CASE STUDY ON EARLY PREGNANCY BLEEDING FOR UNDERGRADUATE

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How to approch A case of vaginal bleeding in
early pregnancy
DR Manal Behery Assistant Professor Zagazig
University ,2013
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ON
Definition
A
Any vaginal bleeding before 20 wks period of
gestation is defined as early pregnancy bleeding
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Case1

• A 28 YS G1 P00,noticed some bleeding this
  morning after 5 wks amenorrhea which causes her
  concern.
• She took a pregnancy test and was positive 1 week
  ago.

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Case cont

• She feels no pain and has not had any other
  symptoms apart from slight morning sickness
• She describes the bleeding as spotting on her
  underwear.
• On physical examination there are no signs of
  abdominal tenderness or intra-abdominal bleeding.

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Question 1

• AS pregnancy was confirmed a week ago, so you do
  not consider it necessary to conduct a pregnancy
  test.
• Given that patient reports no other symptoms and
  clearly describes the nature of the bleeding as
  spotting, you decide that vaginal examination
  will not be necessary.

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Does she need an onward referral?

• As her pregnancy is less than 6 weeks gestation
  and there is no pain, you would aim to see
  whether the condition will resolve naturally (an
  expectant management approach).

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She expresses concern that no further action is
being taken.How do you explain this decision?

• You explain that at this stage, the pregnancy is
  too small to see, and any further investigations
  such as scanning are unlikely to yield any
  information.
• You also note that many women experience
  spotting during early pregnancy that resolves
  without the need for further intervention.
• Therefore you advise waiting to see how things
  progress during the next week before any further
  action can be considered.

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What patient she should do during the course of
the expectant management week.?

• You advise her to repeat a urine pregnancy test
  after 710 days
• A negative pregnancy test means that the
  pregnancy has miscarried
• You emphasise that given the nature of her
  symptoms the outcome of the test is just as
  likely to be positive.
• You advise her to return if her symptoms continue
  or worsen.

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Case 2

• A34 year old, G1 P0,did not have a period for 5
  weeks and so had a pregnancy test at home which
  was positive.
• She now phones you at 2am when you are at home on
  outpatient call.
• She tells you that she has seen spotting with
  mild abdominal cramping which causes her some
  discomfort rather than pain.
• However, she is very anxious and is crying.

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• What differential diagnoses are you thinking
  about? Try to name at least three!

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Causes of bleeding in early pregnancy
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Related to pregnant state
Related to pregnant state

• Abortion
• Ectopic pregnancy
• Molar pregnancy

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Related to pregnant state
Associated with the pregnant state

• Abortion
• Ectopic pregnancy
• Molar pregnancy

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Does the patient need to be seen tonight?

• Bleeding in the first trimester can be a medical
  emergency! Even spotting can be enough to
  warrant a visit to the ER.
• Best practice is to send her for an exam tonight.
  Particularly given her disposition she is
  anxious.

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Patient arrived ER at 3.45am
Patient arrived ER at 3.45am

• It
• She has no further spotting and only mild
  cramping
• She still appears tearful and anxious
• After confirming she is pregnant,
• what should the next step be?
• Bi-manual pelvic exam
• Sterile speculum exam
• Order an Ultra-sound
• Send her home as the bleeding seems to have
  resolved

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Case Study - next steps

• Answer b is correct Sterile speculum exam
• She needs to have her bleeding assessed now

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This would now be a good time to think about lab
work. What labs would you order for her ?

• Serum hCG
• This should be done now. We know she is pregnant
  but it will help correlate with the ultrasound
  exam
• and again in 48 hours - this second draw is done
  to ensure that the pregnancy is progressing
• CBC and type
• We need to see if she lost any significant
  amount of blood and
• ascertain her blood group to see if she is Rh
  negative

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Case Study patient outcome

• Her CBC is normal and she is A ve
• This rules out severe blood loss and no Rhoram
  required
• Her hCG levels are 900
• This will enable you to assess what should be
  seen on ultrasound
• NOW you can order a stat ultra sound

next

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What would the ultra sound show at this stage?
- 4
What would the ultra sound show at this stage?
- 4 weeks and a few days
Trans-vaginal findings Weeks from LMP ß-HCG (mIU/ml)
Gestational sac (25 mm) 4.5-5 1000
Yolk sac 5-5.5 1500-2500
Fetal pole 5-6 2000-5000
Fetal cardiac activity 5.5-6.5 4000-17000
Click for view
Click for view
Click for view

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The ß-hCG level at which an intra-uterine
pregnancy (IUP) should be visualized by
transvaginal ultrasound, with near 100
sensitivity, is 1000-2000 mIU/mL.
The level for transabdominal sonography is less
certain but has been suggested to be between 4000
and 6500 mIU/mL.
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Case study - current diagnosis

• She has a closed cervix and no additional blood
  visualized in the vaginal vault.
• It was too early to show any IUP evidence of a
  yolk sac.
• What type of abortion would you consider
  classifying She at this stage?
• Complete
• Incomplete
• Inevitable
• Missed
• Threatened

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Case Study patient outcome

• Her bleeding and cramping
• Was most likely a threatened abortion
• You tell her that you are going to send her home
• You advise her to take it easy
• no strenuous activity or heavy lifting or
  exercise for the next 7 days
• to follow up with a hCG serum level in two days
  to ensure that the levels are doubling every 48
  hours
• Doubling hCG levels are a sign of well being in
  early pregnancy

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abortion-definition
Termination of pregnancy before the fetus is
capable of extra-uterine survival i.e. 20 wks or
500gm birth wt

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Related to pregnant state
Pathology

• Abortion
• Ectopic pregnancy
• Molar pregnancy

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Types
Types of abortion

• Threatened abortion.
• Incomplete abortion.
• Complete abortion.
• Missed abortion
• Septic abortion Any type of abortion, which is
  complicated by infection

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Miscarriage

• Approximately 30 of pregnant women will
  experience bleeding in early pregnancy
• At least 50 of women with threatened miscarriage
  will have continuing pregnancy
• Miscarriage occurs in 15-20 of clinically
  diagnosed pregnancies

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Case Study return visit

• She returns to visit you in clinic three weeks
  later
• She is 6 weeks post LMP
• Looking at her history you note that her hCG had
  doubled on a second lab visit
• and therefore you had told her that at that time
  her pregnancy was progressing well
• However, she is now experiencing increased
  abdominal pain in the right side and is bleeding
• The bleeding is described as more than spotting
  a cupful.

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What differential diagnoses do you have now?

• What is the next step?

Differential diagnosis of pain and bleeding at 7
weeks the same as 4 weeks


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Ectopic work up

• Since SHE has unilateral pain, your thought is
  directed towards a possible ectopic pregnancy
• This means an emergency ultrasound in the ER
• Remember on her first visit to the er the
  ultrasound was unable to visualize an
  intra-uterine pregnancy
• This was because it was too early
• We now do a serum hCG and get 7000

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Site
Ectopic pregnancy .Definition SITE
Implantation of fertlized ovum outside the normal
uterinse cavity Fallopian tube Ovary Abdominal
cavity Cervix
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Risk factors

• Previous PID
• Previous ectopic pregnancy
• Previous tubal surgery (e.g. sterilisation,
  reversal)
• Pregnancy in the presence of IUCD
• POP

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Diagnosis

• Ultrasound
• Empty uterus, adnexal mass,
• free fluid,
• occasionally live pregnancy outside
• of uterus
• Serum ßhCG
• Slow rising, plateau
• Laparoscopy the surest method

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Ultrasound of ectopic pregnancy
Same images Uterus outlined in red, uterine
lining in green, ectopic pregnancy yellow. Fluid
in uterus at blue circle - sometimes called a
"pseudosac
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Ectopic pregnancies
Laparoscopic view of ectopic
Uterus with fallopian ectopic
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Management

• Conservative
• Self resolving with close watch
• Medical
• Methotrexate
• Surgical
• Laparoscopic salpingectomy / salpingotomy
• Laparotmy

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On a transvaginal ultrasound you find
Gestational sac in utero Fetal pole at 2cm No
cardiac activity Cardiac activity should become
visible and begin once the fetal pole reaches
5mm. No cardiac activity at this stage means a
non-viable fetus

• Gestational sac in utero
• Fetal pole at 2cm
• No cardiac activity
• Cardiac activity should become visible and begin
  once the fetal pole reaches 5mm. No cardiac
  activity at this stage means
• a non-viable fetus

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On doing a Pelvic exam you find

• blood in vaginal vault
• Cervix is partially open
• No tissue is seen
• What type of abortion would you consider
  classifying her now?
• Complete
• Incomplete
• Inevitable
• Missed
• Threatened

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Management of inevitable (or incomplete or
missed) abortion

• Medical
• Misoprostol
• Surgical
• Dilation and curettage
• Manual or Standard Vacuum Curettage
• Dilation and evacuation

So which would you offer for her ?
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The first choice would be medical -Misoprostol

• Or watch and wait. Some women may choose to
  remain at home for a miscarraige, unless bleeding
  becomes heavy or concerning.
• Only if failed medical treatment would you need
  to offer the surgical route

next
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On the third day she passed clots and plenty of
blood.

• Tissue expulsed should be sent for
  histopathological exam to assure that it is POC
  not a molar tissue
• If histopathoogy isnot available follow up with
  HCG until fall to zero to exclude the possibility
  of a molar pregnancy

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Patient asks you

• What are the chances of having a successful next
  pregnancy?
• What if she was 37 YO or she had a history of
  previous abortions?

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Answers
Click here to see epi statistic slide

• In women with an unknown etiology of prior
  pregnancy loss, the probability of achieving
  successful pregnancies is 40-80.
• As stated earlier, increased age increases
  chances of spontaneous abortion.
• This is also the case with patients who have
  three or more previous abortions

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Clinical approach

• History
• Examination
• Special Investigations

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History

• VAGINAL BLEEDING
• 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

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Abdominal Pain

• Minimal
• Acute , agonising or colicky
• Shoulder pain
• Fever

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Symptoms of early pregnancy

• Amenorrhoea
• Morning sickness
• Frequency of micturition
• Breast discomfort
• Fatigue

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Careful menstrual history

• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use

• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use

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Classical triad of ectopic pregnancy

• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use

• Amenorrhea
• Abdominal pain
• Irregular vaginal bleeding

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Examination

• General look
• Lies quiet and conscious, perspires and looks
  blanched
• Looks more ill than accounted for- molar pregnancy

General look Lies quiet and conscious, perspires
and looks blanched Looks more ill than accounted
for- molar pregnancy
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Vital signs
Vital signs

• Temperature
• Febrile/a febrile
• Pulse
• Tachycardia/normal
• Blood pressure
• Low/normal

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Size of uterus
Size of uterus
Guarding and rebound tenderness
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Speculum examination
Speculum examination

• Trauma
• Cervical pathology
• Open cervical os- incomplete abortion

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Bimanual examination

• 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

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Investigations
Investigations

• Hb
• TLC
• DLC
• Platelet
• PCV
• ABO and Rh grouping
• Thyroid function test

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Investigations
Ultrasonography

• Routinely used
• Main modality of diagnosis
• Transvaginal and Transabdominal

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Blighted ovum Incomplete abortion
Compelet abortion

• BLIGHTED OVUM

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Ectopic pregnancy
Vesicular mole

• BLIGHTED OVUM

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DIAGNOSIS

• Threatened abortion
• Positive UPT
• Intrauterine pregnancy
• Viable fetus
• Incomplete abortion
• Positive UPT
• Product of conception in-situ
• Non viable fetus

• Complete abortion
• 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

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• Complete abortion
• 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

• Complete abortion
• 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

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THANK YOU