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PV BLEEDING IN early pregnancy

PV BLEEDING IN early pregnancy. DDx of bleeding in early pregnanCy. Physiologic – implantation Ectopic Subchorionic haematoma Gestational trophoblastic disease Cervical, vaginal or uterine pathology (Ectropion, Cervical neoplasia, vaginal trauma). Ectropian. Subchorionic haemorrhage.

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PV BLEEDING IN early pregnancy

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  1. PV BLEEDING IN early pregnancy

  2. DDx of bleeding in early pregnanCy • Physiologic – implantation • Ectopic • Subchorionic haematoma • Gestational trophoblastic disease • Cervical, vaginal or uterine pathology (Ectropion, Cervical neoplasia, vaginal trauma)

  3. Ectropian

  4. Subchorionichaemorrhage

  5. Early pregnancy lossDefinition pregnancy loss prior to 20 weeks gestation or expulsion of foetus/embryo </= 500g

  6. Epidemiology 8-20%

  7. Classification • Threatened Miscarriage • Cardiac activity present. PVB. Cervical os closed. • Mx: repeat USS in 7-10days • Inevitable miscarriage • Bleed and abdominal cramping, os open, may see POC through os • Missed Miscarriage • - Nil FHR, dropping Bhcg • - Failed pregnancy. RPOC have not been expelled . Cervical os is closed. may have small pv loss and cramping • - mx: conservative, medical, surgical

  8. Incomplete Miscarriage • PVB and pain. Cervical os open with POC in os • History of passage of some POC • Mx: remove POC from Cxos, IV syntocinon, D&C Complete Miscarriage • PVB and pain mild or resolving. Closed cervix. Empty uterus. • Mx: nil intervention required Anembryonic / blighted ovum • Empty GS >25mm with no YS/FP Septic Miscarriage - RPOC become infected

  9. Diagnostic USS criteria (TV USS) for miscarriage • MSD >/equal to 25mm with NO embryo or yolk sac = diagnostic of failed pregnancy • Absence of FH with CRL>7mm = diagnostic of failed pregnancy

  10. Risk factors • Previous M/C – 20% risk after 1 M/C. 30% after 2 consecutive M/C. 40% after 3/more M/C • Multip • STIs • Abnormal uterine receptivity e.g. PCOS, endometriosis • Advanced maternal age • Medications/Substance abuse

  11. Aetiology Chromosomal abnormalities (aneuploidy, triploidy etc.) 50% of all miscarriage Congenital Anomalies: teratogens e.g. DM Trauma: amniocentesis, CVS Multiple pregnancy Uterine structural abnormalities - Uterine septum, fibroids - Cervical incompetence (2nd trimester loss) Maternal Disease - Infections – TORCH, Listeria, parvo, rubella, herpes simplex, CMV, BV - Endocrine: Thyroid dysfunction, Cushings, PCOS, endometriosis - Thrombophilia, SLE, antiphospholipid syndrome Drugs, smoking, alcohol

  12. Clinical presentation • - PVB – with or without passage of foetal tissue • - Even heavy/prolonged bleed can have normal outcome • 90% of first trimester bleeds where FHR present (between 7-11 weeks) continue the pregnancy. Success rate increases with gestation • Signs • - Pallor, Tachycardia, hypotension (shock/collapse). Abdominal distension, tenderness, cervical motion tenderness. • - Cervical shock

  13. investigations - Serial bhcg monitoring, 48 hours apart - Blood Group/ Rhesus status - USS

  14. What we will ask • Pain? • PV bleeding? How much? • How many weeks • Is it intrauterine (prior scans) • Vital signs • Bhcg, Hb, USS

  15. MANAGEMENT – UNCERTAIN VIABILITY OR LOW BHCG Monitoring with bhcg and USS • If bhcg doubles in 48hrs -> repeat USS in 7 -10 days once bhcg in discriminatory zone for viability • If bhcg dropping or plateaus -> failed IUP or ectopic pregnancy

  16. Confirmed non viable intrauterine pregnancy

  17. Conservative management • majority of expulsions occur in first two weeks after diagnosis • May require medical/surgical management if does not spontaneously miscarry. • Not suitable if • significant haemorrhage • Evidence of infection • Risk from effects of haemorrhage e.g. coagulopathies / unable to have blood transfusion

  18. Medical management • - Misoprostil (Prostaglandin E1 analog) • Protocol based, PV or oral • can do progesterone antagonist mifepristone + misoprostol combination • - Expect bleeding within 24 hrs • - Medical help/EPAS contact if pain/bleeding • - S/E: GI – nausea, vomiting, diarrhoea. Pyrexia -> Analgesia, antiemetics • - risk of D&C

  19. Surgical management – D&C • - Risks: general, Uterine perforation, cervical trauma, retained products & need for repeat procedure, ashermans • - lowers risk of unplanned hospital admissions and need for subsequent treatment. • Chance of Complete evacuation surgery > medical > expectant

  20. Ectopic pregnancy

  21. incidence • 1-2%

  22. classification • Tubal 90% • 70% ampullary

  23. Risk factors • PID • IVF • Previous ectopic • Tubal pathology / surgery • congenital anomalies • tumour • endometriosis • IUD • Smoking • Age – extremities of age 18 AMA>35

  24. Symptoms & Signs • PV bleeding • abdominal pain • Amenorrheoa • if ruptured -> haemoperitoneum -> peritonism / shoulder tip pain / syncope • Cervical excitation, adnexal mass • Hypotension, tachycardia, pallor

  25. investigation • FBC • beta HCG • 70% ectopic pregnancy < 6000iu • < 53-66% increase in 48 hr • Pelvic ultrasound (TV)

  26. Ultrasound FINDINGS • adnexal mass separate to ovary • echogenic FF • pseudosac • ring of fire

  27. Initial Management DR ABC IVC FBC + G+H NBM Analgesia Resuscitate with IVT/blood products

  28. Inpatient management Depends on • Vital signs • Size of ectopic • Level and trend of bhcg • Clinical signs of ectopic rupture? Blood in pelvis? • Patient compliance • Presence of a FHR • Conservative • Medical : methotrexate • Surgical: salpingectomy, salpingotomy

  29. Pregnancy of unknown location • Normal IUP • Miscarriage • Ectopic • Hcg secreting tumors (GTD, germ cell of ovary)

  30. The Gynaecology consult

  31. History • Age • Pain: SOCRATES (assoc. sx incl. N+V, bladder, bowel, temp, rigors, vaginal discharge) • PVB • Gynae Hx: LMMPPSC • LMP • Menarche • Menses : dysmenorrheoa, AUB, regularity/length • PID/STI • Pap smear (CST) • Sexual activity • Contraception • Obstetric Hx: pregnancies, outcomes, complication

  32. PMHx/surg/psyche/meds, allergies – complications of surgery in the past? • FHx: malignancy • SHx • Cancer: weight loss, LOA, fevers, bloating

  33. Examination • UA, bhcg • Abdomen • Spec: Swabs • Bimanual: cervix, adnexal masses, cervical excitation

  34. Investigation • Bhcg • FBC, G+H • UECs/LFTs/coags? • UA, MSU • STIs screen • Chase outpatient images and bhcg results • Radiology: USS, CT

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