First Trimester Bleeding Flashcards
what % of women have first trimester bleeding
20-40%
how might first trimester bleeding present
light or heavy
intermittent or constant
painless or painful
list causes of first trimester bleeding from NON viable pregnancies
miscarriage
ectopic pregnancies
molar pregnancy (rare)
list causes of first trimester bleeding from viable pregnancies
implantation of pregnancy
subchorionic hematoma
list causes of first trimester bleeding from non-pregnancy-related causes
cervical/vaginal or vulvar pathology
non-gyne bleeding (rectal, urinary)
what is the most common cause of first trimester bleeding
miscarriage
15-20% of pregnancies
what % of pregnancies are ectopic
2%
what is the most serious etiology of first trimester bleeding
ectopic
because rupture of the extrauterine pregnancy is life threatening
risk factors for ectopic pregnancy
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
what investigations should you do to manage first trimester bleeding
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
what is the first thing to ask on history for first trimester bleeding?
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
where do most ectopics implant
tube (98%)
what should you look for on physical exam in first trimester bleeding
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)
how do you manage a spontaneous abortion
options;
1. expectant management
- expedite miscarriage with misoprostol–> expect bleeding/cramping within 12 hours
- D&C
- Rh immunoglobin if Rh negative
- tissue for cytogenetics of recurrent
- counseling
in which spontaneous abortions should you definitely do surgery
sepsis
heavy bleeding
what dose of misoprostol do you use for medical management of SA
misoprostol 800 ug orally or vaginally
contraindications to misoprostol use
coagulopathy
evidence of infection
heavy bleeding
side effects of misoprostol
pain
nausea and vomiting
when should you follow if in expectant management of SA
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
presentation of ectopic pregnancy
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
list symptoms suggestive of rupture
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)
what are the typical findings of ruptured ectopic pregnancy
abdo tenderness and signs of peritoneal irritation by blood, eventually leading to hypotension and shock
what is the risk of recurrent ectopic
10-15%
should get 7 week U/S in next pregnancy to make sure intrauterine
how do you diagnose ectopic pregnancy
empty uterus with beta nCG over 1500-1800
ectopic itself may or may not be seen
peritoneal free fluid if ruptured
what should you think in a patient who has positive pregnancy test + hemodynamic instability + peritoneal signs?
ruptured ectopic until proven otherwise
list the eligibility criteria for methotrexate tx for ectopic
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
what is the dose for methotrexate for ectopic
50 ug/M2
what tests should you do before starting methotrexate
LFTs
BUN
Cr
(do not use in kidney or liver dysfunction)
what is the follow up for methotrexate tx for ectopics
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
what is the surgical mgmt for ectopics
laparoscopic salpingostomy
laparoscopic salpingectomy for severe tubal damage or no desire for fertility
laparotomy if unstable patient
