CASE STUDY ON EARLY PREGNANCY BLEEDING FOR UNDERGRADUATE - PowerPoint PPT Presentation

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CASE STUDY ON EARLY PREGNANCY BLEEDING FOR UNDERGRADUATE

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Undergraduate course lectures in Obstetrics&Gynecology Prepared by DR Manal Behery .Faculty of Medicine,Zagazig University – PowerPoint PPT presentation

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Title: CASE STUDY ON EARLY PREGNANCY BLEEDING FOR UNDERGRADUATE


1
How to approch A case of vaginal bleeding in
early pregnancy
DR Manal Behery Assistant Professor Zagazig
University ,2013
2
ON
Definition
A
Any vaginal bleeding before 20 wks period of
gestation is defined as early pregnancy bleeding
3
Case1
  • A 28 YS G1 P00,noticed some bleeding this
    morning after 5 wks amenorrhea which causes her
    concern.
  • She took a pregnancy test and was positive 1 week
    ago.

4
Case cont
  • She feels no pain and has not had any other
    symptoms apart from slight morning sickness
  • She describes the bleeding as spotting on her
    underwear.
  • On physical examination there are no signs of
    abdominal tenderness or intra-abdominal bleeding.

5
Question 1
  • AS pregnancy was confirmed a week ago, so you do
    not consider it necessary to conduct a pregnancy
    test.
  • Given that patient reports no other symptoms and
    clearly describes the nature of the bleeding as
    spotting, you decide that vaginal examination
    will not be necessary.

6
Does she need an onward referral?
  • As her pregnancy is less than 6 weeks gestation
    and there is no pain, you would aim to see
    whether the condition will resolve naturally (an
    expectant management approach).

7
She expresses concern that no further action is
being taken.How do you explain this decision?
  • You explain that at this stage, the pregnancy is
    too small to see, and any further investigations
    such as scanning are unlikely to yield any
    information.
  • You also note that many women experience
    spotting during early pregnancy that resolves
    without the need for further intervention.
  • Therefore you advise waiting to see how things
    progress during the next week before any further
    action can be considered.

8
What patient she should do during the course of
the expectant management week.?
  • You advise her to repeat a urine pregnancy test
    after 710 days
  • A negative pregnancy test means that the
    pregnancy has miscarried
  • You emphasise that given the nature of her
    symptoms the outcome of the test is just as
    likely to be positive.
  • You advise her to return if her symptoms continue
    or worsen.

9
Case 2
  • A34 year old, G1 P0,did not have a period for 5
    weeks and so had a pregnancy test at home which
    was positive.
  • She now phones you at 2am when you are at home on
    outpatient call.
  • She tells you that she has seen spotting with
    mild abdominal cramping which causes her some
    discomfort rather than pain.
  • However, she is very anxious and is crying.

10
  • What differential diagnoses are you thinking
    about? Try to name at least three!

11
Causes of bleeding in early pregnancy
12
Related to pregnant state
Related to pregnant state
  • Abortion
  • Ectopic pregnancy
  • Molar pregnancy

13
Related to pregnant state
Associated with the pregnant state
  • Abortion
  • Ectopic pregnancy
  • Molar pregnancy

14
Does the patient need to be seen tonight?
  • Bleeding in the first trimester can be a medical
    emergency! Even spotting can be enough to
    warrant a visit to the ER.
  • Best practice is to send her for an exam tonight.
    Particularly given her disposition she is
    anxious.

15
Patient arrived ER at 3.45am
Patient arrived ER at 3.45am
  • It
  • She has no further spotting and only mild
    cramping
  • She still appears tearful and anxious
  • After confirming she is pregnant,
  • what should the next step be?
  • Bi-manual pelvic exam
  • Sterile speculum exam
  • Order an Ultra-sound
  • Send her home as the bleeding seems to have
    resolved

16
Case Study - next steps
  • Answer b is correct Sterile speculum exam
  • She needs to have her bleeding assessed now


17
This would now be a good time to think about lab
work. What labs would you order for her ?
  • Serum hCG
  • This should be done now. We know she is pregnant
    but it will help correlate with the ultrasound
    exam
  • and again in 48 hours - this second draw is done
    to ensure that the pregnancy is progressing
  • CBC and type
  • We need to see if she lost any significant
    amount of blood and
  • ascertain her blood group to see if she is Rh
    negative

18
Case Study patient outcome
  • Her CBC is normal and she is A ve
  • This rules out severe blood loss and no Rhoram
    required
  • Her hCG levels are 900
  • This will enable you to assess what should be
    seen on ultrasound
  • NOW you can order a stat ultra sound

next

19
What would the ultra sound show at this stage?
- 4
What would the ultra sound show at this stage?
- 4 weeks and a few days
Trans-vaginal findings Weeks from LMP ß-HCG (mIU/ml)
Gestational sac (25 mm) 4.5-5 1000
Yolk sac 5-5.5 1500-2500
Fetal pole 5-6 2000-5000
Fetal cardiac activity 5.5-6.5 4000-17000
Click for view
Click for view
Click for view

20
The ß-hCG level at which an intra-uterine
pregnancy (IUP) should be visualized by
transvaginal ultrasound, with near 100
sensitivity, is 1000-2000 mIU/mL.
The level for transabdominal sonography is less
certain but has been suggested to be between 4000
and 6500 mIU/mL.
21
Case study - current diagnosis
  • She has a closed cervix and no additional blood
    visualized in the vaginal vault.
  • It was too early to show any IUP evidence of a
    yolk sac.
  • What type of abortion would you consider
    classifying She at this stage?
  • Complete
  • Incomplete
  • Inevitable
  • Missed
  • Threatened

22
Case Study patient outcome
  • Her bleeding and cramping
  • Was most likely a threatened abortion
  • You tell her that you are going to send her home
  • You advise her to take it easy
  • no strenuous activity or heavy lifting or
    exercise for the next 7 days
  • to follow up with a hCG serum level in two days
    to ensure that the levels are doubling every 48
    hours
  • Doubling hCG levels are a sign of well being in
    early pregnancy

23

abortion-definition
Termination of pregnancy before the fetus is
capable of extra-uterine survival i.e. 20 wks or
500gm birth wt

24
Related to pregnant state
Pathology
  • Abortion
  • Ectopic pregnancy
  • Molar pregnancy

25
Types
Types of abortion
  • Threatened abortion.
  • Incomplete abortion.
  • Complete abortion.
  • Missed abortion
  • Septic abortion Any type of abortion, which is
    complicated by infection

26
Miscarriage
  • Approximately 30 of pregnant women will
    experience bleeding in early pregnancy
  • At least 50 of women with threatened miscarriage
    will have continuing pregnancy
  • Miscarriage occurs in 15-20 of clinically
    diagnosed pregnancies

27
Case Study return visit
  • She returns to visit you in clinic three weeks
    later
  • She is 6 weeks post LMP
  • Looking at her history you note that her hCG had
    doubled on a second lab visit
  • and therefore you had told her that at that time
    her pregnancy was progressing well
  • However, she is now experiencing increased
    abdominal pain in the right side and is bleeding
  • The bleeding is described as more than spotting
    a cupful.



28
What differential diagnoses do you have now?
  • What is the next step?

Differential diagnosis of pain and bleeding at 7
weeks the same as 4 weeks


29
Ectopic work up
  • Since SHE has unilateral pain, your thought is
    directed towards a possible ectopic pregnancy
  • This means an emergency ultrasound in the ER
  • Remember on her first visit to the er the
    ultrasound was unable to visualize an
    intra-uterine pregnancy
  • This was because it was too early
  • We now do a serum hCG and get 7000



30
Site
Ectopic pregnancy .Definition SITE
Implantation of fertlized ovum outside the normal
uterinse cavity Fallopian tube Ovary Abdominal
cavity Cervix
31
Risk factors
  • Previous PID
  • Previous ectopic pregnancy
  • Previous tubal surgery (e.g. sterilisation,
    reversal)
  • Pregnancy in the presence of IUCD
  • POP

32
Diagnosis
  • Ultrasound
  • Empty uterus, adnexal mass,
  • free fluid,
  • occasionally live pregnancy outside
  • of uterus
  • Serum ßhCG
  • Slow rising, plateau
  • Laparoscopy the surest method

33
Ultrasound of ectopic pregnancy
Same images Uterus outlined in red, uterine
lining in green, ectopic pregnancy yellow. Fluid
in uterus at blue circle - sometimes called a
"pseudosac
34
Ectopic pregnancies
Laparoscopic view of ectopic
Uterus with fallopian ectopic
35
Management
  • Conservative
  • Self resolving with close watch
  • Medical
  • Methotrexate
  • Surgical
  • Laparoscopic salpingectomy / salpingotomy
  • Laparotmy

36
On a transvaginal ultrasound you find
Gestational sac in utero Fetal pole at 2cm No
cardiac activity Cardiac activity should become
visible and begin once the fetal pole reaches
5mm. No cardiac activity at this stage means a
non-viable fetus
  • Gestational sac in utero
  • Fetal pole at 2cm
  • No cardiac activity
  • Cardiac activity should become visible and begin
    once the fetal pole reaches 5mm. No cardiac
    activity at this stage means
  • a non-viable fetus



37
On doing a Pelvic exam you find
  • blood in vaginal vault
  • Cervix is partially open
  • No tissue is seen
  • What type of abortion would you consider
    classifying her now?
  • Complete
  • Incomplete
  • Inevitable
  • Missed
  • Threatened


38
Management of inevitable (or incomplete or
missed) abortion
  • Medical
  • Misoprostol
  • Surgical
  • Dilation and curettage
  • Manual or Standard Vacuum Curettage
  • Dilation and evacuation

So which would you offer for her ?
39
The first choice would be medical - Misoprostol
  • Or watch and wait. Some women may choose to
    remain at home for a miscarraige, unless bleeding
    becomes heavy or concerning.
  • Only if failed medical treatment would you need
    to offer the surgical route

next
40
On the third day she passed clots and plenty of
blood.
  • Tissue expulsed should be sent for
    histopathological exam to assure that it is POC
    not a molar tissue
  • If histopathoogy isnot available follow up with
    HCG until fall to zero to exclude the possibility
    of a molar pregnancy

41
Patient asks you
  • What are the chances of having a successful next
    pregnancy?
  • What if she was 37 YO or she had a history of
    previous abortions?

42
Answers
Click here to see epi statistic slide
  • In women with an unknown etiology of prior
    pregnancy loss, the probability of achieving
    successful pregnancies is 40-80.
  • As stated earlier, increased age increases
    chances of spontaneous abortion.
  • This is also the case with patients who have
    three or more previous abortions

43
Clinical approach
  • History
  • Examination
  • Special Investigations

44
History
  • VAGINAL BLEEDING
  • Slight and bright red
  • Associated with fleshy mass
  • Associated with fowl smell and discharge
  • Associated with grape like vesicle
  • Sanguinous or dark coloured and continuous
  • White currant in red currant juice

45
Abdominal Pain
  • Minimal
  • Acute , agonising or colicky
  • Shoulder pain
  • Fever

46
Symptoms of early pregnancy
  • Amenorrhoea
  • Morning sickness
  • Frequency of micturition
  • Breast discomfort
  • Fatigue

47
Careful menstrual history
  • Previous cycles
  • LMP
  • Past history
  • Similar episodes
  • Infertility
  • Details of contraceptive use
  • Previous cycles
  • LMP
  • Past history
  • Similar episodes
  • Infertility
  • Details of contraceptive use

48
Classical triad of ectopic pregnancy
  • Previous cycles
  • LMP
  • Past history
  • Similar episodes
  • Infertility
  • Details of contraceptive use
  • Amenorrhea
  • Abdominal pain
  • Irregular vaginal bleeding

49
Examination
  • General look
  • Lies quiet and conscious, perspires and looks
    blanched
  • Looks more ill than accounted for- molar pregnancy

General look Lies quiet and conscious, perspires
and looks blanched Looks more ill than accounted
for- molar pregnancy
50
Vital signs
Vital signs
  • Temperature
  • Febrile/a febrile
  • Pulse
  • Tachycardia/normal
  • Blood pressure
  • Low/normal

51
Size of uterus
Size of uterus
Guarding and rebound tenderness
52
Speculum examination
Speculum examination
  • Trauma
  • Cervical pathology
  • Open cervical os- incomplete abortion

53
Bimanual examination
  • Extreme tenderness on fornix palpation or rocking
    of cervix
  • Palpation of bilateral or unilateral enlargement
    of ovary - molar pregnancy
  • Palpation of adnexal mass- Ectopic pregnancy

54
Investigations
Investigations
  • Hb
  • TLC
  • DLC
  • Platelet
  • PCV
  • ABO and Rh grouping
  • Thyroid function test

55
Investigations
Ultrasonography
  • Routinely used
  • Main modality of diagnosis
  • Transvaginal and Transabdominal

56

Blighted ovum Incomplete abortion
Compelet abortion
  • BLIGHTED OVUM

57

Ectopic pregnancy
Vesicular mole
  • BLIGHTED OVUM

58
DIAGNOSIS
  • Threatened abortion
  • Positive UPT
  • Intrauterine pregnancy
  • Viable fetus
  • Incomplete abortion
  • Positive UPT
  • Product of conception in-situ
  • Non viable fetus
  • Complete abortion
  • Positive UPT
  • Absent product of conception
  • Ectopic pregnancy
  • Positive UPT
  • USG confirmation
  • Product of conception absent in uterus
  • Molar pregnancy
  • Positive UPT
  • Typical USG findings

59
  • Complete abortion
  • Positive UPT
  • Absent product of conception
  • Ectopic pregnancy
  • Positive UPT
  • USG confirmation
  • Product of conception absent in uterus
  • Molar pregnancy
  • Positive UPT
  • Typical USG findings
  • Complete abortion
  • Positive UPT
  • Absent product of conception
  • Ectopic pregnancy
  • Positive UPT
  • USG confirmation
  • Product of conception absent in uterus
  • Molar pregnancy
  • Positive UPT
  • Typical USG findings

60
THANK YOU
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