Pain and Bleeding in Pain and Bleeding in Early PregnancyEarly Pregnancy

Max Brinsmead MB BS PhDFebruary 2015

Sara is a 19-year old who wants Sara is a 19-year old who wants to have a baby. She stopped to have a baby. She stopped taking her Pill a couple of months taking her Pill a couple of months ago and has not had a period ago and has not had a period since. Two days ago a self test since. Two days ago a self test for pregnancy was positive. for pregnancy was positive. Today she has experienced some Today she has experienced some “sharp low abdominal pain” and a “sharp low abdominal pain” and a few spots of dark blood on her few spots of dark blood on her pants. She comes to you for pants. She comes to you for advice…advice…

Sara with 6-8 weeks amenorrhoea, Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal painPV bleeding and abdominal pain

Do you require further history

Do you examine this patient

What tests might be useful

Sara with 6-8 weeks amenorrhoea, Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal painPV bleeding and abdominal pain

Further history that is desirable

Was the LMP a normal period

Exact dateMore info about the

painPregnancy symptoms?Risk factors for

ectopicSocial circumstances,

any other pregnancies etc.

Risk Factors for Ectopic Risk Factors for Ectopic PregnancyPregnancyPrevious ectopicPrevious tubal surgery

Includes tubal ligation And re anastomosis

PIDInfertilityAssisted conceptionIUCD for contraception

Risk Factors for Risk Factors for MiscarriageMiscarriageMaternal age

10% of pregnancies at age 25 But 33% of pregnancies for age >40

Previous miscarriageFamily history of miscarriagesSystemic disease

E.g. Diabetes, Hypertension, Renal, Autoimmune

SmokingInfertility or Assisted conception

Sara with 6-8 weeks amenorrhoea, Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal painPV bleeding and abdominal pain

Further history LMP was a PWB 5 weeks and 6 days ago

Started the Pill at age of 12

Pain was sudden, RIF, during intercourse and lasted about 30 min

Has had nausea and mastalgia for a week

No risk factors for ectopic

Living with a boyfriend, both unemployed and smoking

Sara with 6-8 weeks amenorrhoea, Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal painPV bleeding and abdominal pain

Examination that is essential

Why?

Vital signs

Abdominal palpation for mass or tenderness

Must exclude ectopic pregnancy before Sara walks out your door

A patient with 6-8 weeks A patient with 6-8 weeks amenorrhoea, PV bleeding and amenorrhoea, PV bleeding and abdominal painabdominal painExamination that

is desirable

Why

Vaginal inspection to confirm uterine bleeding

Cervical dilatation and excitation are difficult signs to elicit

Any tissue removed from the cervix or vagina requires histology

A patient with 6-8 weeks A patient with 6-8 weeks amenorrhoea, PV bleeding and amenorrhoea, PV bleeding and abdominal painabdominal painWhat is the best

way to proceed from here?

What other tests may be desirable

PV ultrasound will tells us if there is an IUP, and possibly its viability

Take blood for blood group, antibodies and hold for a possible quantified ßHCG & HB

Cx swab for Chlamydia PCR if PV done

Scan report: No intrauterine sac seen but Scan report: No intrauterine sac seen but thickened endometrium consistent with a decidua thickened endometrium consistent with a decidua reaction is identified. There is a 4 – 5 cm reaction is identified. There is a 4 – 5 cm echolucency in the right adnexa with some mixed echolucency in the right adnexa with some mixed echogenicity. No free fluid in the pelvis. Ectopic echogenicity. No free fluid in the pelvis. Ectopic pregnancy cannot be excludedpregnancy cannot be excluded

What is the next best step(s)

Is referral to hospital required?

Quantified ßHCG

If >3000 IU/L then this is ectopic pregnancy

The result was 980 IU/L

If repeated after 48 hours and >1.5 fold rise then prognosis is good

Two days later Sara has no pain or Two days later Sara has no pain or bleeding. Quant ßHCG is 1200 IU/L. bleeding. Quant ßHCG is 1200 IU/L. HB is 12 and Blood Group O NegHB is 12 and Blood Group O Neg

What steps are now required

Anti-D administration to prevent possible Rhesus isoimmunisation is desirable

A repeat scan in 7 – 14 days to check for signs of IUP and viability is desirable

Two weeks later Sara has had no Two weeks later Sara has had no pain or bleeding but says that she pain or bleeding but says that she “no longer feels pregnant”“no longer feels pregnant”

What steps are now required

Early pregnancy ultrasound or referral to an EPAS for further care

Some counselling about miscarriage may be desirable

Scan report: There is an empty intrauterine sac Scan report: There is an empty intrauterine sac with a mean diameter of 2.6 cm. There is no free with a mean diameter of 2.6 cm. There is no free fluid in the pelvis and the previously identified fluid in the pelvis and the previously identified adnexal mass has disappeared. Appearances are adnexal mass has disappeared. Appearances are consistent with a blighted ovum.consistent with a blighted ovum.

What is the correct diagnosis

What options are available to Sara

Explain each as you would to Sara

Early pregnancy loss

Wait and see

Medical evacuation of the uterus

Surgical evacuation of the uterus

Sara goes home quite upset to think about it. That Sara goes home quite upset to think about it. That night she experiences further crampy abdominal night she experiences further crampy abdominal pain and PV bleeding. She presents to ED feeling pain and PV bleeding. She presents to ED feeling faint and she looks pale.faint and she looks pale.

What would you do if you were the ED officer

Have we missed an ectopic pregnancy?

Vital signsPR 60/min, BP

70/45PV examinationLots of blood in

the vagina, tissue coming through the Cx

This was removed and sent for histology

Sara recovers rapidly after this and her pain Sara recovers rapidly after this and her pain disappearsdisappears

Does she require a curette?

If not, what should be done

Many gynaecologists would recommend curette as the simplest way of ensuring that the uterus is empty

But a PV ultrasound is as effective, cheaper and safer

Or one could just wait and see

Scan report: There is mixed echogenic and Scan report: There is mixed echogenic and echolucent material in the uterine cavity. The echolucent material in the uterine cavity. The appearances are consistent with incomplete appearances are consistent with incomplete abortion.abortion.

What is the correct diagnosis

What options are available to Sara

Explain each as you would to Sara

Incomplete or complete miscarriage depending on the measurements of the intrauterine echoes

In fact, these were <14mm

All symptoms settled over next week

When Sara returns a week later she wants to When Sara returns a week later she wants to know the sex of the baby that she lost and asks know the sex of the baby that she lost and asks when she can try again.when she can try again.

What do you tell her

The tests on the removed tissue were to confirm “a simple miscarriage”. Much more expensive tests are required to determine sex (chromosomes, FISH or DNA)

She should take Folic Acid or pregnancy multivitamins, stop smoking and moderate alcohol intake

And she can “try again” when she is “ready”

Histology of the products of conception from Histology of the products of conception from Sara’s pregnancy loss reveals “trophoblastic Sara’s pregnancy loss reveals “trophoblastic proliferation consistent with a partial mole”proliferation consistent with a partial mole”

What do you tell her

What are the possible outcomes

What steps are required

The tests on the removed tissue shows that there is a small risk of “recurrence of growth of the placenta and a small risk of malignancy”

Fortunately this can be readily detected by “blood tests for the pregnancy hormone”

Weekly tests will be required

Contraception to avoid pregnancy for 6 months is required

Please review the PowerPoint “Gestational Trophoblastic Disease”

Any Questions?Any Questions?

For copies of this PowerPoint go to www.brinsmead.net.au and follow the links

to “Postgraduates”. Called “Case of Pain and Bleeding in

Pregnancy”