Early pregnancy bleeding.ppt

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fantastic approach to deal with patients of early pregnancy bleeding

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Early pregnancy bleeding.ppt

  1. 1. 7 We CareVAGINAL BLEEDING INEARLY PREGNANCYFg Offr P K Dixit MBBS, AFMC7 AF Hospital, Kanpur
  2. 2. 7 We Care
  3. 3. 7 We Care
  4. 4. • Definition 7 We Care• Differential diagnosis• Definition of entities• Clinical approach to a patient• Brief management
  5. 5. DEFINITION 7 We CareAny vaginal bleedingbefore 20 wks period ofgestation is defined asearly pregnancy bleeding
  6. 6. 7 Causes of bleeding in early pregnancy We Care Ectopic pregnancyAbortion Hydatidiform mole
  7. 7. Related to pregnant state 7 We Care• Abortion• Ectopic pregnancy• Molar pregnancy
  8. 8. Associated with the pregnant state 7 We Care• Cervical lesions like • Ruptured varicose veins
  9. 9. 7 We CareCERVICAL EROSION
  10. 10. 7 We CareCERVICAL POLYP
  11. 11. 7 We CareCERVICAL MALIGNANCY
  12. 12. Pathology 7 We Care• 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.
  13. 13. 7 We Care ABORTION-DEFINITIONTermination of pregnancy before the fetusis capable of extra-uterine survival i.e. 20wks or 500gm birth wt
  14. 14. • Types of abortion Threatened abortion. 7 We Care• Incomplete abortion.• Complete abortion.• Missed abortion Septic abortion: Any type of abortion, which is complicated by infection
  15. 15. 7 We Care
  16. 16. 7 We Care
  17. 17. 7 We Care
  18. 18. 7 We Care
  19. 19. 7 We Care
  20. 20. MOLAR PREGNANCY 7 We Care
  21. 21. 7 We Care
  22. 22. • History CLINICAL APPROACH 7 We Care• Examination• Special Investigations
  23. 23. History• VAGINAL BLEEDING 7 We Care • 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’
  24. 24. Pain abdomen • Minimal 7 We Care • Acute , agonising or colicky • Shoulder pain • Fever
  25. 25. Symptoms of early pregnancy • Amenorrhoea 7 We Care • Morning sickness • Frequency of micturition • Breast discomfort • Fatigue
  26. 26. • Hyperemesis 7 We Care• Breathlessness• Thyrotoxic features• Syncopal attack
  27. 27. • Careful menstrual history 7 We Care • Previous cycles • LMP• Past history • Similar episodes • Infertility • Details of contraceptive use
  28. 28. • Classical triad of ectopic pregnancy 7 We Care – Amenorrhoea – Pain abdomen – Irregular vaginal bleeding
  29. 29. EXAMINATION• General look 7 We Care – Lies quiet and conscious, perspires and looks blanched – Looks more ill than accounted for- molar pregnancy
  30. 30. • Temperature VITALS 7 We Care – Febrile/afebrile• Pulse – Tachycardia/normal• Blood pressure – Low/normal
  31. 31. 7 We Care•Empty bladder
  32. 32. 7 We CareGUARDING AND REBOUND TENDERNESS
  33. 33. 7 We CareSize of uterus
  34. 34. • Trauma 7 We Care• Cervical pathology• Open cervical os- incomplete abortion
  35. 35. • Bimanual examination 7 We 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
  36. 36. 7 We CareUrine pregnancy testpositive
  37. 37. • Hb INVESTIGATIONS 7 We Care• TLC• DLC• Platelet• PCV• ABO and Rh grouping• Thyroid function test
  38. 38. • hCG- rapidly increasing values of serum hCG 7 We Care
  39. 39. ULTRASONOGRAPHY• Routinely used 7 We Care• Main modality of diagnosis• Transvaginal and Transabdominal
  40. 40. 7 We CareBLIGHTED OVUM
  41. 41. 7 We CareINCOMPLETE ABORTION COMPLETE ABORTION
  42. 42. 7 We CareECTOPIC PREGNANCY
  43. 43. 7 We Care HYDATIFORM MOLE(Snow storm appearance)
  44. 44. DIAGNOSIS• Threatened abortion 7 We Care – Positive UPT – Intrauterine pregnancy – Viable fetus• Incomplete abortion • Positive UPT • Product of conception in-situ • Non viable fetus
  45. 45. • Complete abortion 7 We Care – 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
  46. 46. Management of Threatened Abortion 7 We Care• Advise woman to avoid strenuous activity and sexual intercourse; bed rest not necessary• If bleeding stops, follow up in antenatal clinic. Reassess if bleeding recurs• If bleeding persists, assess for fetal viability.
  47. 47. Incomplete Abortion 7 We Care• If bleeding light to moderate, use fingers or ring (or sponge) forceps to remove products of conception protruding through cervix• If bleeding heavy, evacuate uterus: – Manual vacuum aspiration (MVA) is preferred method – If evacuation not immediately possible, give ergometrine OR misoprostol47
  48. 48. Incomplete Abortion 7 We Care• Infuse oxytocin 40 units in 1 L IV fluids at 40 drops/min. until expulsion of products of conception occurs• Evacuate any remaining products of conception from uterus by dilatation and curettage• If necessary, give misoprostol 200 µg vaginally every 4 hours until expulsion48
  49. 49. Management of Complete Abortion 7 We Care • Evacuation of the uterus usually not necessary • Observe for heavy bleeding • Ensure followup of woman after treatment49
  50. 50. Follow up After Abortion• Tell woman that spontaneous abortion is common 7 We Care• Reassure woman that chances for subsequent successful pregnancy are good• Encourage her to delay next pregnancy until completely recovered• Advise on contraception
  51. 51. Immediate Management of Molar Pregnancy• If diagnosis is certain, evacuate uterus: 7 We Care – If cervical dilatation is needed, use a paracervical block – Use vacuum aspiration (MVA preferred)• Infuse oxytocin 20 units in I L IV fluids at 60 drops per min.
  52. 52. ECTOPIC PREGNANCY• Expectant 7 We Care• Medical• Surgical
  53. 53. THANK YOU 7 We Care
  54. 54. THANK YOU 7 We Care

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