First Trimester Bleeding

Question 1

what % of women have first trimester bleeding

Answer 1

20-40%

Question 2

how might first trimester bleeding present

Answer 2

light or heavy
intermittent or constant
painless or painful

Question 3

list causes of first trimester bleeding from NON viable pregnancies

Answer 3

miscarriage

ectopic pregnancies

molar pregnancy (rare)

Question 4

list causes of first trimester bleeding from viable pregnancies

Answer 4

implantation of pregnancy

subchorionic hematoma

Question 5

list causes of first trimester bleeding from non-pregnancy-related causes

Answer 5

cervical/vaginal or vulvar pathology

non-gyne bleeding (rectal, urinary)

Question 6

what is the most common cause of first trimester bleeding

Answer 6

miscarriage

15-20% of pregnancies

Question 7

what % of pregnancies are ectopic

Answer 7

2%

Question 8

what is the most serious etiology of first trimester bleeding

Answer 8

ectopic

because rupture of the extrauterine pregnancy is life threatening

Question 9

risk factors for ectopic pregnancy

Answer 9

PID

previous ectopic

tubal surgery

IUCD–> does not cause ectopic pregnancy but if you get pregnancy with one in place there is a higher likelihood of ectopic

Question 10

what investigations should you do to manage first trimester bleeding

Answer 10

transvaginal U/S–> helps to assess viability and location of pregnancy (this is NOT to look for the ectopic although it may be seen)

lab tests–> CBC, Rh blood group, serum quantitative beta hCG, serial beta hCGs are useful in less than 6 weeks where site and viability of pregnancy not yet established

Question 11

what is the first thing to ask on history for first trimester bleeding?

Answer 11

whether the patient has a prior U/S exam in the current pregnancy as well as the results

prior documentation that the pregnancy is in the normal intrauterine location immediately narrows down the ddx

Question 12

where do most ectopics implant

Answer 12

tube (98%)

Question 13

what should you look for on physical exam in first trimester bleeding

Answer 13

vitals

abdo exam–> FHR

pelvic–> bimanual (uterine size, adnexal tenderness, adnexal mass, cervix open or closed); speculum exam (?tissue present, assess for non uterine bleeding i.e cervical ectropion, cervical polyp)

Question 14

how do you manage a spontaneous abortion

Answer 14

options;
1. expectant management

2. expedite miscarriage with misoprostol–> expect bleeding/cramping within 12 hours
3. D&C
4. Rh immunoglobin if Rh negative
5. tissue for cytogenetics of recurrent
6. counseling

Question 15

in which spontaneous abortions should you definitely do surgery

Answer 15

sepsis

heavy bleeding

Question 16

what dose of misoprostol do you use for medical management of SA

Answer 16

misoprostol 800 ug orally or vaginally

Question 17

contraindications to misoprostol use

Answer 17

coagulopathy
evidence of infection
heavy bleeding

Question 18

side effects of misoprostol

Answer 18

pain

nausea and vomiting

Question 19

when should you follow if in expectant management of SA

Answer 19

2-4 weeks

pain and bleeding should be resolved after 2 weeks

after resolved, do urine preg screen–> if +, r/o molar pregnancy and ectopic

Question 20

presentation of ectopic pregnancy

Answer 20

spotting/bleeding (usually not heavy)

pain–> constant, unilateral rather than central and crampy

hemodynamic instability and peritoneal signs suggest rupture

may be ruptured or unruptured at time of presentation

Question 21

list symptoms suggestive of rupture

Answer 21

generalized abdo pain

shoulder pain due to diaphragmatic irritation by blood in the peritoneal cavity

persistent symptoms suggestive of ongoing blood loss (feeling faint, loss of consciousness)

Question 22

what are the typical findings of ruptured ectopic pregnancy

Answer 22

abdo tenderness and signs of peritoneal irritation by blood, eventually leading to hypotension and shock

Question 23

what is the risk of recurrent ectopic

Answer 23

10-15%

should get 7 week U/S in next pregnancy to make sure intrauterine

Question 24

how do you diagnose ectopic pregnancy

Answer 24

empty uterus with beta nCG over 1500-1800

ectopic itself may or may not be seen

peritoneal free fluid if ruptured

Question 25

what should you think in a patient who has positive pregnancy test + hemodynamic instability + peritoneal signs?

Answer 25

ruptured ectopic until proven otherwise

Question 26

list the eligibility criteria for methotrexate tx for ectopic

Answer 26

ectopic less than 4 cm

no fetal heart motion seen

beta hCG less than 5000 (or 10 000)

hemodynamically stable, no signs of rupture

reliable for follow up

Question 27

what is the dose for methotrexate for ectopic

Answer 27

50 ug/M2

Question 28

what tests should you do before starting methotrexate

Answer 28

LFTs

BUN

Cr

(do not use in kidney or liver dysfunction)

Question 29

what is the follow up for methotrexate tx for ectopics

Answer 29

beta hCG weekly

should decrease by 15% per week or need to repeat tx

may initially go up but should be 15% down from day 4-7

Question 30

what is the surgical mgmt for ectopics

Answer 30

laparoscopic salpingostomy

laparoscopic salpingectomy for severe tubal damage or no desire for fertility

laparotomy if unstable patient