Presentazione di PowerPoint

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Bleeding in early pregnancy
Clare Tower MBChB PhD MRCOG Senior Registrar in
Obstetrics and Gynaecology
Subspecialty Trainee in Fetal and Maternal
Medicine/ Clinical Lecturer St Marys Hospital,
Manchester
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Causes of bleeding in early pregnancy

• Placentation
• Miscarriage
• Ectopic pregnancy
• Gestational trophoblastic disease
• Cervical lesions (erosion and/or polyp)
• Unknown

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Assessment

• History
• Examination
• Investigations
• Diagnosis
• Management

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History and examination

• LMP
• Duration of amenorrhea
• Menstrual history
• Contraceptive history
• Planned?
• Nature of bleeding
• pain

• Observations ? Haemodynamically stable
• Abdominal palpation
• Speculum examination
• Vaginal examination

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Investigations

• Swabs
• Urine MSU/PT
• urine PT positive day 9 post con
• FBC
• Quantitative ßHCG
• Progesterone
• USS (transvaginal)
• Group and save

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USS findings

• Transvaginal
• Look for pregnancy within the uterus
• Presence of fetal heart
• Should be present 6 weeks
• If CRLlt 6mm or MSDlt20mm with no yolk sac/fetus
  rescan
• Uncertain viability and unknown location
• Presence of yolk sac
• Adnexal masses
• Free fluid/ endometrial thickness

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6.5 weeks Yolk sac ( left)Fetus is 3mm
longA fetal heartbeat
5.5 weeks Gestation sac and contents
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12 weeks
8.5 weeks Still see yolk sac
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ßHCG

• Pregnancy hormone
• Should approximately double in the first
  trimester every 48 hours
• Usually see something in the uterus on TV scan at
  1000 (1500 TA)
• Ectopics usually visible at this level
• Serial measurements are important every 48
  hours
• Rising, falling, stable, suboptimal rise

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Other investigations

• FBC - can indicate volumes of blood loss
• Progesterone - lt25 mmmol/l is associated with a
  non viable pregnancy.
• Absolute levels here
• gt60 v.strongly associated with viable pregnancy
• Blood group need for anti D

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First Trimester Miscarriage

• Management options
• Expectant management
• Medical evacuation
• Surgical evacuation

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Miscarriage

• Threatened PV bleeding (about 75 carry on to a
  normal delivery)
• Inevitable PV bleeding and uterine activity,
  cervical dilatation and expulsion of POC
• Incomplete POC partially expelled through the
  dilated cervix
• Complete POC completely expelled
• Missed fetus dies and POC retained within the
  uterus

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Expectant Management

• Watch and wait
• Serial scans and HCG
• More successful if incomplete
• 28 success if intact sac
• 94 if incomplete
• May have prolonged bleeding
• Can convert at anytime to medical/surgical

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Medical Management

• Misoprostol (prostaglandin) mifepristone
  (RU486)
• Inpatient
• Higher success rates with incomplete
• 84-94 success
• Cheap and safe
• Counsel may bleed for 3 weeks
• Follow up USS

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Surgical Management

• Evacuation of retained products of conception
• General Anaesthetic
• Risks
• Perforation up to 6
• Infection (higher than medical)
• Bleeding
• Cervical damage
• Intrauterine adhesions - Ashermans
• Cervical priming
• Recommended for persistant/ heavy bleeding,
  haemodynamically unstable, moles
• Preferred by one third of women

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Anti D

• Rhesus negative
• Give to
• All over 12 weeks
• All intervention - medical or surgical, all
  ectopics
• All threatened under 12 weeks when associated
  with heavy bleeding and pain
• Not needed for complete under 12 weeks
• kleihauer

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Further management

• Psychological support written information
• Contraception
• Future pregnancies
• Recurrent miscarriage
• What to expect
• Sexual intercourse
• Folic acid
• Histology
• Cremation forms etc

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Ectopic pregnancy

• History
• Amenorrhoea
• Unilateral pain
• Usually pain before bleeding, prune juice
• Rectal pain/ shoulder tip pain
• Dizzy/faint
• Risk factors
• Examination
• Tenderness, peritonism (rebound/guarding)
• Cervical excitation

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Ectopic pregnancy

• Usually 10-13 maternal deaths per triennia
• Management options
• Expectant
• pregnancy of unknown location 44-66 resolve
  spontaneously
• HCGlt1000 and falling (50 in 7 days) ,
  asymptomatic, no free fluid
• Weekly scans and twice weekly HCG
• Until HCGlt20
• Surgical
• Salpingectomy
• Salpingotomy persistant trophoblast
• Laparoscopically

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Ectopic Pregnancy

• Medical Management
• methotrexate IM
• Minimal symptoms, HCGlt3000, small, no FH
• HCG checked on days 4 and 7, 15 fall should be
  seen
• Side effects
• Abdo pain 75
• Stomatitis, GI upset, conjunctivitis
• Contraception for 3 months

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Gestational Trophoblastic Disease

• Rare complication of pregnancy (1700) in which
  abnormal trophoblastic proliferation occurs
• Benign hydatidiform mole
• Partial Mole
• Highly invasive tumour Choriocarcinoma
• Signs a uterus filled with abnormal placental
  tissue and absence of fetus

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Molar pregnancy
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Gestational trophoblastic neoplasia

• Complete mole
• Diploid
• Androgenetic
• Duplication of paternal chromosomes following
  fertilsation of empty ovum
• No fetus
• Partial Mole
• Triploid
• 2 sets paternal chromosomes, one set maternal
• Dispermic fertilisation of single ovum
• Fetus present

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GTN

• Diagnosis
• Clinical features
• Bleeding, hyperemesis, early onset preeclampsia
• USS finding
• Biochemistry high HCG

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Management

• Surgical evacuation
• Registration
• Charing Cross
• Sheffield (Weston Park)
• Serial HCG monitoring
• 6-24 months
• Blood initially
• Urine
• After each subsequent pregnancy

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Persistent GTN and choriocarcinoma

• Can occur after live birth (150000) and after
  any pregnancy
• 15 need chemotherapy after complete mole
• 0.5 need chemotherapy after partial mole
• Chemotherapy
• Methotrexate 1st line
• Cure rates 98-100

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Further Management

• Future Pregnancy
• Advise to wait until HCG normal for 6 months
• Urine test after
• Contraception
• Barrier
• OCP may be used once HCG normal
• Recurrence rate
• 155

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Case study

• You are the GP at the out of hours Mandoc, 8pm
  in the evening, Sunday night
• 21 year old
• Presents with 6 weeks amenorrhoea
• Positive home pregnancy test
• Says she has been bleeding

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Case

• History
• Previous TOP 2 years ago
• Not using contraception
• Bleeding dark red
• Some pain comes and goes. Left more than right
• Thinks all happened together

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Case

• Examination
• Cardiovascularly stable
• Abdomen soft and minimally tender
• ? PV
• What will you do?
• Options
• Emergency gynae tomorrow?
• Refer to gynae on call now?

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Case

• Attends emergency urgency at 9am following
  morning
• Investigations?
• FBC, group and save, progesterone, quantitative
  ßHCG
• Speculum/PV
• Triple swabs
• USS - transvaginal

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Case- Results

• FBC Hb 11.2g/dl
• GS O positive
• QHCG 950
• Progesterone 20
• USS thickened heterogenous endometrium
  measures 13mm, no intrauterine pregnancy, small
  amount of free fluid, small cyst left ovary,
  measures 2.5mm, normal left ovary

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Case diagnosis?

• Pregnancy of unknown location
• Could be an ectopic
• Could be a failing intrauterine pregnancy
• Management
• Repeat ßHCG in 48 hours
• If well can be managed as outpatient

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Case follow up (A)

• Repeat ßHCG 420
• Still bleeding like a period
• Diagnosis likely a completing miscarriage
• Further management
• Repeat ßHCG and scan in 1 week
• One week later
• ßHCG 25, USS shows normal adnexae, endometrium
  5mm.

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Case Follow up (B)

• ßHCG at 48 hours 1200
• Suboptimal rise
• Bleeding still light-ish, less than period
• Pain some, left sided
• Diagnosis?
• Possible ectopic
• Management?
• Conservative? not appropriate
• Medical
• Surgical