Early pregnancy bleeding
- 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
- Infections (TORCH)
- 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
- Uterine abnormalities
- 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
- Laparoscopic salpingectomy
- Aetiology
- 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
- Urinary and serum hCG
- 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
- Spontaneous miscarriage
- 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
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