This presentation describes approach to a patient presenting with early pregnancy bleeding. It also includes a brief outline about the management of miscarriage, molar pregnancy and ectopic pregnancy.

1. BLEEDING IN EARLY
PREGNANCY
DR KTD PRIYADARSHANI
REGISTRAR IN EMERGENCY MEDICINE
NATIONAL HOSPITAL- KANDY

2. Definition
 Any vaginal bleeding before 20 weeks period of gestation is defined as early
pregnancy bleeding

3. Case scenario..
 A 37years old P4C2 mother presented to ETU with history of PV bleeding for 6days.
 It was a mild to moderate fresh bleeding.
 It was associated with abdominal pain.
 There was no fever or faintishness.
 She had good urine output.
 Her last regular menstrual period was 1st of July with POA of 7+5 weeks
 She was tested for urine hCG and found positive

4. Differential diagnoses to think about..
Bleeding in 1st
trimester
Related to pregnant
state
Miscarriage Ectopic pregnancy
Trophoblastic
disease
Septic abortion
Associated with the
pregnant state
Cervical erosion Cervical polyp Cervical malignancy Post coital bleeding

5. History
 Maternal age, parity, POA, Pregnancy confirmation
 Bleeding
 Number of episodes, Amount of blood loss, color
 Passage of clots or vesicles
 Purulent vaginal discharge, fever
 Associated symptoms- abdominal pain- quality, location, spread
 Past obs & gyn history
 Past medical, surgical history
 Drug history
 Social history

6. Case scenario..
 On admission PR was 88bpm. Blood pressure 120/80mmHg.
 Abdomen was soft in palpation.
 Speculum examination showed mild contact bleeding with closed OS
 VE- No adnexal tenderness or masses palpable

7. Examination
 General
 Febrile, pallor
 CVS
 PR, Pulse characteristics, BP, pulse pressure
 CRT, cold clammy peripheries
 Abdomen
 Tenderness, Guarding, rigidity
 Uterine size
 Speculum examination
 Bleeding from OS or from outside
 Products, clots, blood in posterior fornix
 VE
 Os open or closed
 Cervical excitation
 Adnexal tenderness/ masses

8. Resuscitation
 ABCDE approach
 Main concern in hemodynamic stability
 Fluid resuscitation depends on class of haemorrhage
 2 large bore IV cannula
 DT and reserve blood – 6units
 Urine HCG
 Rhesus status- antiD Immunoglobulin may be required
 Urgent O&G referral

9. This would now be a good time to think
about lab work…
 Urine hCG – already done
 FBC
 Blood grouping and Rh
 Clotting= risk of DIC

10. Urine HCG
USS (TAS/TVS) for
IUP
YES
FETAL HB/ PARTS
FHB+ Threatened
Miscarriage
Fetal products
incomplete
Miscarriage
SNOW STORM
H MOLE
S B hCG CXR
NO
PREGNANCY IN
ECTOPIC SITE
S B hCG

11. Miscarriage

12. Type of miscarriages
1. Threaten miscarriage
2. Inevitable miscarriage
3. Missed miscarriage
4. Incomplete miscarriage
5. Complete miscarriage
6. Pregnancy of uncertain viability

13. Definitions

14. Diagnosis

15. Management of miscarriages
 Factors to be taken into account
01. Type of miscarriage
02. Gestation at which miscarriage is diagnosed
03. Medical history, for example cardiac disease and sickle cell anemia
04. Facilities available at individual units
05. Cost
06. Patient preference
 Options
01. Expectant management
02. Medical management
03. Surgical management

16. Conti…
1. Expectant management
Up to 85% of miscarriages will resolve spontaneously within 3 weeks of the diagnosis
Need adequate counseling
02. Medical management
Induce evacuation with prostaglandin
Misoprostol (PGE1)
fallow FIGO guidance or NICE
03. Surgical management
ERPC

17. Ectopic pregnancy

18. Ectopic pregnancy
 Definition
Implantation of a fertilized ovum outside of endometrial cavity
 Types
1. Tubal ectopic pregnancy
2. Ovarian ectopic
3. Cervical ectopic
4. Interstitial ectopic
5. Abdominal ectopic
6. Caesarean scar ectopic
7. Heterotrophic ectopic

19. Ectopic pregnancy- diagnosis
 Primary diagnostic tool – USS preferably TVS
 Gold standard of diagnosis- laparoscopy

20. Management – Ectopic pregnancy
 Depend on number of factors
01.Symptoms profile – bleeding and degree of pain
02. Type of ectopic
03. Size of the ectopic
04. Level of serum beta Hcg
05 viability
 Options
01. Expectant management
02. Medical management
03. Surgical management

21. Conti…
Factor Expectant Medical Surgical
Type of ectopic(Tubal )
2. Symptoms No internal or genital
bleeding, no significant
abdominal pain
No internal or genital
bleeding, no significant
abdominal pain
Evidence of internal bleeding
and significant pain, unstable
3. Viability Non- viable Non- viable viable
4. Size of ectopic <30mm <35mm >35mm
5. Level of serum beta Hcg <1500 IU 1500 up to 5000 IU >1500IU
6. Procedure • Rpt beta Hcg on day 4
• If >15% drop
• Repeat weekly Hcg until
<20IU/L
• IM MTX 50mg/m2 single
dose
• Rpt beta Hcg day 4 and 7
• If drop >15% repeat
weekly until <15IU/L
To be decide on
Laparotomy/ laparoscopy
And salpingectomy /
salpingotomy

22. Gestational trophoblastic
disease

23. GTD
Classification
1. GTD
1. Complete mole
2. Partial mole
3. Atypical placental site nodule
2. GTN
1. Chorio carcinoma
2. Malignant invasive mole
3. Placental site trophoblastic tumor
4. Epithelioid trophoblastic tumor
Definitive diagnosis done by histological confirmation

24. Management of GTD
1. Patient counseling
2. Pre operative preparation
1. Investigation – FBC/ CXR/ base line beta Hcg level
2. Cross match and DT
3. Fasting
4. Informed written consent
3. Suction evacuation
4. Further management depend on histological diagnosis

25. Conti..
 CHM
 Do Beta Hcg level 1 – 2 weekly until normal
 Rpt Beta Hcg one monthly after normalization for 6 months
 PHM
 Do Beta Hcg level 1-2 weekly until normal
 Rpt beta Hcg level one month after normalization

26. REFERENCES
 Green top guideline No 21- Diagnosis and Management of Ectopic
Pregnancy
 Green top guideline No 38- Management of Gestational Trophoblastic
Disease
 NICE guideline- Ectopic pregnancy and miscarriage: diagnosis and initial
management

27. QUESTIONS?

28. Thank you!