G15 early pregnancy bleeding

Question 1

1. what are the important differential diagnosis?

Answer 1

1. ectopic pregnancy
2. miscarriage
3. pregnancy of unknown location
4. appendicitis
5. ovarian cysts +/- rupture
6. ovarian torsion
7. endometriosis
8. UTI
9. uterine fibroid degeneration

Question 2

how would you differentiate these diagnosis from each other from the history and examination?

Answer 2

history

• ask about the bleeding; how much, appearance, constant, clots, tissue
• ask about the pain; character, severity, site, unilateral vs bilateral, radiation, precipitating, relieving factors
• continuity of sx of pregnancy; nausea, breast fullness, fatigue, low abdo pain, heavy cramping,
• other symptoms; shoulder tip pain,dizziness
• past obstetric history; recurrent miscarriage, termination, ectopic pregnancy
• contraception; IUD
• STI/infections
• Past medical history + surgical pelvic and abdomen
• smear - lletz
• examination
  
  • general wellbeing; shock vs stable
  • obs
  • abdominal examination; peritonism, mass
  • pelvic examination
  • speculum; bleeding, RPOC, cerival os
  • VE: adnexal mass/tenderness, uterine size
• i

Question 3

what are the principle management of this patient?

Answer 3

1. check whether patient is haemodynamically stable, if no then initiate resuscitation and surgical management
2. investigate

• pregnancy test
• urine dipstick +MSU
• blood test; FBC (anaemia), CRP(infection), U+E
  
  • cross match +Rh antibody
  • LFT and RFT if medical management with metothrexate
  • serum bHCG > 25 IU/L confirm pregnancy. normally doubled every 48hr
    
    • <66% ectopic or failing IUP
• TVUSS- confirm intrauterine pregnancy, viability (gestation sac, fetal cardiac activity) ectopic pregnancy. using the results from serum bHCG to produce concept of discrimatory zone.
  
  • if bhcg >5000 IU/L , IU gestational sac visible on pelvic examination, or >2000 with TVUSS
  • look for adnexal mass + free peritoneal fluid suggesting rupture
• laparoscopy to diagnose ectopic pregnancy

management depends on the patient and findings and patients preference

if the patient has ectopic pregnancy and haemodynamically unstable-> surgical option

if haemodynamically stable, and bHCG<1500U/L and no fetal cardiac activity -> expectant if prefer

otherwise if no CI mtx -> medical management with MTX

• renal/liver disease
• hepatic abnormality, KFT normal
• breastfeeding not
• allergic/hypersensitive

if theres fetal cardiac activity -> surgical management (laptomy/ecmy)

if miscarriage, depending on the findings and patients preference

stable and prefer expectant (wait and see) -> see in 2 weeks, if there is suspicious of not complet e- USS. no sac/ RPOC => discharge with repeat bHCG

otherwise, can consider medical/surgical

up to 4 weeks wait

medical management with mifepristone and misoprostol.

ERPOC