PV bleeding and pain in early pregnancy
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Transcript of PV bleeding and pain in early pregnancy
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
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
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
Unstable› Treat shock
Hypovolaemic Cervical
Stable› History / Examination / Investigations› Specific management
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
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
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)
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
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
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
Rhesus status› Rh-ve – anti D
Possibility of heterotropic pregnancy› Require exclusion of ectopic even if IUP
identified› Refer to KEMH
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