This document describes the case of a 34-year-old woman who is 5 weeks pregnant based on a home pregnancy test. She presented with 1 day of spotting and abdominal cramps. Her exam and initial ultrasound were normal. However, she returned 3 weeks later with increased abdominal pain and heavier bleeding. A follow up ultrasound showed a pseudosac in the uterus with no heartbeat, and a mass in her right fallopian tube with no heartbeat, diagnosing her with an ectopic pregnancy in the fallopian tube. She was treated with a single dose of methotrexate to resolve the ectopic pregnancy non-surgically.

1. BLEEDING IN EARLY
PREGNANCY
Dr .Dinesh Gehlot

2. CASE SCENARIO
 A 34 Y/OLD WIFE OF SERVING WITH AMENORRHEA OF 5 WEEKS DURATION,
 DID UPT AT HOME 3 DAYS AGO– POSITIVE
 SPONTANEOUS CONCEPTION
 PRESENTED WITH COMPLAINTS OF 1. SPOTTING PER VAGINUM ONE DAY AGO
2.MILD ABDOMINAL CRAMP SINCE 1 DAY

3. DIFFERNTIAL DIAGNOSIS
 THOSE RELATED TO PREGNANCY – ABORTION
ECTOPIC PREGNANCY
MOLAR PREGNANCY
 THOSE ASSOCIATED WITH PREGNANCY – CERVICAL ECTOPY
POLYP
CERVICAL CARCINOMA

4. HISTORY OF PRESENTING ILLNESS
 PATIENT WAS APPARENTLY ASYMPTOMATIC 1 DAY AGO WHEN SHE NOTICED
SPOTTING PER VAGINUM WHICH STOPPED SPONTANEOUSLY AFTER A SINGLE
EPISODE
 THE BLEEDING WAS FOLLOWED BY MILD ABDOMINAL PAIN WHICH WAS OF A
CRAMPING NATURE AND IS CONTINOUS SINCE 1 DAY
 THERE IS NO H/O FEVER WITH RASHES
 NO H/O FOUL SMELLING DISCHARGE
 NO H/O PASSAGE OF FLESHY MASS PER VAGINUM
 NO H/O BURNING MICTURITION
 NO H/O EXPOSURE TO RADIATION

5. PAST OBSTETRIC HISTORY
 PATIENT IS A G2P1L1
 L1 – FEMALE /5 YEARS /UNEVENTFUL HISTORY /NORMAL VAGINAL DELIVERY
 WEIGHT OF THE BABY- 3.1 KG

6. PAST HISTORY
 NO H/O DM-2, TB, ASTHMA, HYPERTENSION, HYPOTHYROIDISM
 THERE IS A HISTORY OF APPENDICECTOMY 2 YEARS AGO
 NO H/O USE OF ORAL CONTRACEPTIVES
 NO H/O POST COITAL BLEEDING
 NO H/O INFERTILITY

7. MENSTRUAL HISTORY
 AGE OF MENARCHE – 14YEARS
 REGULAR CYCLES
 3-4 DAYS BLEED
 NORMAL FLOW
 NO H/O DYSMENORRHEA , PASSAGE OF CLOTS

8. PERSONAL AND FAMILY HISTORY
 NORMAL APPETITE AND SLEEP HABITS
 NO H/O SMOKING / ALCOHOL ABUSE
 NO H/O BOWEL AND BLADDER ABNORMALITY
 NO H/O SIGNIFICANT FAMILY HISTORY

9. EXAMINATION
 GENERAL EXAMINATION – GC WAS FAIR
 VITALS –STABLE
 NO PALLOR SEEN
 SYSTEMIC EXAMINATION
 PER ABDOMEN – SOFT , NON TENDER , NO ORGANOMEGALY
 PER SPECULUM – NO BLEEDING THROUGH CERVIX
 BIMANUAL EXAMINATION – EXTERNAL OS CLOSED, CERVIX SOFT
 CVS -S1S2 HEARD
 CNS - NO SENSORIMOTOR DEFICIT
 R/S – CLEAR CHEST B/L

10. INVESTIGATIONS
 CBC – HEMOGLOBIN WAS 11.3 g/Dl
 WBC – WITHIN NORMAL LIMITS
 BLOOD GROUP – A+
 BETA HCG- DONE ON DAY 1 AND DAY 3 TO MONITOR PROGRESSION OF
PREGNANCY
 HCG FOUND TO BE 700 IU/L on day 1 and 1100 IU/lL on day 3
 ULTRASOUND(TVS) WAS DONE BUT THE SENSITIVITY WAS LOW AS HCG LEVELS
ARE BELOW THE RANGE AT WHICH GESTATIONAL SAC IS VISIBLE

11. DIAGNOSIS AND MANAGEMENT
 DIAGNOSIS – 34 Y/OLD G2P1L1 WAS DIAGNOSED AS A CASE OF THREATENED
ABORTION WITH NO SIGNS OF SHOCK
 MANAGEMENT -1. SHE WAS ADVISED 2 WEEKS OF COMPLETE BED REST
 2. INJECTION PROLUTON DEPOT WEEKLY
 3. PARACETAMOL FOR PAIN RELIEF
 4. BETA HCG TEST AFTER 48 HOURS

12. RETURN VISIT
 3 WEEKS AFTER DISCHARGE FROM HOSPITAL SHE CAME BACK TO THE MI ROOM WITH
 COMPLAINTS OF
 1. INCREASED ABDOMINAL PAIN WHICH IS SOMETIMES COLICKY IN RIGHT LOWER
QUADRANT SINCE 2 DAYS
 2. BLEEDING PER VAGINUM WHICH IS MORE THAN SPOTTING (AROUND A CUPFUL) SINCE
1 DAY
 WITH NO H/O FEVER, FOUL SMELLING DISCHARGE , BURNING MICTURITION, PASSAGE OF
FLESHY MASS OR CLOTS
 NO H/O SYNCOPE/ FAINTNESS
 NO HO PASSAGE OF GRAPE LIKE VESICLES

13. EXAMINATION
 GENERAL EXAMINATION – GC FAIR
 VITALS – STABLE (P-81/M)
(BP-116/74 mmhg)
(spo2- 97% on room air)
 SYSTEMIC EXAMINATION
 PER ABDOMEN – SOFT , TENDERNESS PRESENT IN RIGHT ILOAC FOSSA , NO REBOUND
TENDERNESS AND GUARDING
 BIMANUAL EXAMINATION– UTERUS NORMAL IN SIZE , TENDERNESS ON MOVEMENT
OF CERVIX
 CVS -S1S2 HEARD
 CNS - NO SENSORIMOTOR DEFICIT
 R/S – CLEAR CHEST B/L

14. INVESTIGATIONS
 EMERGENCY ULTRASONOGRAPHY(TVS)WAS DONE
 UTERUS SHOWED A PSEUDO SAC WITH NO CARDIAC ACTIVITY
 PRESENCE OF ADNEXAL MASS AND NO CARDIAC ACTIVITY IN RIGHT FALLOPIAN
TUBE
 BETA HCG – 6800 IU/L ( IT DID NOT RISE AS IT SHOULD HAVE IN CASE OF
INTRAUTERINE PREGNANCY)

15. DIAGNOSIS AND MANAGEMENT
 DIAGNOSIS- 34 Y/OLD ,G2P1 AT POG -8WEEKS WAS DIAGNOSED AS A CASE OF
TUBAL ECTOPIC PREGNANCY WITH NO FEATURES OF RUPTURE, HEMORRHAGE
AND SHOCK
 MANAGEMENT – MEDICAL /CONSERVATIVE
 1. METHOTREXATE 50mg/M2 i/m Single dose
 MONITORING OF BETA HCG WAS DONE ON DAY 4(4100IU/L) AND DAY7(900IU/L)

16. THANK YOU