Fictional case: any resemblance to persons living or passed is coincidental. Presented at medical student teaching Jan 2020 at JGH

1. A Case Study in Early
Pregnancy Loss
DR LYNDON WOYTUCK, BSC, MBBS

2. Presentation
 23 year old lady attends A&E for PV bleeding.
 She has been triaged by the nurse.
 PC: Vaginal bleeding over the past 2 days. She also has lower abdo crampy pains.
Urinalysis shows +ve Pregnancy test, Blood ++, Pro+.
 The triage nurse calls the O+G registrar for a direct referral.
 The Registrar asks you, as the house officer, to see this patient and then report
back.

3. Panic!
 The nurse on Rayner is inexperienced with gynae problems and asks you what you
would like to be done for her when she arrives
 She arrives on Rayner ward as a ward attender and the A&E has handed over to
the nurse on the ward that she has been bleeding heavily for the last 24 hours and
they are worried she will need intervention
 Obs / NEWs Chart
 Urinalysis / Preg test
 Make her comfortable
 Detail how quickly you can see her

4. Arrival on Rayner
 You arrive on Rayner after finishing assisting in theatre for an elective Caesarean
section
 The nurse looks quite busy and flushed, rushing around the ward. She sees you
and goes in for the kill. She runs up to you to see this patient right away. She has
been having PV bleeding and soaked three pads since arriving in A&E. There seem
to be clots and it’s not really stopping.
 What do you do?
 SBAR – Adhere to orderly relay of information so as to not miss important info
 Look at the Obs / NEWs ?any concerns
 Observe the patient from the corridor – it helps to know if they are on the floor!

5. Nursing Handover
 S – 23 year old patient with a lot of PV bleeding, +ve Pregnancy test
 B – Never been pregnant before, has had a new partner for past few months, and
has never had any other real medical problems. The patient is worried she might
die, and her parents are on the way. This is way more bleeding than her normal
period.
 A – She is currently stable. BP 121/78, HR 95, Sat 98% on room air, T 36.7C
 R – Please see this lady as soon as possible!
 What do you do next?

6. History
 You invite her over to the treatment room and walk her over to take a history. She
looks a little pale and quite anxious. She has no trouble walking.
 She says she’s been bleeding for the last two days, but had a bit of spotting just
before it started. She has lower abdominal crampy pain, like her period, but much
worse. She is confused and asks you why this is happening and if she is going to
bleed to death.
 What elements of her history are you going to elicit?
 Gynae focused history: LMP, STI, sexual partners, menarche, period and cycle length,
usual bleeds, pain during periods, contraception, adherence, med/OTC
 PC history: SOCRATES, blood loss / number of pads/tampons, tissue loss / clots /
discharge, smoking, alcohol, pain relief use

7. History
 Cycle length usually 22-26 days since age 14 (menarche).
 Period length 3-5 days. No painful periods or need to see doctor for these.
 Usually uses 1-2 pads per day, with few tablespoons brownish blood daily.
 Now she has soaked through 6 pads today and actually ruined her jeans – she is in
a hospital gown now with a hospital pad on.
 There is clotting, but no discharge or tissues
 She smokes ~10 per day since 16, and she is breaking up with her current
boyfriend, because she discovered he was cheating
 Her last menstrual period was 10 weeks ago, but she has been too busy at work to
test herself (finance administrative assistant), and she has been on the COCP
besides.

8. Examination
 What elements of a focused clinical examination would you perform?
 CV status: conjunctival pallor, CR <3s, bounding pulse HR ~100bpm, dry mucus
membranes, chest clear, HS1+2+0, peripherally clammy, but warm
 Abdomen: Soft abdomen, RIF tenderness with rebound and guarding, no flank
tenderness, no hepatosplenomegaly, BS+
 What special tests could you do?
 What else should you examine?
 How would you contact your senior to review? What would you say?
 What is your preliminary diagnosis?

9. Senior review
 You call the registrar, who was now unscrubbed from theatre and is on labour
ward reviewing some ward attenders
 S – High suspicion of ectopic in a 23 year-old lady, bleeding heavily
 B – LMP 10 weeks ago, COCP with poor adherence, non-fidelity in recent partner,
never been tested for STI.
 A – Currently cardiovascular stable, but likely compensating well for heavy blood
loss. Acute RIF tenderness with peritoneal signs.
 R – Will you please come review, do a speculum exam together, and for further
investigation / management

10. Intimate exam
 Your registrar arrives on the ward in a sprightly pair of scrubs, putting your
wardrobe to shame, theatre hat still on.
 He greets you on the ward and you go in to see the lady together.
 He asks all the same questions as you did, simultaneously relieving you that you
took all the relevant points, but seemingly wasting previous time
 He asks you to consent the patient while he prepares the items for exam
 What should you ask her? What items will you need?
 Position, discomfort, alternative manoeuvers, what you are looking for
 Speculum, lubricant, swabs, gloves, good lighting, chaperone, dress

11. Intimate exam
 She lies down on the bed and you leave while she prepares herself
 One of the staff nurses has come round to chaperone
 You explain the procedure well and perform a speculum under supervision
 The os is open, with active red bleeding, no discharge.
 Swabs are taken for culture + chlamydia/gonorrhoea PCR
 Bimanual exam is significant for RIF tenderness and adnexal mass ~8cm and
lumpy/heterogeneous
 What next?

12. Investigation
 USS done by the registrar – Shows R sided mass with blood in the abdomen.
There is no gestational sac in the uterus.
 What should be done next?
 You rush together to get this lady booked for theatres and reviewed by the anaesthetist
 The registrar asks you to cross match 4 units of blood, take an FBC, U+E, CRP
 She has a R sided excision of the ectopic and salpingectomy. The ovary is spared. The
tubes are somewhat adherent to the pelvis and there is some fibrous tissue there. The
ectopic and tube are sent for histology.

13. Post-operatively
 You see her on the ward as she is having a transfusion for 2 units of packed RBC
 She looks much better than a few hours earlier, and is relieved that the bleeding is
slowing down significantly
 What results are important to chase?
 What should happen in the post-op period and what should be discussed with
her?
 Should she have any additional treatment?