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CAUSES OF BLEEDING IN EARLY PREGNANCY Miscarriage Fibroids Ectopic pregnancy Subchorionic haematoma Cervical Trauma ectropion Cervical/vaginal cancer Implantation Pelvic inflammatory bleed disease Polyps
Case-based discussion: 1 History A 36-year-old G3P1+1, presents with vaginal bleeding. Her last menstrual period was 7 weeks ago and she had a positive urine pregnancy test 2 weeks ago. She has a 2-day history of generalised abdominal pain, which is now localised to the lower abdomen/pelvis. She has had vaginal bleeding for 2 weeks. She feels dizzy and light-headed. On examination, she is pale and is in discomfort. The abdomen is soft with lower abdominal tenderness. Speculum examination: cervix seen, not actively bleeding. Observations HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2 4
Question 1 What is the most likely diagnosis? a) Ectopic pregnancy b) Complete miscarriage c) Incomplete miscarriage d) Threatened miscarriage e) I’m not sure 5
Clinical history: bleeding in early pregnancy Age Degree of the bleeding • When did it start • Sanitary pads: size, how often changed/clots/flooding Pain SOCRATES = S ite, O nset, C haracter, R adiates, A ssociated • symptoms, T ime/duration, E xacerbating/ relieving factors, S everity Passing products/tissue? Menstrual history • LMP • Cycles - regular/irregular Any scans in pregnancy 6
Clinical history: bleeding in early pregnancy Obstetric history • Gravidity, parity, pregnancy losses • Mode of delivery Gynaecological history • Pelvic inflammatory disease, previous ectopic pregnancies Smear history Contraceptive history • Coil in situ • Progesterone only pill (>99% effective but of those who become pregnant, 1 in 10 ectopic pregnancy) Medical and surgical history Drug history and allergies Social history • Smoking and alcohol 7
Examination General inspection • Pale • Alert or drowsy • Blood stained clothing • Soaked pads Hands • Warm, well perfused (capillary refill time) • Pulse: volume, regular Abdominal examination • Tenderness/peritonism/guarding/rebound Speculum examination WITH chaperone • Cervix open? Products seen? Bleeding? • Take relevant swabs – high vaginal +/- endocervical Bimanual examination gently • Cervical excitation? Any pelvic masses? 8
Investigations Bedside Observations: HR, BP, RR, SpO2, Temperature • Bloods FBC • Group and save • +/- Beta hCG • Imaging • Ultrasound (transvaginal) Intrauterine pregnancy: gestation sac, yolk sac, fetal • pole, fetal heart activity Ectopic pregnancy: adnexal mass, fetal pole, fetal heart • activity, free fluid in pouch of douglas Pregnancy of unknown location (not seen intrauterine • or extrauterine) 9
Case-based discussion: 2 History What is the most likely diagnosis? A) Complete miscarriage A 36-year-old primiparous lady, presents with heavy vaginal B) Missed miscarriage bleeding. Her last menstrual period was 7 weeks ago and C) Threatened miscarriage she had a positive pregnancy test 2 weeks ago. She woke D) Incomplete miscarriage up with lower abdominal cramping and a pool of blood in E) Hydatidiform mole her bed. She has been continuously bleeding for the past 2 hours and is flooding through pads. She feels dizzy and light headed. On examination : she looks pale and is wearing trousers which are soaked with blood. The abdomen is soft with mild suprapubic tenderness. Per speculum – she is actively bleeding and it is difficult to visualise the cervix Observations HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2 10
Case-based discussion: 2 You remove clots from the vagina and are now able to visualise the cervix. The external cervical os is open but the bleeding is ongoing. She is very pale and her BP is 60/40 and HR 117. She is resuscitated with IV fluids and O negative blood is on it’s way. Bloods were taken 20 minutes ago. You estimate her cumulative estimated blood loss to be 1000ml. What is the best management option for this patient? A) Expectant management B) Medical management with misoprostol C) Surgical management - evacuation of retained products of conception D) Medical management with mifepristone E) Medical management with methotrexate 11
Introduction: Miscarriage Definition • Pregnancy loss before 24/40 gestation (UK) • Expulsion of fetus/embryo weighing ≤ 500g and gestational limit < 22 completed weeks of pregnancy (WHO) Epidemiology • Affects 1 in 5 pregnancies • Majority before 12/40 • < 4% miscarriages occur in second trimester • < 5% miscarriage occur after fetal heart activity identified • Early pregnancy loss accounts for 50,000 UK admissions annually • Significant psychological impact 12
Aetiology Causes CHROMOSOMAL ABNORMALITIES in most • Maternal age Risk of miscarriage (%) • Others: • < 20 15.8 Infection (Listeria, Toxoplasmosis, malaria) • Advanced maternal age 25-29 10 • Multiple pregnancy ≥ 45 53 • Assisted conception • Fibroids • Uncontrolled diabetes 13
Miscarriage Bleeding Abdominal pain Cervical os Pregnancy Threatened Yes Yes/No Closed Viable Complete Settling Settling Closed Products passed: uterus not enlarged Incomplete Yes Yes Open Non-viable Inevitable Heavy Yes Open Fetal heartbeat may be present but miscarriage about to occur Missed Yes/No No Closed Uterus smaller than expected for dates No fetal heartbeat 14
Management Conservative/ Expectant: • 50% success • As long as the woman is willing Recommended as first line for first 7-14 days • • No signs of infection (vaginal discharge, excessive bleeding, pyrexia or abdominal pain) : 3% infection • Can take as long as 6–8 weeks • Follow-up appointment 2 weeks later 15
Management Medical: • 85% success Misoprostol: unlicensed for this purpose but supported by the Royal • College of Obstetricians and Gynaecologists Analgesia and antiemetics • Urine pregnancy test 3 weeks after medical management or contact • early pregnancy unit if symptoms worsen/signs of infection • If positive consider molar pregnancy/ectopic Surgical: Manual vacuum aspiration under local anaesthetic in an outpatient or • clinic setting or Surgical management in theatre under general anaesthetic • • Overall significant complication rate 6% • 4% need repeat procedure Similar rates of complications between all 3 management options 16
Case-based discussion: 1 History What is the most likely diagnosis? A) Threatened miscarriage A 36-year-old G3P1+1, presents with vaginal bleeding. Her last B) Pelvic inflammatory disease menstrual period was 7 weeks ago and she had a positive pregnancy test 2 weeks ago. She has a 2-day history of generalised abdominal C) Ectopic pregnancy pain, which is now localised to the left iliac fossa. She has had D) Incomplete miscarriage vaginal spotting for 2 weeks. She feels dizzy and light-headed and is E) Endometriosis complaining of shoulder tip pain. She tells you she had an ectopic pregnancy, which was managed medically 2 years ago. She has IV access and bloods have been sent including FBC, G&S and beta-hCG. On examination, she appears to be in significant pain and is lying very still on the examination couch. The abdomen is soft with significant tenderness and rebound in the left iliac fossa. What investigation should be done next? Speculum examination: cervix seen, minimal dark blood seen in A) Progesterone levels vagina. B) Pelvic ultrasound scan Bimanual examination: Cervical excitation present C) Diagnostic laparoscopy D) Diagnostic laparotomy Observations E) CT abdomen and pelvis HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2 17
Introduction: Ectopic Pregnancy Definition • Implantation outside the uterine cavity • 98% occur in the fallopian tube of which the ampulla is the most common site (NICE) Epidemiology • Incidence: 11 per 1000 clinical pregnancies • Risk of ectopic in future pregnancy 10% 18
Aetiology Risk factors: • Previous tubal surgery • Previous ectopic pregnancy • History of pelvic inflammatory disease • History of infertility • Concurrent IUCD use • Use of progesterone only pill • Assisted conception • Smoking • Maternal age > 40 years The majority of women have no risk factors 19
Investigations Bedside Urine beta human chorionic gonadotrophin (beta-hCG) • Bloods FBC • Beta-hCG • Serial hCG: <66% rise over 48 hours OR decline in hCG • • Useful for planning management Group and save • Imaging Transvaginal ultrasound: first-line diagnostic investigation • 20
Investigations Transvaginal ultrasound: • Sensitivity: 87-99% • Specificity: 94-99% • Laparoscopy no longer the gold standard for diagnosis • False-negative laparoscopies if performed too early in development of ongoing ectopic: 3-4.5% • Inhomogenous or non cystic adnexal mass most common finding 50-60% • EMPTY EXTRAUTERINE GESTATION SAC 20-40% • Extrauterine gestation sac containing yolk sac and/or embryonic pole (+/- cardiac activity) 15 -20% • Small amount anechoic free fluid in pouch of Douglas found in intrauterine and extrauterine pregnancies 21
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