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7We Care
DR Manal Behery
Assistant Professor
Zagazig University ,2013
How to approch
A case of
vaginal bleeding
in
early pregnancy
7We Care
ON
A
Any vaginal bleeding
before 20 wks period of
gestation is defined as
early pregnancy bleeding
Definition
7We Care
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.
7We Care
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.
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.
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).
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.
7We Care
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.
7We Care
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.
7We Care
 What differential
diagnoses are you
thinking about? Try to
name at least three!
7We Care
Causes of
bleeding in early
pregnancy
7We Care
Related to pregnant state
• Abortion
• Ectopic pregnancy
• Molar pregnancy
Related to pregnant
state
abortion ectopic Vesicular
mole
7We Care
Related to pregnant state
• Abortion
• Ectopic pregnancy
• Molar pregnancy
Associated with the
pregnant state
Cervical
erosion
Cervical
polyp
Cervical
malignancy
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.
7We Care
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
7We Care
Case Study - next steps
• Answer b is correct: Sterile
speculum exam
• She needs to have her bleeding
assessed now
7We Care
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
7We Care
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
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
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.
7We Care
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
7We Care
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
7We Care
abortion-definition
Termination of
pregnancy
before the
fetus is
capable of
extra-uterine
survival i.e. 20
wks or 500gm
birth wt
7We Care
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.
7We Care
Types
Threatened abortion.
Incomplete abortion.
Complete abortion.
Missed abortion
Septic abortion: Any
type of abortion, which
is complicated by
infection
Types of abortion
7We Care
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
7We Care
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.
7We Care
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
7We Care
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
7We Care
Site
Ectopic pregnancy .Definition & SITE
Implantation of
fertlized ovum
outside the normal
uterinse cavity
Fallopian tube
Ovary
Abdominal cavity
Cervix
7We Care
Risk factors
• Previous PID
• Previous ectopic pregnancy
• Previous tubal surgery (e.g.
sterilisation, reversal)
• Pregnancy in the presence of IUCD
• POP
7We Care
Diagnosis
• Ultrasound
– Empty uterus, adnexal mass,
– free fluid,
– occasionally live pregnancy outside
– of uterus
• Serum βhCG
– Slow rising, plateau
Laparoscopy: the surest method
7We Care
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“
7We Care
Ectopic pregnancies
Laparoscopic view of ectopic Uterus with fallopian ectopic
7We Care
Management
• Conservative
– Self resolving with close watch
• Medical
– Methotrexate
• Surgical
– Laparoscopic salpingectomy /
salpingotomy
– Laparotmy
7We Care
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
7We Care
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
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 ?
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
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
7We Care
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?
7We Care
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
7We Care
Clinical approach
• History
• Examination
• Special Investigations
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’
7We Care
Abdominal Pain
• Minimal
• Acute , agonising or
colicky
• Shoulder pain
• Fever
7We Care
Symptoms of early pregnancy
• Amenorrhoea
• Morning sickness
• Frequency of
micturition
• Breast discomfort
• Fatigue
7We Care
• 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
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
7We Care
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
7We Care
Vital signs
• Temperature
– Febrile/a febrile
• Pulse
– Tachycardia/normal
• Blood pressure
– Low/normal
Vital signs
7We Care
Size of uterus
Size of uterus Guarding and rebound tenderness
7We Care
Speculum examination
 Trauma
 Cervical pathology
 Open cervical os-
incomplete
abortion
Speculum examination
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
7We Care
Investigations
• Hb
• TLC
• DLC
• Platelet
• PCV
• ABO and Rh grouping
• Thyroid function test
Investigations
7We Care
Investigations
Routinely used
Main modality of diagnosis
Transvaginal and Transabdominal
Ultrasonography
7We Care
BLIGHTED OVUM
Blighted ovum Incomplete abortion Compelet abortion
7We Care
BLIGHTED OVUM
Ectopic pregnancy Vesicular mole
7We Care
• 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
Threatened abortion
Positive UPT
Intrauterine pregnancy
Viable fetus
Incomplete abortion
•Positive UPT
•Product of conception in-situ
•Non viable fetus
DIAGNOSIS
7We Care
• 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
7We Care
THANK YOU
Thank you

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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
  • 3. 7We Care 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.
  • 4. 7We Care 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.
  • 8. 7We Care 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.
  • 9. 7We Care 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.
  • 10. 7We Care  What differential diagnoses are you thinking about? Try to name at least three!
  • 11. 7We Care Causes of bleeding in early pregnancy
  • 12. 7We Care 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.
  • 15. 7We Care 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
  • 16. 7We Care Case Study - next steps • Answer b is correct: Sterile speculum exam • She needs to have her bleeding assessed now
  • 17. 7We Care 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
  • 18. 7We Care 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.
  • 21. 7We Care 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
  • 22. 7We Care 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
  • 23. 7We Care abortion-definition Termination of pregnancy before the fetus is capable of extra-uterine survival i.e. 20 wks or 500gm birth wt
  • 24. 7We Care 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.
  • 25. 7We Care Types Threatened abortion. Incomplete abortion. Complete abortion. Missed abortion Septic abortion: Any type of abortion, which is complicated by infection Types of abortion
  • 26. 7We Care 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
  • 27. 7We Care 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.
  • 28. 7We Care 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
  • 29. 7We Care 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
  • 30. 7We Care Site Ectopic pregnancy .Definition & SITE Implantation of fertlized ovum outside the normal uterinse cavity Fallopian tube Ovary Abdominal cavity Cervix
  • 31. 7We Care Risk factors • Previous PID • Previous ectopic pregnancy • Previous tubal surgery (e.g. sterilisation, reversal) • Pregnancy in the presence of IUCD • POP
  • 32. 7We Care Diagnosis • Ultrasound – Empty uterus, adnexal mass, – free fluid, – occasionally live pregnancy outside – of uterus • Serum βhCG – Slow rising, plateau Laparoscopy: the surest method
  • 33. 7We Care 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“
  • 34. 7We Care Ectopic pregnancies Laparoscopic view of ectopic Uterus with fallopian ectopic
  • 35. 7We Care Management • Conservative – Self resolving with close watch • Medical – Methotrexate • Surgical – Laparoscopic salpingectomy / salpingotomy – Laparotmy
  • 36. 7We Care 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
  • 37. 7We Care 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
  • 41. 7We Care 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?
  • 42. 7We Care 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
  • 43. 7We Care Clinical approach • History • Examination • Special Investigations
  • 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’
  • 45. 7We Care Abdominal Pain • Minimal • Acute , agonising or colicky • Shoulder pain • Fever
  • 46. 7We Care Symptoms of early pregnancy • Amenorrhoea • Morning sickness • Frequency of micturition • Breast discomfort • Fatigue
  • 47. 7We Care • 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
  • 49. 7We Care 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
  • 50. 7We Care Vital signs • Temperature – Febrile/a febrile • Pulse – Tachycardia/normal • Blood pressure – Low/normal Vital signs
  • 51. 7We Care Size of uterus Size of uterus Guarding and rebound tenderness
  • 52. 7We Care Speculum examination  Trauma  Cervical pathology  Open cervical os- incomplete abortion Speculum examination
  • 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
  • 54. 7We Care Investigations • Hb • TLC • DLC • Platelet • PCV • ABO and Rh grouping • Thyroid function test Investigations
  • 55. 7We Care Investigations Routinely used Main modality of diagnosis Transvaginal and Transabdominal Ultrasonography
  • 56. 7We Care BLIGHTED OVUM Blighted ovum Incomplete abortion Compelet abortion
  • 57. 7We Care BLIGHTED OVUM Ectopic pregnancy Vesicular mole
  • 58. 7We Care • 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 Threatened abortion Positive UPT Intrauterine pregnancy Viable fetus Incomplete abortion •Positive UPT •Product of conception in-situ •Non viable fetus DIAGNOSIS
  • 59. 7We Care • 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