Bleeding in early pregnancy

Question 1

History questions for bleeding in early pregnancy.

Answer 1

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
Meds
Allergies
Social Hx

Question 2

DDx of bleeding in early pregnancy.

Answer 2

• Abortion/miscarriage (threatened, inevitable, incomplete, complete)
• Ectopic pregnancy
• Molar pregnancy
• Physiologic: spotting due to implantation of the placenta
• Trauma: post-coital, after pelvic exam
• Genital lesion
• Bleeding from other site (urinary tract, bowel)

Question 3

Ix of bleeding in early pregnancy.

Answer 3

B-hCG - serial, should double in 48hrs in viable pregnancy. (positive when B-hCG >25mIU/ml)
U/S to confirm intrauterine pregnancy and fetal viability
FBC - assess bleeding
Group and hold, consider cross match if ectopic is suspected.
MSU

Question 4

Threatened miscarriage.

Answer 4

Threatened: any vaginal bleeding during early pregnancy without cervical dilatation or change in cervical consistency. Usually, no pain, mild cramps may occur. More severe cramps may lead to an inevitable abortion.

Question 5

Criteria for non-viable pregnancy.

Answer 5

mean gestational sac diameter >25mm with no fetal pole.
fetal pole>7mm with no fetal heart activity
inadequate growth of the gestational sac or fetal pole over the course of 1wk

Question 6

Inevitable miscarriage

Answer 6

an early pregnancy with vaginal bleeding and dilatation of the cervix. Typically, the vaginal bleeding is worse than with a threatened abortion, and more cramping is present. No tissue has passed yet. On ultrasound, the products of conception are located in the lower uterine segment or the cervical canal.

Question 7

Incomplete miscarriage

Answer 7

pregnancy that is associated with vaginal bleeding, dilatation of the cervical canal, and passage of products of conception. Usually, the cramps are intense, and the vaginal bleeding is heavy. Patients may describe passage of tissue, or the examiner may observe evidence of tissue passage within the vagina. Ultrasound may show that some of the products of conception are still present in the uterus.

Question 8

Complete miscarriage

Answer 8

ypically, a history of vaginal bleeding, abdominal pain, and passage of tissue exists. After the tissue passes, the patient notes that the pain subsides and the vaginal bleeding significantly diminishes. The examination reveals some blood in the vaginal vault; a closed cervical os; and no tenderness of the cervix, uterus, adnexa, or abdomen. The ultrasound demonstrates an empty uterus.

Question 9

Missed miscarriage

Answer 9

a nonviable intrauterine pregnancy that has been retained within the uterus without spontaneous abortion. Typically, no symptoms exist besides amenorrhea, and the patient finds out that the pregnancy stopped developing earlier when a fetal heartbeat is not observed or heard at the appropriate time. An ultrasound usually confirms the diagnosis. No vaginal bleeding, abdominal pain, passage of tissue, or cervical changes are present.

Question 10

Aetiology of miscarriage.

Answer 10

• Chromosomal abnormalities are the most common.
• Endocrine: poorly controlled diabetes, thyroid disease and hyperanadrogenism
• Thrombophilia. Antiphospholipid syndrome.
• Uterine abnormalities.
• Chronic maternal disease
• Toxins. e.g. tobacco, alcohol.
• Trauma

Question 11

Clinical features of abortion/miscarriage

Answer 11

• Pregnancy symptoms (may diminish)
• Bleeding: amount depends type of miscarriage
• Pain as uterus contracts or cervix dilates (usually cramp like and follows bleeding)
• passage of products of conception

Question 12

Management of miscarriage/abortion

Answer 12

Resuscitation as necessary
Anti-D for rh -ve women (250 IU is adequate)
Explanation and support.
Specific management is dependent on type of miscarriage.

Question 13

Risk factors for ectopic pregnancy.

Answer 13

• Previous ectopic
• Gynaecologic: current IUD use, history of PID (50%), salpingitis.
• Previous surgeries: any surgery on fallopian tube (inc. tubal ligation), abdominal surgery
• Smoking
• Structural: uterine leiomyomas, adhesions, abnormal uterine anatomy.
• IVF

Question 14

Clinical presentation of ectopic pregnancy.

Answer 14

4Ts and 1s
Temperature >38 (20%)
Tenderness: abdominal (90%) +/- rebound (45%)
Tenderness on bimanual examination, cervical motion tenderness.
Tissue: palpable adnexal mass (50%)
Signs of pregnancy (chadwick’s, Hegar’s)

+/- Bleeding (50-80%)
+/- Delayed menses (75-90%)

Sx of shock if ruptured.

Question 15

Ix for suspected ectopic pregnancy.

Answer 15

Serial serum B-hCG levels - rise of 53% in 2 days. rise of

Question 16

Medical management of ectopic pregnancy

Answer 16

Methotrexate 50mg/m2, IMI with follow up at day 4 and 7. B-hCG should have fallen by >25%, if not then repeat dose of methotrexate.

Side effects: Nausea, vomiting, diarrhoea, neutropenia, abdo pain.

Anti-D if Rh -ve

Question 17

What are the criteria for eligibility for medical management of ectopic pregnancy?

Answer 17

Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:

-no significant pain
- an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
no intrauterine pregnancy (as confirmed on an ultrasound scan)
- Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates.

Question 18

What is the surgical management of ectopic pregnancy?

Answer 18

Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility.

Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage.

Repeat ectopic rate is 50% higher with salpingotomy as comapred to salpingectomy

Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:

an ectopic pregnancy and significant pain
an ectopic pregnancy with an adnexal mass of 35 mm or larger
an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more

Question 19

What are the risks associated with a laproscopic removal of ectopic pregnancy?

Answer 19

General: bleeding (more common if anticoagulated), atelectasis, MI, CVA, DVT, PE, death.

Specific:

• Bleeding in the abdomen
• damage to bladder, bowel, ureter.
• Damage to uterus, hysterectomy
• Further intervention required
• Wound infection
• Endometritis
• Adhesions

Question 20

What is a heterotropic pregnancy?

Answer 20

Occurrence of ectopic pregnancy along with normal IUP.

1 in 300 with assisted reproduction.

Question 21

Clinical presentation of molar pregnancy.

Answer 21

Vaginal bleeding
uterus large for dates
Severe hyperemesis
Early pre-eclampsia
Markedly elevated serum B-hCG level.

Question 22

Types of molar pregnancy (Gestational trophoblastic disease -GTD).

Answer 22

Partial - usually triploidy or tetraploidy, may contain fetal parts. Low potential for malignancy.

Complete - the result of fertilisation of an ovum lacking maternal genes. Bunch of grapes appearance on US. 16% proceed to develop malignant disease.

Question 23

Mx of GTD.

Answer 23

• Suction curettage + uterotonic agents
• Follow up to exclude persistent trophoblastic disease. –> weekly serum B-hCG until -ve for 3 weeks, then monthly for 6 months.