Bleeding in early pregnancy

Question 1

differentials of bleeding in early pregnancy ?

Answer 1

miscarriage
ectopic pregnancy
molar pregnancy
cervical lesions i.e. ectropion, polyps, erosions

Question 2

risk factors for recurrent miscarriages ?

Answer 2

anti phospholipid syndrome 
smoking 
poorly controlled diabetes, thyroid disease
infections
parental chromosomal abnormalities
uterine septum

Question 3

parts of the fallopian tube?

commonest site of ectopic pregnancy ?

Answer 3

fimbriae, infundibulum, ampulla and isthmus

ampulla commonest but isthmus is most severe with highest risk of rupture

Question 4

indications for surgical management of ectopic pregnancy ?

Answer 4

unable to attend follow up appointment 
contraindicated to methotrexate 
foetal heart beat 
adnexal mass > 35mm 
heavy bleeding 
severe pain 
bHCG > 5000umol/L

Question 5

criteria for expectant management for ectopic pregnancy ?

Answer 5

minimal or no symptoms 
no foetal heart beat 
adnexal mass < 35mm 
bHCG < 1000 and is decreasing 
able to return for follow up appointments

Question 6

criteria for medical management for ectopic pregnancy ?

Answer 6

failed expectant management
no foetal heart beat
bHCG < 1500
adnexal mass < 35mm
rupture
able to return for follow up appointment
can wait at least 3 months for future pregnancy

Question 7

what is the medical management for Coptic pregnancy ?

Answer 7

methotrexate

Question 8

for medical management of ectopic pregnancy, what drugs should be avoided and why ?

Answer 8

NSAIDS and folic acid can make methotrexate inactive

Question 9

presenting features of ectopic pregnancy ?

Answer 9

lower right pelvic pain and tenderness is main feature
PV bleeding
amenorrhoea (usually last period was 6-8 weeks ago, if > 10 likely to be miscarriage)
pain during urination and defecation
shoulder tip pain (rupture)

Question 10

1st line diagnostic investigation for ectopic pregnancy ?

Answer 10

transvaginal USS

Question 11

investigations to confirm suspected ectopic ?

Answer 11

urinary bHCG
bloods;
- serial bHCG: < 53% in 48 hours or plateau
- FBC, U&E, LFT, clotting, group and save

transvaginal USS
pelvic USS

Question 12

differentiating features between ectopic vs miscarriage ?

Answer 12

pain usually dominant feature of ectopic

bleeding is often less in ectopic than miscarriage which can be heavy

amenorhoeic for roughly 6-8 weeks, miscarriage usually > 10 weeks

signs of shock if rupture in ectopic i.e. shoulder tip pain

Question 13

management of an incomplete miscarriage ?

Answer 13

medical: misoprostol (prostaglandin)
surgical: manual vacuum aspiration, suction curettage or evacuation of retained products of conception

Question 14

risk factors for miscarriage ?

Answer 14

• diabetes, thyroid disease
• antiphospholipid syndrome
• double uterus, uterine septum
• smoking, alcohol
• extremities of weight
• trauma
• ## chromosomal abnormalities

Question 15

light PV bleeding

cervical os is closed ?

Answer 15

threatened miscarriage

Question 16

heavy PV bleeding

cervical os is open ?

Answer 16

inevitable miscarriage

Question 17

heavy PV bleeding
cervical os is open
on USS not all products have been expelled ?

Answer 17

incomplete miscarriage

Question 18

light PV bleeding
cervical os is closed
non viable products of conception on USS ?

Answer 18

missed

Question 19

management of septic miscarriage ?

Answer 19

IV antibiotics and urgent evacuation of the uterus

Question 20

describe the management of a miscarriage ?

Answer 20

1st line: expectant
- wait 7-14 days for spontaneous miscarriage to occur

medical: vaginal misoprostol (+ antiemetics and pain relief)
surgical: vacuum aspiration, suction curettage or ERPC

Question 21

what is cervical ectropion ? how does it present ?

Answer 21

columnar epithelium of the uterus extends down to the vaginal surface of the os

Question 22

how would you differentiate between cervical ectropion or cervical cancer on examination ?

Answer 22

ectropion is inflamed, red, discharge and bleeding. bleeding and discharge often post coital but can be spontaneous

cancer is hard and irregular