Early pregnancy bleeding

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  • Created by: AL
  • Created on: 06-02-13 14:13
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  • Bleeding in Early pregnancy
    • Spontaneous miscarriage
      • Prior to 24 weeks most common before 12 wks after 24 weeks= viable foetus so intrapartum haemorrhage
      • Most common cause of early bleeding
      • Incomplete
        • Lower abdo pain
        • Heavy vaginal bleeding
        • Shock + uterine tenderness
          • blood transfusion if needed
        • Use forceps to  remove remainder
          • On scan still see parts left behind/ empty/ foetus at cervix
        • Cervix open
        • On scan still see parts left behind/ empty/ foetus at cervix
        • FH -ve
      • Inevitable
        • FH +ve
        • Similar to incomplete
        • Bleeding and pain worse
        • Cervical os can be beginning to open
        • Nothing to be done. can give oxytoxic to contract uterus
      • Complete
        • No Tx- spontaneous- conservation
      • Threatened
        • Pain -ve
        • Bleeding not profuse + settles
        • Cervix closed
        • Uterus size= gestational age
        • FH +ve
        • Conservative mment and usually good outcome
        • Reassurance+ rest. Remove IUCD if present. Aspirin low dose
          • Conservative mment and usually good outcome
      • Septic
        • Rare in UK
        • All features of miscarriage + sepsis- eg from back street abortion
        • Empty uterus + abx
      • Aetiology
        • Uterine abnormalities
          • bicornuate uterus, uterine septae, fibroids (esp if protruding into uterine cavity), incompetent cervix
        • Acquired disease
          • Infections (TORCH)
            • Toxoplasmosis, others, rubella, cytomegalovirus, herpes simplex
          • listeria, malaria, influenza virus, hypertension, renal, DM, thyroid
        • Abnormal conceptus- chromosomal
        • Toxins
          • Alcohol, smoking, anti-metabolites, chemotherapy, anaesthetic cases
        • Endocrine- deficient corpus luteum and progesterone production, high LH
        • Trauma: amniocentesis, abdo surgery
        • FB- IUCD
        • Immunological- antiphospholipid syndrome,  lupus anticoagulent
        • Psych
      • Ix
        • Hb, blood group and Rh typing ( risk of rh iso immunisation), group and save.
        • b-hCG pregnancy test
        • serum b-hCG if hydratiform mole is suspected
          • Tracking disease. Also for ectopic
        • ECS and blood culture if sepseis
          • Swab + blood culture
        • USS
          • Transvaginalscan. Do need chaperone + more invasive. Gives superior picture
          • Transabdominal scan/ probe. Less clear in early pregnancy. Can't do without full bladder
          • Amniotic sac present from about 5 weeks. FH from 7 weeks
    • Ectopic pregnancy
      • Aetiology
        • Chlamydial/ gonococcal salpingitis
        • Previous tubal surgery (narrowing)
        • IUCD
        • Previous tubal ligation
      • Implantation of conceptus outside uterine cavity
      • Most 1st trimester, fallopian tube
      • 10-15% recurrent
      • Clinical features
        • Amenorrhea
        • Lower abdo pain
        • Vaginal bleeding
          • Shoulder tip pain if irritating diaphragm/ adnexal tenderness if in pouch of douglas
      • Outcomes
        • Tubal abortion
        • Tubal rupture
      • Sites
        • Isthmal, ampullary, interstitial, ovarian, peritoneal, cervical
      • Mment
        • 1) pregnancy test 2) scan. cannot always see pregnancy. If more than 7 weeks, should see something in uterus
        • Ix
          • Urine b- hCG pregnancy test
          • Paired serum b- hCG
            • Should  more than double, if falling- not viable, if small increase- ectopic
          • transvaginal uss
          • Diagnostic laparoscopy
            • risky for patient + pregnancy try to avoid!
        • Tx
          • Laparoscopic salpingectomy
            • ok if not wanting more pregnancies. Can use IVF after. best.
          • laparoscopic salpingotomy
            • only remove part with pregnancy
          • IM methotrexate
            • inj to avoid surgery. does not eliminate risk of rupture
          • Intratubal methotrexate
          • Conservative mment
          • laparotomy if ruptured
    • Hydratiform mole
      • Developmental anomaly of trophoblas or placenta. local or general vesicular change in chorionic villi
      • Amenorrhea, vaginal bleeding, uterus larger than dates , FH -ve, haemoptysis, pleuritic chest pain (spread)
        • No as much pain as in miscarriage
        • spread to lung/ breast
      • may see part of pregnancy but always not viable
      • Outcome
        • 1)  tumor gone
        • 2) hCG doesn't fall so tumor cells somewhere in body. Not malignant- but "persistent" mole
      • Ix
        • Urinary and serum hCG
          • 2000-1000 IU in normal pregnancy. Mole= 100 000's
        • USS- snowstorm appearance, theca-lutein ovarian cysts
        • CXR
      • Tx
        • Evacuation of uterus. More difficult to empty due to tissue
        • Prolonged follow-up of urinary + serum b-hCG
        • Avoid pregnancy 1 yr (dont know if increased hCG is due to new pregnancy or mole)
        • Hysterectomy if no desire for further childbearing.
        • Persistent mole= chemo
      • Poss malignant change to choriocarcinoma
    • Lower genital tract causes
    • Cervical incompetence
      • cervical dilation in abscence of abdo pain
      • Aetiology
        • Cervical dilatation during TOP
        • Cone biopsy of cervix
        • cervical amputation during Manchester repair
        • Exposure to DES
        • Idiopathic
      • Cervical cerclage- suture at 14 weeks.
        • Risk of ROM and infection
        • removed at 36 wks
  • Recurrent miscarriage
    • On 3 or more  consecutive occasions
    • Probability of live birth with next pregnancy 40-50%
    • Ix
      • GTT, T4, TSH
      • Karyotyping of both parents + foetal tissue
      • Hysteroscopy, HSG (fibroids/ shape), IVT (renal)
      • Most couples: all normal
    • Tx
      • Any underlying cause
      • TLC
  • Isthmal, ampullary, interstitial, ovarian, peritoneal, cervical

Comments

rac1

This is so sad...

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