Early pregnancy bleeding Flashcards
What are key features on history to determine?
Age
LMP/gestation
Spontaneous pregnancy?
Volume of blood loss
CLOTS
Associated pain - before or after bleeding?
Haemodynamic state - dizziness, SOB, palpitations, LOC
Early pregnancy symptoms - did they have them and then suddenly stop?
Trauma?
Any other abnormal bleeding or pain? PCB or dysparunia?
Abnormal discharge?
Urinary symptoms?
Exposures - radiation, chemicals
Previous pregnancies - ectopics, recurrent miscarriage
Past history
FHx genetic conditions or carrier screening known?
Known uterine abnormalities, fibroids, polyps
Pap smear history
STIs or risk of them?
Bleeding history, diabetes, thyroid
What are key features on examination to determine?
Vitals and fluid status - anaemia, fluid status, infection
Abdominal palpation - peritonitis, haemoperitoneum
Speculum examination - obvious cause of bleeding (ectropion, polyps, trauma), POC in cervix, cervix open or closed
Bimanual examination - adnexal mass or tenderness, cervical motion tenderness (ectopic or infection/PID)
What investigations are required?
Serum beta-hCG TV ultrasound FBE G&H Rh status Urine - chlamydia +/- gonorrhoea, MCS
What are the features of complete miscarriage?
Hx of early pregnancy bleeding with passing of POC
Low/falling B-hCG
No IU sac seen and no POC in uterus (no extrauterine pregnancy)
Cervix closed
What is the follow-up Rx of complete miscarriage
If clinical certain that complete miscarriage and there is no further bleeding, no Ix follow-up required
May need emotional counselling and follow-up and if recurrent may be need Ix to cause of miscarriage
If available send POC for pathology - karyotype
What are the features of a missed miscarriage?
No POC passed and IU sac seen
Cervix closed
Non-viable confirmed by:
- presence of foetal pole >7mm but no foetal heart OR
- Sac size >25mm but with no foetal pole (blighted ovum)
What are the features of an inevitable miscarriage?
Bleeding but no POC
Cervix open
Confirmed non-viable on US
What are features of incomplete miscarriage?
Cervix open
IU sac seen
Some POC may have passed/be seen in cervix + POC seen in uterus on U/S
How should a lady <6W gestation (that is stable) be investigated for early pregnancy bleeding?
- Initial Serum quantitative B-hCG
- If <1,500 (TV) - 2,500 (TA) won’t see anything on U/S
- Consider levels in respect to expected level for gestation - if too low suggests failing pregnancy or ectopic and very high suggests molar pregnancy - Repeat B-hCG or Ultrasound
If stable and levels < then what would allow visible products then repeat B-hCG in 48-72 hours
- If levels rising slowly/plateauing suspect ectopic and U/S
- If levels falling suspect failing pregnancy - Rx after this depends on type of miscarriage
If levels are high enough to see something on US determine if intrauterine pregnancy or extrauterine and if viable or non-viable intrauterine pregnancy
What are the features of an inconclusive intrauterine pregnancy (viability) and what can it mean?
Intrauterine sac seen on US
Either the sac is <25mm (with no foetal pole seen) or no heart rate is detected but the foetal pole seen is <7mm
May suggest normal viable early pregnancy (just to small to be sure) or missed miscarriage
Need to repeat ultrasound in 7-10 days
How should a lady >6W with early pregnancy bleeding be investigated?
Serum B-hCG and U/S
- U/S most important in determining if pregnancy intrauterine or ectopic and if intrauterine if it is viable or non-viable
What are the management options for miscarriage?
- Expectant
- Medical - misoprostol
- Surgical - suction curettage
What are the specific features of expectant management of miscarriage?
~70% success of complete miscarriage within 14 days
Allow 14 days for passing of POC or clear hx suggesting this
Avoids risks of surgery/anaesthetic but time frame for success is variable and unpredictable
Associated with continued bleeding and abdo cramping - provide appropriate analgesia and advice about when to represent
Advise may require emergency suction & curretage
Need follow up at 1 and 2 week points
What are the specific features of medical management of miscarriage?
Admit for administration of misoprostol (prostaglandin analogue), analgesia and ant-emetics and observation (6 hours total)
80% within 3-4 days
Avoids risks of anaesthetic/surgery but unpredictable time frame of success, associated with bleeding/pain and may have severe N+V
Small risk of emergency suction & curettage
When should you use expectant vs. medical vs. surgical Rx of miscarriage?
If POC <15mm expectant is preferred Rx
If Sac or POCs 15-35mm, CRL<25mm can consider any of the 3, depends on patient preference etc
If size larger than this usually surgical Rx
What is the follow-up guidelines for medical and expectant management of miscarriage?
If no POC passed at 1 week can continue expectant management but consider U/S and review of Rx options
Review at 2 weeks - negative urine pregnancy test and no symptoms - no U/S required. If still positive need U/S and review of Rx
What are the specific features of surgical Rx of miscarriage?
+/- Misoprostol administration to cervix to soften and dilate
Suction and curettage under GA
Nearly 100% effective, can be planned, immediate relief of symptoms and will significantly shorten duration of bleeding cf. medical Rx
Generally recommended for any miscarriage >=9 weeks gestation
If women is unstable, signs of infections, significant bleeding/symptoms or patient preference also indicated
Follow-up with GP in 4-6 weeks
What are the general principles of management & follow-up for miscarriage?
Determine expectant, medical or surgical Rx approach based on gestation, size of POC/sac, clinical state/features and patient preference
Work up - chlamydia swab PCR and bacterial vaginosis if indicated
Provide Anti-D within 3 days if Rh negative
Emotional counselling/support
If expectant or surgical - advise on pain & bleeding, variable time frame, possibility of emergency suction and provide analgesia.
Need to review at 1 week and 2 weeks - no U/S if urine preg test negative
Discuss future pregnancy planning/contraception
Follow-up with GP 4-6 weeks regardless of type of management
What are some epidemiological features of ectopic pregnancy?
1/60 pregnancies
95% occur in the fallopian tubes
10-15% risk of recurrence
Leading cause of maternal death in 1st trimester - most in groups with poor access to services (i.e. indigenous, rural)
What are risk factors for ectopic pregnancy?
Previous ectopic pregnancy (7-8x increased)
Hx surgery - appendectomy, C-section, tubal surgery
Progesterone only contraception, IUD in situ - affects transport through tube and implantation
PID or pelvic infection
IVF, fertility issues
What are the clinical features of ectopic pregnancy?
Amenorrhoea + abdominal pain +++
50% bleeding - bright or brown/dark
Abdo pain usually colicky and may become constant and severe
Rupture/bleeding - dizziness, fainting/collpase, shoulder tip pain
Examination - adnexal tenderness, cervical motion tenderness
Signs of peritonism, tachycardia (early warning sign)
What investigations are performed in suspected ectopic pregnancy?
Quantitative b-hCG - confirm pregnancy and guide to further Ix and treatment
Usually U/S asap (unless beta low + stable)
- blood in PoD
- Adnexal mass may be seen
- absence of intrauterine sac
Decreased serum progesterone (<5) sensitive indicator
If clinical/ultrasound diagnosis unclear laparascopic ultrasound = gold standard
What are the management options for ectopic pregnancy?
Expectant - rarely do this
Medical - methotrexate
Surgical - salpingectomy vs. salpingostomy/salpingotomy
What are the features of medical management of ectopic pregnancy?
Ensure no C/I to methotrexate
Requires regular follow-up 1-2/week for a couple of weeks
High dose methotrexate given
Anti-D if Rh negative
Day 4 - beta level (expect to rise)
Day 7 - beta level, LFTs, U&Es, FBE
Expect to see small decrease between day 4 and 7 (>=15%) of beta
Day 14 - beta level and other if clinically indicated
Weekly beta if required until levels <5
Advise that will likely experience pain - simple analgesia (except NSAIDs), can’t take folate supplements but should recommence soon after due to risk of malformations, avoid alcohol and discuss adequate contraception
When is medical Rx of ectopic pregnancy appropriate?
Women is able and likely to come for regular follow-up
Will use reliable contraception for next 3 months
No C/I to methotrexate - liver, bones, renal
No/minimal symptoms (abdo pain or tenderness on examination) and haemodynamically stable
Low risk of bleeding or rupture
No foetal heart beat
B-hCG <3500
What are the surgical Rx options for ectopic pregnancy?
Give anti-D if Rh negative
- Salpingectomy
Removal of tube, generally preferred as definitive treatment (less risk of complications of rupture or 2nd surgery), avoid scar which may increase risk of subsequent ectopic
Doesn’t decrease fertility by 50% as remaining tube will move to side of ovulation
- Salpingostomy
Incision into tube to remove ectopic tissue
Usually if contralateral tube disease and wish to preserve future fertility
Higher risk of recurrence and failure of surgery - may have remaining tissue after surgery
Psychological counselling
Review (Day 3 and 7 beta level and review of sutures)
When is surgical Rx indicated for ectopic pregnancy?
It is the preferred treatment due to the risk of bleeding and rupture
If beta >3500, foetal heart rate present, haemodynamically unstable/signs of rupture, large adnexal mass seen on U/S, moderate-severe pelvic pain - surgical is only option
