How to approch a case of bleeding in early pregnancy with case illustration
1. 7We Care
DR Manal Behery
Assistant Professor
Zagazig University ,2013
How to approch
A case of
vaginal bleeding
in
early pregnancy
2. 7We Care
ON
A
Any vaginal bleeding
before 20 wks period of
gestation is defined as
early pregnancy bleeding
Definition
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Case1
A 28 YS G1 P0+0,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.
5. 7We Care
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.
6. 7We Care
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).
7. 7We Care
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
7–10 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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Related to pregnant state
• Abortion
• Ectopic pregnancy
• Molar pregnancy
Related to pregnant
state
abortion ectopic Vesicular
mole
13. 7We Care
Related to pregnant state
• Abortion
• Ectopic pregnancy
• Molar pregnancy
Associated with the
pregnant state
Cervical
erosion
Cervical
polyp
Cervical
malignancy
14. 7We Care
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
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?
a. Bi-manual pelvic exam
b. Sterile speculum exam
c. Order an Ultra-sound
d. Send her home as the bleeding
seems to have resolved
Patient arrived ER at 3.45am
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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
19. 7We Care
What would the ultra sound
show at this stage? - 4
Trans-vaginal findings
Weeks from
LMP β-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
What would the ultra sound show at this stage?
- 4 weeks and a few days
20. 7We Care
The β-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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Related to pregnant state
• Abortion
• Ectopic pregnancy
• Molar pregnancy
Pathology
Haemorrhage into the
decidua basalis.
Necrotic changes in the tissue adjacent to the
bleeding.
Detachment of the conceptus.
The above will stimulate uterine contractions
resulting in expulsion.
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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 βhCG
– 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“
35. 7We Care
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
38. 7We Care
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 ?
39. 7We Care
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
40. 7We Care
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
• 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
44. 7We Care
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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Symptoms of early pregnancy
• Amenorrhoea
• Morning sickness
• Frequency of
micturition
• Breast discomfort
• Fatigue
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• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use
•Previous cycles
•LMP
Past history
•Similar episodes
•Infertility
•Details of contraceptive use
Careful menstrual history
48. 7We Care
• Previous cycles
• LMP
• Past history
• Similar episodes
• Infertility
• Details of contraceptive use
Amenorrhea
Abdominal pain
Irregular vaginal bleeding
Classical triad of ectopic pregnancy
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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
53. 7We Care
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
Bimanual examination