Introducing our guest speaker CAUSES OF BLEEDING IN EARLY PREGNANCY - - PowerPoint PPT Presentation

Introducing our guest speaker

CAUSES OF BLEEDING IN EARLY PREGNANCY

Miscarriage

Ectopic pregnancy Cervical ectropion Fibroids Trauma Polyps Pelvic inflammatory disease Cervical/vaginal cancer Implantation bleed Subchorionic haematoma

History

A 36-year-old G3P1+1, presents with vaginal bleeding. Her last menstrual period was 7 weeks ago and she had a positive urine pregnancy test 2 weeks ago. She has a 2-day history of generalised abdominal pain, which is now localised to the lower abdomen/pelvis. She has had vaginal bleeding for 2 weeks. She feels dizzy and light-headed. On examination, she is pale and is in discomfort. The abdomen is soft with lower abdominal tenderness.

Speculum examination: cervix seen, not actively

bleeding.

Observations

HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2

4

Case-based discussion: 1

5

Question 1

What is the most likely diagnosis? a) Ectopic pregnancy b) Complete miscarriage c) Incomplete miscarriage d) Threatened miscarriage e) I’m not sure

6

Clinical history: bleeding in early pregnancy

Age Degree of the bleeding

• When did it start
• Sanitary pads: size, how often changed/clots/flooding

Pain

• SOCRATES = Site, Onset, Character, Radiates, Associated

symptoms, Time/duration, Exacerbating/ relieving factors, Severity Passing products/tissue? Menstrual history

• LMP
• Cycles - regular/irregular

Any scans in pregnancy

7

Clinical history: bleeding in early pregnancy

Obstetric history

• Gravidity, parity, pregnancy losses
• Mode of delivery

Gynaecological history

• Pelvic inflammatory disease, previous ectopic pregnancies

Smear history Contraceptive history

• Coil in situ
• Progesterone only pill (>99% effective but of those who become

pregnant, 1 in 10 ectopic pregnancy) Medical and surgical history Drug history and allergies Social history

• Smoking and alcohol

8

Examination

General inspection

• Pale
• Alert or drowsy
• Blood stained clothing
• Soaked pads

Hands

• Warm, well perfused (capillary refill time)
• Pulse: volume, regular

Abdominal examination

• Tenderness/peritonism/guarding/rebound

Speculum examination WITH chaperone

• Cervix open? Products seen? Bleeding?
• Take relevant swabs – high vaginal +/- endocervical

Bimanual examination gently

• Cervical excitation? Any pelvic masses?

9

Investigations

Bedside

• Observations: HR, BP, RR, SpO2, Temperature

Bloods

• FBC
• Group and save
• +/- Beta hCG

Imaging

• Ultrasound (transvaginal)
• Intrauterine pregnancy: gestation sac, yolk sac, fetal

pole, fetal heart activity

• Ectopic pregnancy: adnexal mass, fetal pole, fetal heart

activity, free fluid in pouch of douglas

• Pregnancy of unknown location (not seen intrauterine
• r extrauterine)

History

A 36-year-old primiparous lady, presents with heavy vaginal

• bleeding. Her last menstrual period was 7 weeks ago and

she had a positive pregnancy test 2 weeks ago. She woke up with lower abdominal cramping and a pool of blood in her bed. She has been continuously bleeding for the past 2 hours and is flooding through pads. She feels dizzy and light headed.

On examination: she looks pale and is wearing trousers

which are soaked with blood. The abdomen is soft with mild suprapubic tenderness. Per speculum – she is actively bleeding and it is difficult to visualise the cervix

Observations

HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2

10

Case-based discussion: 2

What is the most likely diagnosis? A) Complete miscarriage B) Missed miscarriage C) Threatened miscarriage D) Incomplete miscarriage E) Hydatidiform mole

11

Case-based discussion: 2

You remove clots from the vagina and are now able to visualise the cervix. The external cervical os is open but the bleeding is ongoing. She is very pale and her BP is 60/40 and HR 117. She is resuscitated with IV fluids and O negative blood is on it’s way. Bloods were taken 20 minutes ago. You estimate her cumulative estimated blood loss to be 1000ml. What is the best management option for this patient? A) Expectant management B) Medical management with misoprostol C) Surgical management - evacuation of retained products of conception D) Medical management with mifepristone E) Medical management with methotrexate

Definition

• Pregnancy loss before 24/40 gestation (UK)
• Expulsion of fetus/embryo weighing ≤ 500g and gestational

limit < 22 completed weeks of pregnancy (WHO)

Epidemiology

• Affects 1 in 5 pregnancies
• Majority before 12/40
• < 4% miscarriages occur in second trimester
• < 5% miscarriage occur after fetal heart activity identified
• Early pregnancy loss accounts for 50,000 UK admissions

annually

• Significant psychological impact

12

Introduction: Miscarriage

13

Aetiology

Causes

• CHROMOSOMAL ABNORMALITIES in most
• Others:
• Infection (Listeria, Toxoplasmosis, malaria)
• Advanced maternal age
• Multiple pregnancy
• Assisted conception
• Fibroids
• Uncontrolled diabetes

Maternal age Risk of miscarriage (%) < 20 15.8 25-29 10 ≥ 45 53

14

Miscarriage

Bleeding Abdominal pain Cervical os Pregnancy Threatened Yes Yes/No Closed Viable Complete Settling Settling Closed Products passed: uterus not enlarged Incomplete Yes Yes Open Non-viable Inevitable Heavy Yes Open Fetal heartbeat may be present but miscarriage about to occur Missed Yes/No No Closed Uterus smaller than expected for dates
 
 No fetal heartbeat

15

Management

Conservative/ Expectant:

• 50% success
• As long as the woman is willing
• Recommended as first line for first 7-14 days
• No signs of infection (vaginal discharge, excessive bleeding, pyrexia
• r abdominal pain) : 3% infection
• Can take as long as 6–8 weeks
• Follow-up appointment 2 weeks later

16

Management

Medical:

• 85% success
• Misoprostol: unlicensed for this purpose but supported by the Royal

College of Obstetricians and Gynaecologists

• Analgesia and antiemetics
• Urine pregnancy test 3 weeks after medical management or contact

early pregnancy unit if symptoms worsen/signs of infection

• If positive consider molar pregnancy/ectopic

Surgical:

• Manual vacuum aspiration under local anaesthetic in an outpatient or

clinic setting or

• Surgical management in theatre under general anaesthetic
• Overall significant complication rate 6%
• 4% need repeat procedure

Similar rates of complications between all 3 management options

History

A 36-year-old G3P1+1, presents with vaginal bleeding. Her last menstrual period was 7 weeks ago and she had a positive pregnancy test 2 weeks ago. She has a 2-day history of generalised abdominal pain, which is now localised to the left iliac fossa. She has had vaginal spotting for 2 weeks. She feels dizzy and light-headed and is complaining of shoulder tip pain. She tells you she had an ectopic pregnancy, which was managed medically 2 years ago. On examination, she appears to be in significant pain and is lying very still on the examination couch. The abdomen is soft with significant tenderness and rebound in the left iliac fossa. Speculum examination: cervix seen, minimal dark blood seen in vagina. Bimanual examination: Cervical excitation present Observations HR 110, BP 96/62, RR 15, SpO2 98%, Temp 37.2

17

Case-based discussion: 1

What is the most likely diagnosis? A) Threatened miscarriage B) Pelvic inflammatory disease C) Ectopic pregnancy D) Incomplete miscarriage E) Endometriosis She has IV access and bloods have been sent including FBC, G&S and beta-hCG. What investigation should be done next? A) Progesterone levels B) Pelvic ultrasound scan C) Diagnostic laparoscopy D) Diagnostic laparotomy E) CT abdomen and pelvis

Definition

• Implantation outside the uterine cavity
• 98% occur in the fallopian tube of which the

ampulla is the most common site (NICE)

Epidemiology

• Incidence: 11 per 1000 clinical pregnancies
• Risk of ectopic in future pregnancy 10%

18

Introduction: Ectopic Pregnancy

19

Aetiology

Risk factors:

• Previous tubal surgery
• Previous ectopic pregnancy
• History of pelvic inflammatory disease
• History of infertility
• Concurrent IUCD use
• Use of progesterone only pill
• Assisted conception
• Smoking
• Maternal age > 40 years

The majority of women have no risk factors

20

Investigations

Bedside

• Urine beta human chorionic gonadotrophin (beta-hCG)

Bloods

• FBC
• Beta-hCG
• Serial hCG: <66% rise over 48 hours OR decline in hCG
• Useful for planning management
• Group and save

Imaging

• Transvaginal ultrasound: first-line diagnostic investigation

21

Investigations

Transvaginal ultrasound:

• Sensitivity: 87-99%
• Specificity: 94-99%
• Laparoscopy no longer the gold standard for diagnosis
• False-negative laparoscopies if performed too early in development of
• ngoing ectopic: 3-4.5%
• Inhomogenous or non cystic adnexal mass most common finding 50-60%
• EMPTY EXTRAUTERINE GESTATION SAC 20-40%
• Extrauterine gestation sac containing yolk sac and/or embryonic pole (+/-

cardiac activity) 15 -20%

• Small amount anechoic free fluid in pouch of Douglas found in intrauterine and

extrauterine pregnancies

22

Management

Conservative

Offer as an option to women who:

• Are clinically stable and pain free and
• Tubal ectopic pregnancy measuring < 35 mm with no visible heartbeat on TVUS
• Serum beta-hCG levels < 1,000 IU/L
• Are able to return for follow-up

Consider as an option for women who:

• Same criteria as above except serum beta-hCG levels > 1,000 IU/L and < 1,500 IU/L
• Repeat hCG levels on days 2, 4 and 7 and then weekly until a negative result (less than

20 IU/L) is obtained

• If hCG levels do not fall by 15%, stay the same or rise from the previous value, review

the woman's clinical condition and consider management

23

Management

Medical

Offer methotrexate (cytotoxic drug) to women who:

• No significant pain
• Unruptured tubal ectopic pregnancy measuring < 35 mm with no visible heartbeat on

TVUS

• Serum beta-hCG < 1,500 IU/litre
• Do not have an intrauterine pregnancy (as confirmed on an ultrasound scan)
• Are able to return for follow-up
• Wait at least 3 months for future pregnancy
• Must explain that it is unlicensed for use in ectopic pregnancy

24

Management

Surgical

Salpingectomy / salpingostomy Offer as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:

• Significant pain
• Adnexal mass ≥ 35 mm
• Foetal heartbeat visible on an ultrasound scan
• Serum beta-hCG level ≥ 5,000 IU/litre

25

Management

Methotrexate or surgery

• Serum hCG between 1500 - 5000 IU/litre
• No significant pain
• Unruptured ectopic pregnancy
• Adnexal mass <35 mm with no visible heartbeat
• No intrauterine pregnancy

26

Management

Summary of initial management

27

References

• 1. Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage – results from a

UK-population-based case–control study. BJOG 2007 Feb;114:170–86.

• 2. Ectopic pregnancy and miscarriage: diagnosis and initial management. NICE guideline[NG126].

Published date: 17 April 2019

• 3. Yasmin Sana (2017) RCOG eLearning Core Knowledge tutorial on Early pregnancy loss - management.
• 4. Diagnosis and management of ectopic pregnancy (Green-top Guideline No. 21). Published 4 November

2016

28

Q&A

29

Further information

You will now receive a Certificate of Attendance for attendance at each webinar! Simply fill out the feedback form. Want to get involved? Contact us at

• pportunities@bitemedicine.com to get your information pack.

Stay up-to-date!

• Website: www.bitemedicine.com
• Facebook: www.facebook.com/biteemedicine
• Instagram: @bitemedicine
• Email: admin@bitemedicine.com

Presenter’s contact details

• Instagram: @doctorpavan