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Bleeding in early pregnancy
The document discusses early pregnancy bleeding, defining it as any vaginal bleeding before 20 weeks of gestation. It outlines differential diagnoses such as miscarriages and ectopic pregnancies, presents a specific case scenario, and details the assessment and management approaches for various complications including gestational trophoblastic disease. The document also emphasizes the importance of appropriate diagnostic tools and guidelines for managing such conditions.
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Bleeding in early pregnancy
- 1. BLEEDING IN EARLY PREGNANCY DRKTD PRIYADARSHANI REGISTRAR IN EMERGENCY MEDICINE NATIONAL HOSPITAL- KANDY
- 2. Definition Any vaginalbleeding before 20 weeks period of gestation is defined as early pregnancy bleeding
- 3. Case scenario.. A37years 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 tothink 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.. Onadmission 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 nowbe 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
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- 12. Type of miscarriages 1.Threaten miscarriage 2. Inevitable miscarriage 3. Missed miscarriage 4. Incomplete miscarriage 5. Complete miscarriage 6. Pregnancy of uncertain viability
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- 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 Upto 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
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- 18. Ectopic pregnancy Definition Implantationof 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 – Ectopicpregnancy 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 MedicalSurgical 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
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- 23. GTD Classification 1. GTD 1. Completemole 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 DoBeta 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 topguideline 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
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