicity beta-blocker, pre eclampsia with MgSO4 and Anti HTN,
May need prophylactic chemotherapy if high risk of malignancy.
Followup
Serial BHCG to with weekly tests until negative.
If not dropping BHCG – Persistent GTD
COCP or effective contraception for 6 months to ensure no early pregnancies
Complete miscarriage
bleeding and complete passage, cervix open
Incomplete miscarriage
Extremely heavy bleeding and cramps, may have passage of tissue, cervix open, mx by watch and wait, misoprostol, D and C, oxytocin
Inevitable Miscarriage
Increasing bleeding and cramps may have ROM, Cervix closed until product start to pass, USS shows non viable fetus, Watch and wait, Misoprostol, D and C, may oxytocin.
Threatened miscarriage
Vaginal bleeding may have cramping, Cervix closed and soft, USS shows viable fetus, Watch and wait, Less then 5% abort.
Missed miscarriage
no bleeding but USS show death.
Types of mIscarriage
Complete incomplete Inevitable Threatened Septic Missed
Symptoms of ectopic
Symptoms - Triad - abdominal pain, delayed menses and vaginal bleeding not sensitive. Lightheadedness
Ix of ectopic
B hCG, USS with empty uterus and more than 2000 B hCG.
Mx of ectopic
Medical
Methotrexate
indications
hemodynamic stable
ectopic mass <3.5-4cm
no free fluid
serum HCG <5000
reliable follow up
no significant hepatic, renal, hematologic disease
75% success rate -
Monitoring - IM, follow up required on day 4 and day 7
if levels are not failing, rpt injection or surgery
side effects - N/V/D neutropenia, abdominal pain
surgical - Laparoscopy vs laparotomy, salpingectomy vs salpingotomy - similar IUP, more ectopic with salpinotomy 18% vs 8%
