Bleeding in Early Pregnancy.pptx fgfgfgf

fgfgfgf

1. Bleeding in Early Pregnancy Presenter Kuhan Kalaichelvan

2. Content

3. Definition Any vaginal bleeding before 20 weeks period of gestation is defined as early pregnancy bleeding

4. Case scenario  Madam k 37years old G2P1 9w POA, presented to PAC with history of PV bleeding for 6days.  It was a mild to moderate fresh bleeding.  It was associated with abdominal pain. ? passing out poc Othervise no anemic symptoms  Self upt done positive

5. Differential diagnoses to think about local cause pregnancy related

6. History  Maternal age, parity, POA, Pregnancy confirmation  Bleeding Number of episodes, Amount of blood loss, color Passage of clots or vesicles Purulent vaginal discharge, fever Associated symptoms- abdominal pain- quality, location, spread  Past obs & gyn history  Past medical, surgical history  Drug history  Social history

7. Case scenario - clinical assesment  Generally patient alert, not pale not tachpnic Vital signs: bp 125/78 mmHg , PR 88bpm , temp 37, RR18 PS 4  Abdomen was soft in palpation. uterus not palpable  Speculum examination and vaginal examination vv nad, cervix healthy, os open poc seen at os  poc inspection -sac like , no vesicles seen TAS/TVS - ET 12.4mm no free fluid or adnexal mass seen

8. Examination  General - Febrile, pallor  CVS - PR, Pulse characteristics, BP, pulse pressure - CRT, cold clammy peripheries  Abdomen - Tenderness, Guarding, rigidity - Uterine size  Speculum examination - Bleeding from OS or from outside - Products, clots, blood in posterior fornix  VE - Os open or closed - Cervical excitation - Adnexal tenderness/ masses

9. Miscarriage

10. Type of miscarriages 1. Threaten miscarriage 2. Inevitable miscarriage 3. Missed miscarriage 4. Incomplete miscarriage 5. Complete miscarriage 6. Pregnancy of uncertain viability

11. DEFINITION: Fetal loss between the time of conception & the time of fetal viability (at 24 weeks gestation) OR expulsion of a fetus or embryo weighing ＜500g ● Product of conception : - Placental tissues - Fetal tissues

12. Management of miscarriage

13. ECTOPIC PREGNANCY DEFINITION: - Gestation that implantation occurs outside the uterine cavity. RISK FACTORS: 1. History of tubal inflammation (ie; PID / endometriosis) 2. History of tubal surgery 3. Use of Assisted Reproductive Technologies 4. Previous history of ectopic pregnancy

14. CLINICAL FEATURES: Symptoms ○ Triad of missed menses + PV bleed + lower abdominal pain ○ Ipsilateral shoulder pain (phrenic nerve irritation) in ruptured ectopic Signs ○ Pallor ○ Abdominal distension ○ Abdominal tenderness and guarding ○ Vaginal exam : cervical excitation positive , adnexal tenderness

15. INVESTIGATIONS: FBC (Hb and platelet) GXM Coagulation profile Renal profile UPT Pelvic ultrasound (Transvaginal Ultrasound, TVS) ○ Empty uterus ○ Adnexal mass - Double ring sign ○ Free fluid in POD

16. GESTATIONAL TROPHOBLASTIC DISEASE/ HYDATIDIFORM MOLE (MOLAR PREGNANCY) TYPES OF MOLAR PREGNANCIES: 1. Hydatidiform (Complete mole) 2. Partial mole 3. Choriocarcinoma* 4. Invasive mole (rare) 5. Placenta site trophoblastic tumour, PSTT (rare) *Choriocarcinoma: can arise from normal pregnancy but rare, presented as secondary postpartum haemorrhage

17. clinical features

18. INVESTIGATIONS: How to diagnose molar pregnancy? 1. USS: multiple sonolucent appearance with various shapes and sizes in the uterine cavity (snowstorm appearance), fetal echo (present: partial, absent: complete),presence/absence of ovarian cyst (theca lutein cyst) 2. Blood test: Beta HCG> 100, 000IU/L 3. Chest X-rays But can both of the tests confirm the diagnosis? NO, they can only suspect. Therefore, to confirm we need to do HPE. **Theca lutein cyst most likely appears in complete mole, because to have the TLC, very high levels of B-HCG is needed, which can be found in complete mole.

19. MANAGEMENTS: Once diagnosed with molar pregnancy: 1. Admit the patient to ward 2. For suction and curettage (S&C) 3 . Do blood test for Beta HCG monitoring. 6 . Discharge the patient after 2 days and follow her up at the molar clinic: need to follow up because risks of choriocarcinoma, follow up 1 week later to see whether there are any complications of the S&C done, to review the HPE results and to see the B-HCG levels. Watchout forbleeding i/v/o: i. placenta is very vascularised ii. uterus is very soft, therefore easy to perforate