Successfully reported this slideshow.

How to approch a case of bleeding in early pregnancy with case illustration

11,262 views

Published on

Undergraduate course lectures in Obstetrics&Gynecology .Prepared by DR Manal Behery.Faculty of Medicine,Zagazig University

Published in: Education, Health & Medicine

How to approch a case of bleeding in early pregnancy with case illustration

  1. 1. 7We Care DR Manal Behery Assistant Professor Zagazig University ,2013 How to approch A case of vaginal bleeding in early pregnancy
  2. 2. 7We Care ON A Any vaginal bleeding before 20 wks period of gestation is defined as early pregnancy bleeding Definition
  3. 3. 7We Care Case1 A 28 YS G1 P0+0,noticed some bleeding this morning after 5 wks amenorrhea which causes her concern. She took a pregnancy test and was positive 1 week ago.
  4. 4. 7We Care Case cont’ She feels no pain and has not had any other symptoms apart from slight morning sickness She describes the bleeding as ‘spotting’ on her underwear. On physical examination there are no signs of abdominal tenderness or intra-abdominal bleeding.
  5. 5. 7We Care Question 1 AS pregnancy was confirmed a week ago, so you do not consider it necessary to conduct a pregnancy test. Given that patient reports no other symptoms and clearly describes the nature of the bleeding as ‘spotting’, you decide that vaginal examination will not be necessary.
  6. 6. 7We Care Does she need an onward referral? As her pregnancy is less than 6 weeks’ gestation and there is no pain, you would aim to see whether the condition will resolve naturally (an ‘expectant management’ approach).
  7. 7. 7We Care She expresses concern that no further action is being taken.How do you explain this decision? You explain that at this stage, the pregnancy is too small to see, and any further investigations such as scanning are unlikely to yield any information. You also note that many women experience ‘spotting’ during early pregnancy that resolves without the need for further intervention. Therefore you advise waiting to see how things progress during the next week before any further action can be considered.
  8. 8. 7We Care What patient she should do during the course of the ‘expectant management’ week.? You advise her to repeat a urine pregnancy test after 7–10 days  A negative pregnancy test means that the pregnancy has miscarried You emphasise that given the nature of her symptoms the outcome of the test is just as likely to be positive. You advise her to return if her symptoms continue or worsen.
  9. 9. 7We Care Case 2  A34 year old, G1 P0,did not have a period for 5 weeks and so had a pregnancy test at home which was positive.  She now phones you at 2am when you are at home on outpatient call.  She tells you that she has seen spotting with mild abdominal cramping which causes her some discomfort rather than pain. However, she is very anxious and is crying.
  10. 10. 7We Care  What differential diagnoses are you thinking about? Try to name at least three!
  11. 11. 7We Care Causes of bleeding in early pregnancy
  12. 12. 7We Care Related to pregnant state • Abortion • Ectopic pregnancy • Molar pregnancy Related to pregnant state abortion ectopic Vesicular mole
  13. 13. 7We Care Related to pregnant state • Abortion • Ectopic pregnancy • Molar pregnancy Associated with the pregnant state Cervical erosion Cervical polyp Cervical malignancy
  14. 14. 7We Care Does the patient need to be seen tonight?  Bleeding in the first trimester can be a medical emergency! Even spotting can be enough to warrant a visit to the ER.  Best practice is to send her for an exam tonight. Particularly given her disposition – she is anxious.
  15. 15. 7We Care Patient arrived ER at 3.45am It  She has no further spotting and only mild cramping  She still appears tearful and anxious After confirming she is pregnant, what should the next step be? a. Bi-manual pelvic exam b. Sterile speculum exam c. Order an Ultra-sound d. Send her home as the bleeding seems to have resolved Patient arrived ER at 3.45am
  16. 16. 7We Care Case Study - next steps • Answer b is correct: Sterile speculum exam • She needs to have her bleeding assessed now
  17. 17. 7We Care This would now be a good time to think about lab work. What labs would you order for her ? • Serum hCG – This should be done now. We know she is pregnant but it will help correlate with the ultrasound exam – and again in 48 hours - this second draw is done to ensure that the pregnancy is progressing • CBC and type – We need to see if she lost any significant amount of blood and – ascertain her blood group to see if she is Rh negative
  18. 18. 7We Care Case Study – patient outcome • Her CBC is normal and she is A +ve – This rules out severe blood loss and no Rhoram required • Her hCG levels are 900 – This will enable you to assess what should be seen on ultrasound • NOW you can order a stat ultra sound next
  19. 19. 7We Care What would the ultra sound show at this stage? - 4 Trans-vaginal findings Weeks from LMP β-HCG (mIU/ml) Gestational sac (25 mm) 4.5-5 1000 Yolk sac 5-5.5 1500-2500 Fetal pole 5-6 2000-5000 Fetal cardiac activity 5.5-6.5 4000-17000 What would the ultra sound show at this stage? - 4 weeks and a few days
  20. 20. 7We Care The β-hCG level at which an intra-uterine pregnancy (IUP) should be visualized by transvaginal ultrasound, with near 100% sensitivity, is 1000-2000 mIU/mL. The level for transabdominal sonography is less certain but has been suggested to be between 4000 and 6500 mIU/mL.
  21. 21. 7We Care Case study - current diagnosis • She has a closed cervix and no additional blood visualized in the vaginal vault. • It was too early to show any IUP evidence of a yolk sac. • What type of abortion would you consider classifying She at this stage? – Complete – Incomplete – Inevitable – Missed – Threatened
  22. 22. 7We Care Case Study – patient outcome Her bleeding and cramping  Was most likely a threatened abortion  You tell her that you are going to send her home   You advise her to take it easy no strenuous activity or heavy lifting or exercise for the next 7 days to follow up with a hCG serum level in two days to ensure that the levels are doubling every 48 hours Doubling hCG levels are a sign of well being in early pregnancy
  23. 23. 7We Care abortion-definition Termination of pregnancy before the fetus is capable of extra-uterine survival i.e. 20 wks or 500gm birth wt
  24. 24. 7We Care Related to pregnant state • Abortion • Ectopic pregnancy • Molar pregnancy Pathology Haemorrhage into the decidua basalis. Necrotic changes in the tissue adjacent to the bleeding. Detachment of the conceptus. The above will stimulate uterine contractions resulting in expulsion.
  25. 25. 7We Care Types Threatened abortion. Incomplete abortion. Complete abortion. Missed abortion Septic abortion: Any type of abortion, which is complicated by infection Types of abortion
  26. 26. 7We Care Miscarriage • Approximately 30% of pregnant women will experience bleeding in early pregnancy • At least 50% of women with threatened miscarriage will have continuing pregnancy • Miscarriage occurs in 15-20% of clinically diagnosed pregnancies
  27. 27. 7We Care Case Study – return visit She returns to visit you in clinic three weeks later She is 6 weeks post LMP Looking at her history you note that her hCG had doubled on a second lab visit and therefore you had told her that at that time her pregnancy was progressing well However, she is now experiencing increased abdominal pain in the right side and is bleeding The bleeding is described as more than spotting – a cupful.
  28. 28. 7We Care What differential diagnoses do you have now? What is the next step? Differential diagnosis of pain and bleeding at 7 weeks – the same as 4 weeks
  29. 29. 7We Care Ectopic work up • Since SHE has unilateral pain, your thought is directed towards a possible ectopic pregnancy – This means an emergency ultrasound in the ER • Remember on her first visit to the er the ultrasound was unable to visualize an intra-uterine pregnancy – This was because it was too early • We now do a serum hCG and get 7000
  30. 30. 7We Care Site Ectopic pregnancy .Definition & SITE Implantation of fertlized ovum outside the normal uterinse cavity Fallopian tube Ovary Abdominal cavity Cervix
  31. 31. 7We Care Risk factors • Previous PID • Previous ectopic pregnancy • Previous tubal surgery (e.g. sterilisation, reversal) • Pregnancy in the presence of IUCD • POP
  32. 32. 7We Care Diagnosis • Ultrasound – Empty uterus, adnexal mass, – free fluid, – occasionally live pregnancy outside – of uterus • Serum βhCG – Slow rising, plateau Laparoscopy: the surest method
  33. 33. 7We Care Ultrasound of ectopic pregnancy Same images Uterus outlined in red, uterine lining in green, ectopic pregnancy yellow. Fluid in uterus at blue circle - sometimes called a "pseudosac“
  34. 34. 7We Care Ectopic pregnancies Laparoscopic view of ectopic Uterus with fallopian ectopic
  35. 35. 7We Care Management • Conservative – Self resolving with close watch • Medical – Methotrexate • Surgical – Laparoscopic salpingectomy / salpingotomy – Laparotmy
  36. 36. 7We Care On a transvaginal ultrasound you find – Gestational sac in utero – Fetal pole at 2cm – No cardiac activity • Cardiac activity should become visible and begin once the fetal pole reaches 5mm. No cardiac activity at this stage means: – a non-viable fetus Gestational sac in utero Fetal pole at 2cm No cardiac activity Cardiac activity should become visible and begin once the fetal pole reaches 5mm. No cardiac activity at this stage means: a non-viable fetus
  37. 37. 7We Care On doing a Pelvic exam you find – blood in vaginal vault – Cervix is partially open – No tissue is seen • What type of abortion would you consider classifying her now? – Complete – Incomplete – Inevitable – Missed – Threatened
  38. 38. 7We Care Management of inevitable (or incomplete or missed) abortion • Medical – Misoprostol • Surgical – Dilation and curettage • Manual or Standard Vacuum Curettage – Dilation and evacuation • So which would you offer for her ?
  39. 39. 7We Care The first choice would be medical - Misoprostol – Or watch and wait. Some women may choose to remain at home for a miscarraige, unless bleeding becomes heavy or concerning. • Only if failed medical treatment would you need to offer the surgical route next
  40. 40. 7We Care On the third day she passed clots and plenty of blood.  Tissue expulsed should be sent for histopathological exam to assure that it is POC not a molar tissue  If histopathoogy isnot available follow up with HCG until fall to zero to exclude the possibility of a molar pregnancy
  41. 41. 7We Care Patient asks you: – What are the chances of having a successful next pregnancy? – What if she was 37 YO or she had a history of previous abortions?
  42. 42. 7We Care Answers • In women with an unknown etiology of prior pregnancy loss, the probability of achieving successful pregnancies is 40- 80%. • As stated earlier, increased age increases chances of spontaneous abortion. • This is also the case with patients who have three or more previous abortions
  43. 43. 7We Care Clinical approach • History • Examination • Special Investigations
  44. 44. 7We Care History • VAGINAL BLEEDING • Slight and bright red • Associated with fleshy mass • Associated with fowl smell and discharge • Associated with grape like vesicle • Sanguinous or dark coloured and continuous • ‘White currant in red currant juice’
  45. 45. 7We Care Abdominal Pain • Minimal • Acute , agonising or colicky • Shoulder pain • Fever
  46. 46. 7We Care Symptoms of early pregnancy • Amenorrhoea • Morning sickness • Frequency of micturition • Breast discomfort • Fatigue
  47. 47. 7We Care • Previous cycles • LMP • Past history • Similar episodes • Infertility • Details of contraceptive use •Previous cycles •LMP Past history •Similar episodes •Infertility •Details of contraceptive use Careful menstrual history
  48. 48. 7We Care • Previous cycles • LMP • Past history • Similar episodes • Infertility • Details of contraceptive use Amenorrhea Abdominal pain  Irregular vaginal bleeding Classical triad of ectopic pregnancy
  49. 49. 7We Care Examination • General look – Lies quiet and conscious, perspires and looks blanched – Looks more ill than accounted for- molar pregnancy General look Lies quiet and conscious, perspires and looks blanched Looks more ill than accounted for- molar pregnancy
  50. 50. 7We Care Vital signs • Temperature – Febrile/a febrile • Pulse – Tachycardia/normal • Blood pressure – Low/normal Vital signs
  51. 51. 7We Care Size of uterusSize of uterus Guarding and rebound tenderness
  52. 52. 7We Care Speculum examination  Trauma  Cervical pathology  Open cervical os- incomplete abortion Speculum examination
  53. 53. 7We Care  Extreme tenderness on fornix palpation or rocking of cervix  Palpation of bilateral or unilateral enlargement of ovary - molar pregnancy  Palpation of adnexal mass- Ectopic pregnancy Bimanual examination
  54. 54. 7We Care Investigations • Hb • TLC • DLC • Platelet • PCV • ABO and Rh grouping • Thyroid function test Investigations
  55. 55. 7We Care Investigations Routinely used Main modality of diagnosis Transvaginal and Transabdominal Ultrasonography
  56. 56. 7We Care BLIGHTED OVUM Blighted ovum Incomplete abortion Compelet abortion
  57. 57. 7We Care BLIGHTED OVUM Ectopic pregnancy Vesicular mole
  58. 58. 7We Care • Complete abortion – Positive UPT – Absent product of conception • Ectopic pregnancy – Positive UPT – USG confirmation – Product of conception absent in uterus • Molar pregnancy – Positive UPT – Typical USG findings Threatened abortion Positive UPT Intrauterine pregnancy Viable fetus Incomplete abortion •Positive UPT •Product of conception in-situ •Non viable fetus DIAGNOSIS
  59. 59. 7We Care • Complete abortion – Positive UPT – Absent product of conception • Ectopic pregnancy – Positive UPT – USG confirmation – Product of conception absent in uterus • Molar pregnancy – Positive UPT – Typical USG findings Complete abortion Positive UPT Absent product of conception Ectopic pregnancy Positive UPT USG confirmation Product of conception absent in uterus Molar pregnancy Positive UPT Typical USG findings
  60. 60. 7We Care THANK YOU Thank you

×