PV bleeding and pain in early pregnancy

PV bleeding and pain in early pregnancy

2. 20-25% pregnancies have PVB
›~50% of these have miscarriage
80% occur in first trimester
Miscarriage - classification
›Threatened
›Inevitable
›Incomplete
›Complete
›Missed
›Blighted ovum
›Septic

3. Ectopic
›Fertilized ovum that implants in a location other
than the fundus or body of the uterus
›~2% of pregnancies
›Higher incidence in ED pts ~4-13%
Heterotropic
›Concomitant intrauterine and extrauterine
pregnancy
›Spontaneous pregnancy ~1/30000
›High risk pregnancy ~1/300

4. There is only one
Shagging!
Things that increase the risk

8. Never believe a woman who says ‘I can’t be
pregnant I use contraception’
›See above risk factors
Never believe a woman who says ‘I can’t be
pregnant I am not sexually active’
›Especially if her mother is in the room
Never be fooled by the LMP
All women with abdominal pain and/or PVB are
pregnant until proven otherwise
›See above risk factors and rules for any doubt

9. Never believe a woman!

10. Pregnancy related
›Miscarriage
›Ectopic
›GTD
Non pregnancy related
›Urological
›GIT
›Gynaecological

11. ?Pregnant
If pregnant
›?intrauterine
›?viable
›?Rh status

12. Unstable
›Treat shock
Hypovolaemic
Cervical
Stable
›History / Examination / Investigations
›Specific management

13. Have they had a previous US
Ectopic
›Risk factors
PID / previous ectopic / tubal surgery / IUD /
IVF / induced ovulation
Heterotropic pregnancy
›Risk factors
Induced ovulation / IVF

14. Do you need to do a PV / speculum?
›Yes - If significant pain / bleeding / cervical
shock
›Otherwise if US is available then the utility of
PV is questionable
›Other considerations
Cervical pathology - ?last PAP

15. Increases until ~10-12/40
›Doubles every 48hrs (min rise 67%)
Serial levels more sensitive for detecting
abnormal pregnancy
›Decreasing levels indicate non viable pregnancy
 Does not differentiate miscarriage from ectopic
›Rising levels decrease chance of miscarriage
Risk of ectopic remains
Discriminatory zone
›Level at which pregnancy should be visible on US
(different levels for TV and TA)
›1500 (TV) / 6000 (TA)

16. Traditional teaching
›QβhCG <DZ
No US
Serial hCG until DZ then US
›Miss ~50% ectopics at first presentation
Risk of ectopic actually higher in symptomatic
pts with QβhCG <DZ
>70% ectopics have abnormal rise / fall
Current Mx
›US is first line investigation

17. TVUS
›Highly accurate for IUP and ectopic
(sensitivities - 98% and 89.9%, specificities -
100% and 99.8%)
Aim to identify
›GS location
›GA
Mean sac diameter / CRL
›Viability
FHR

18. Patients classified into
›IUP
Follow up to assess viability
›Miscarriage
Treatment - conservative / misoprostol / D+C
›Ectopic / probably ectopic
Treatment – methotrexate / surgery
›Pregnancy of unknown location
Early pregnancy not seen
Ectopic
Complete miscarriage

19. What now?
QβhCG
›>DZ – O+G referral
›<DZ and pt well
f/u 48hrs for repeat hCG / US

20. Rhesus status
›Rh-ve – anti D
Possibility of heterotropic pregnancy
›Require exclusion of ectopic even if IUP
identified
›Refer to KEMH

21. Generally after hours US will not be
available (unless US qualified ED
Consultant available)
If no previous US
›Discuss case with KEMH O+G Reg regarding
appropriate timing of f/u
›Worth doing QβhCG primarily for their f/u