Tutorial - cases in early pregnancy.

1. Early Pregnancy

2. Case 1: Bleeding In Pregnancy
• A 20-year-old woman presents at 3 months gestation with vaginal
bleeding and a smelly watery discharge.
• She mentions she feels generally unwell and has been having fevers
for the last 48 hours.
• How would you assess this patient further?

3. • She is at 13+2 weeks gestation by dates.
• She is complaining of reduced appetite, abdominal pain, vomiting and
had loose stools.
• All booking bloods were normal.
• 11 week dating scan saw a viable fetus matching dates.
• 1 NVD at 38 weeks gestation. No PGH, PMH, PSH.

4. • Parameters:
• T: 38.5 °C
• Pulse: 100 /min
• BP: 105/60 mmHg
• Chest + Cardiac: Normal
• Abdomen:
• Tender supra-pubically, over the uterus.
• Approximate uterine size 14/40.
• No rebound or guarding.
• Speculum: Cervical Os < 1cm. Bloody / Foul smelling discharge.
• Bimanual: Very tender, hot uterus. “Boggy”. Adnexae: no masses
palpated, but bilateral tenderness.

5. • Blood Investigations:
• Haemoglobin: 10.3 g/dl (11-14 g/dl)
• WCC: 23.9 ×109/L (6-16 ×109/L)
• Neutrophils: 18 ×109/L (2.5-7 ×109/L)
• Platelets: 556 ×109/L (150-400 ×109/L)
• Sodium: 135 mmol/L (130-140 mmol/L)
• Potassium: 3.6 mmol/L (3.3-4.1 mmol/L)
• Urea: 6 mmol/L (2.4-4.3 mmol/L)
• Creatinine: 80 µmol/L (34-82 µmol/L)
• CRP: 127 mg/L (<5 mg/L)

6. TV Scan Report:
• Single intra-uterine
gestational sac.
• Fetus present, CRL 42.7
mm.
• FH absent.

7. • Summary:
• 13+2 weeks gestation
• Septic ( Fever, Tachycardia, High WCC / Neutrophils / CRP)
• Non-viable Fetus.

8. • What is the likely diagnosis?
• How would you asses the patient further?

9. SEPTIC MISCARRIGE

10. • Further Investigations
• Blood Cultures
• Liver Function Tests
• Coagulation Screen
• Group and Save
• High Vaginal & Endo-cervical Swabs

11. • Management:
• Admit. Frequent parameter charting.
• IV Access, then Antibiotics – broad spectrum, pending C&S.
• IV Fluids – due to the intravascular depletion from sepsis and vomiting.
• Urinary Catheter – monitor I/O charting and obtain samples for MC&S.
• Surgical Management of Miscarriage – evacuation of the retained products of
conception needs to be organised urgently once the first does of antibiotics
has been given.
• Complications: Massive Haemorrhage, Uterine Perforation.
• Others: Hysterectomy, DIC, Multi-system Failure needing ITU, Death

12. • Definition of Miscarriage - WHO:
oLoss of pregnancy before 22 completed weeks of gestation
oExpulsion of a fetus or embryo weighing less than 500 g
• Miscarriage can be classified as either:
• early – when pregnancy loss occurs before 12 weeks of gestation (first
trimester)
• late – when pregnancy loss occurs between 12 and 24 weeks of gestation
(second trimester).
• Incidence: Between 10 to 20 % of clinically recognizable pregnancies
will end in miscarriage. Recurrent pregnancy loss occurs in 1–2% of
fertile women.

13. • Aetiology:
• Majority have no identifiable cause.
• Genetic – 50% of clinically identifiable 1st trimester miscarriages are
chromosomally abnormal. The risk of chromosomal abnormality falls with
advanced gestation (50% at 8-11 weeks and 12% at 20-23 weeks). The most
common is trisomy, followed by monosomy X and triplody.
• Infection – rare, but several organisms have been implicated in miscarriage
including Listeria monocytogenes, Campylobacter sp., Brucella sp.,
Mycoplasma hominis, CMV, rubella, coxsackie, herpes, varicella zoster and
malaria (Plasmodium falciparum).
• Second trimester miscarriages may be associated with uterine abnormalities,
cervical incompetence, bacterial vaginosis and multiple pregnancy.

14. • Recurrent Miscarriage:
• Definition: Three consecutive pregnancy losses < 22 completed weeks of
gestation.
• 1% of women suffer from recurrent miscarriage. This is higher than the
statistical prediction of three consecutive miscarriages (calculated as 0.4 %).
• It has been estimated that 1–2% of second-trimester pregnancies miscarry
before 24 weeks of gestation.

15. • Aetiology in recurrent miscarriage:
• Majority have no identifiable cause.
• Age – there is an increased risk of chromosomal abnormalities with advancing
maternal age and an increased risk of miscarrying such a pregnancy. These
women may also suffer infertility owing to diminished ovarian reserve. 20–24
years, 11% vs 40–44 years, 51%; and ≥45 years, 93%.
• Abnormal parental karyotype – 3 to 5% of couples will have one partner who
carries a chromosomal abnormality. In 60% of cases this is a balanced
reciprocal translocation and 30% have a Robertsonian Translocation.
• Antiphospholipid syndrome (APS) – this affects 15% of women. There is a well
recognised association between recurrent miscarriage and antiphospholipid
antibodies, lupus antibodies and anti-cardiolipin antibodies. Mechanism of
pregnancy loss may be related to abnormal placentation.

16. • Aetiology in recurrent miscarriage: [2]
• Genetic thrombophilia – up to 5% of women will have a hereditary
thrombophilia, including activated protein C resistance (Factor V Leiden
mutation), Anti-thrombin III deficiency, Protein C and S deficiencies.
• Congenital uterine anomalies – this affects 6% of women. The sub-septate
uterus is classically associated with recurrent first trimester miscarriage.
Mechanism remains uncertain.

18. • Other Risk Factors:
• stress (including the number of stressful or traumatic events)
• previous termination
• low pre-pregnancy weight
• change of partner
• previous miscarriage
• infertility
• assisted conception
• regular or high alcohol consumption
• chronic illnesses
• thyroid disorders
• uncontrolled diabetes
• trauma
• radiotherapy and chemotherapy
• uterine malformations/fibroids
• high maternal BMI
• heavy bleeding
• general anaesthetic during early pregnancy

19. • Factors associated with reduced risk of miscarriage include:
• previous live birth
• nausea
• vitamin supplementation
• feeling well enough to fly or have sex
• eating fresh fruits and vegetables daily
• Factors with no evidence of association with miscarriage include:
• caffeine consumption
• smoking
• moderate or occasional alcohol consumption
• education level
• socio-economic status
• working during pregnancy

20. Case 2: Abdominal Pain
• A 30 year old woman presents with abdominal pain . It started around
2 hours ago, it was initially in the lower abdomen but has now
become generalised .
• How would you assess this patient further?

21. • She feels nauseated and dizzy, especially when she sits up. She also
feels as if she has bruised her shoulder .
• Denies PVB or discharge, no bowel or urinary symptoms.
• Does not know LMP, but was around a month ago. Is in a long term
relationship with no contraceptive use.
• Had a TOP 3 years ago. At 19 she was diagnosed with chlamydia when
she was admitted to hospital due to a pelvic infection.
• No other PMH, PSH.

22. • Looks pale and unwell. Intermittently drowsy. Lying flat and still on the
bed.
• Parameters:
• T: 36.0 °C
• Pulse: 120 /min
• BP: 90/50 mmHg
• Chest + Cardiac: Peripherally cool, the hands are clammy. Rest: Normal.
• Abdomen:
• Generally slim, but symmetrically distended.
• Generalised tenderness on light palpation.
• Rebound and guarding.
• Vaginal examination not carried out.

23. • Urine Pregnancy Test: Positive
• Blood Investigations:
• Haemoglobin: 9.6 g/dl (11-14 g/dl)
• Mean Cell Volume: 87 fL (80-99 fL)
• WCC: 7.1 ×109/L (6-16 ×109/L)
• Platelets: 204 ×109/L (150-400 ×109/L)
• Sodium: 131 mmol/L (135-145 mmol/L)
• Potassium: 6 mmol/L (3.5-4.5 mmol/L)
• Urea: 6 mmol/L (2.5-6.7 mmol/L)
• Creatinine: 72 µmol/L (70-120 µmol/L)

24. • Summary:
• Positive Pregnancy Test
• Peritonitic (Rebound + Guarding)
• Hemodynamically unstable (cold, clammy hands, hypotensive, tachycardia,
normochromic, normocytic anaemia)

25. • What is the likely diagnosis?
• How would you manage the patient?

26. RUPTURED
ECTOPIC PREGNANCY

27. • Dizziness, Nausea, Abdominal and and Shoulder Pain are classical
signs of haemoperitoneum.
• Any woman who is unwell with abdominal pain should be assumed to
have an ectopic pregnancy unless proved otherwise. Urine HCG!
• Young women tend to compensate very well for hypovolaemia. The
fact that this lady looks unwell and has peripheral shut down further
outlines the graveness of the situation.
• Should be transferred to theatre without delay. An ultrasound would
only delay her transfer to theatre in what is an obvious clinical
diagnosis.

28. • Management:
• Facial Oxygen
• Lie flat, with head down.
• IV Access: 2 large bore cannulae with 2L of fluids, running.
• xMatch 4 Units – and alert blood bank + haematologist of the haemorrhage
• Consent for laparotomy and salpingectomy (+/- oophorectomy)
• Transfer to theatre.

29. Case 3: Bleeding and Pain
• A 29 year old woman presents with irregular vaginal bleeding and
adnominal discomfort .
• How would you assess this patient further?

30. • Bleeding started 2 days ago. Dark red/brown and though not heavy
sufficient to require wearing a sanitary towel.
• Abdominal discomfort is suprapubic and crampy, slightly more on the right
hand side.
• No change in appetite, nausea or vomiting.
• BO regularly, and normal. No LUTS.
• LMP 45 days ago. Usual cycles slightly irregular varying 3-5/28-35 days .
• Regular partner, for 3 years occasionally does not use barrier
contraception.
• STI screen 6 months ago NAD.
• No other POH, PMH, PSH.

31. • Comfortable, not distressed.
• Parameters:
• T: 36.3 °C
• Pulse: 85 /min
• BP: 125/75 mmHg
• Chest + Cardiac: Normal.
• Abdomen:
• Slightly overweight, soft and not distended.
• Tenderness to deep palpation in the RIF.
• No rebound and guarding.
• Vaginal examination not carried out.

32. • Urine Pregnancy Test: Positive
• Blood Investigations:
• Haemoglobin: 12.6 g/dl (11-14 g/dl)
• Mean Cell Volume: 86 fL (80-99 fL)
• WCC: 7.1 ×109/L (6-16 ×109/L)
• Platelets: 182 ×109/L (150-400 ×109/L)
• Sodium: 140 mmol/L (135-145 mmol/L)
• Potassium: 3.6 mmol/L (3.5-4.5 mmol/L)
• Urea: 5.3 mmol/L (2.5-6.7 mmol/L)
• Creatinine: 75 µmol/L (70-120 µmol/L)

35. • Summary:
• Positive Pregnancy Test
• Tender abdomen, not peritonitic.
• Stable relationship, no safe contraception. No STIs.
• Adnexal mass on TVS.
• Distended right fallopian tube at laparoscopy.
• No evidence of blood in the POD to suggest rupture and haemoperitoneum.

36. • What is the likely diagnosis?
• What are the management options in this case?
• How would you counsel the woman post-operatively?

37. ECTOPIC PREGNANCY

38. • Classic symptoms of Ectopic Pregnancy are amenorrhoea, iliac fossa
pain and dark vaginal bleeding.
• Symptoms however do vary. From heavy vaginal bleeding, to period
pain to no symptoms at all.
• Occur in 1-2 % of pregnancies. Majority are diagnosed before
catastrophic rupture.

39. • Management:
• Surgical (salpingectomy or salpingotomy)
• Medical (methotrexate injection)
• Expectant
• In view of a viable pregnancy, conservative options (methotrexate or
expectant) are not an option since treatment failure is a likely possibility and
consequences of such are dangerous (rupture).
• Surgical intervention should be in the form of laparoscopy if expertise is
available, to minimise post-operative pain, hospital stay, and reduce post-
operative complications including adhesions.
• If the contralateral tube is healthy, salpingectomy should be the treatment
option of choice. In case the other tube is damaged, salpingotomy should be
attempted.

40. • Post-Operative Counselling:
• Explain diagnosis and operation.
• Explain it is normal to grieve (this is a loss of a pregnancy) and offer advice
about further support.
• Will need to avoid the Progesterone Only Pill (POP) and the Intra-Uterine
Contraceptive Device (IUCD) – both being associated with a slightly higher risk
of ectopic pregnancy.
• 65–70% of women who have had an ectopic pregnancy will go on to have a
normal live birth if they continue trying to conceive. There is a residual 10 –
15% chance of a second ectopic pregnancy.
• Early TVS at around 5 weeks gestation is recommended to confirm the
location of any future pregnancy.
• Effective contraception should be offered if she does not wish to conceive
again.

41. Case 4: Abdominal Pain
• A 24-year-old woman attends the emergency department
complaining of abdominal pain.
• How would you assess this patient further?

42. • 7 weeks 4 days pregnant by certain menstrual dates.
• NVD at term 18 months ago.
• Periods are usually regular 3-5/27 days,
• No PGH.
• PMH: mild asthma and two episodes of cystitis.
• The pain started suddenly two nights ago and is localized to the right iliac fossa with
some radiation down the right thigh.
• It is constant though worse on movement, so she has tended to lie still.
• She has not taken any analgesia as she is uncertain whether this is safe for the baby.
• She is always constipated and this is worse since she became pregnant.
• She has urinary frequency but no dysuria or haematuria.
• She has a slightly reduced appetite but does not feel feverish or sweaty.
• No other PMH, PSH.

43. • Slightly uncomfortable on moving. Not distressed. Warm and well
perfused.
• Parameters:
• T: 36.2 °C
• Pulse: 87 /min
• BP: 96/57 mmHg
• Chest + Cardiac: Normal.
• Abdomen:
• Slim, abdomen is soft and not distended.
• Focal tenderness on palpation of the right iliac fossa.
• Slight rebound tenderness but no guarding. Rovsing's sign negative.
• Vaginal examination:
• Speculum examination is unremarkable.
• The uterus is bulky and retroverted with no cervical excitation.
• The right adnexa is tender with a suggestion of “fullness”.

44. • Blood Investigations:
• Haemoglobin: 12.1 g/dl (11-14 g/dl)
• MCV: 89 fL (74.4-95.6 fL)
• WCC: 5.1 ×109/L (6-16 ×109/L)
• Platelets: 223 ×109/L (150-400 ×109/L)
• CRP: <5 mg/L (<5 mg/L)
• Sodium: 135 mmol/L (130-140 mmol/L)
• Potassium: 3.6 mmol/L (3.3-4.1 mmol/L)
• Urea: 3 mmol/L (2.4-4.3 mmol/L)
• Creatinine: 60 µmol/L (34-82 µmol/L)
• Pregnancy Test: Positive
• Urinalysis: protein trace, nitrites negative, blood negative, leucocytes negative.

46. • Summary:
• IUGS, viable pregnancy.
• Tender abdomen, slight rebound.
• Adnexal mass on TVS.
• Not septic, not hypovolemic.
• No suggestion of UTI

47. • What is the likely diagnosis?
• What are the differential diagnoses for the pain?
• How would you further investigate and manage this woman?

48. HAEMORRHAGIC LUTEAL CYST

49. • The ultrasound shows a single viable intrauterine pregnancy and
haemorrhage into a corpus luteal cyst.
• DD:
• Corpus luteum
• Ectopic pregnancy
• Miscarriage
• Ovarian cyst
• UTI
• Renal tract calculus
• Constipation
• Appendicitis
• Unexplained pain

50. • Urinary tract infection or calculi are excluded by the urinalysis result.
• Constipation is more likely to cause left-sided pain and the sudden onset of
pain would perhaps be unusual.
• Appendicitis should be considered but the lack of systemic features, the
normal temperature, white count and C-reactive protein are suggestive of
this not being the diagnosis.
• The corpus luteum is the cystic area that develops on the ovary at the
ovulation site. It may be solid, cystic or haemorrhagic and may vary in size.
On colour Doppler ultrasound it has a typical 'ring of fire' appearance,
distinguishing it from other types of ovarian cyst. In this case the 'spider
web' or reticulated pattern of echoes within the cyst suggests that it is
haemorrhagic.

51. • Management:
• Supportive with analgesia (paracetamol +/- codeine derivatives if necessary)
• Reassurance.
• There is no evidence that bleeding into the corpus luteum adversely affects
the pregnancy outcome.
• Repeat an ultrasound scan in 2-4 weeks to confirm resolution – during dating
/ ‘nuchal’ scan.