Bleeding in Early Pregnancy Max Brinsmead PhD FRANZCOG February 2015

Margaret H is a 26 year old Para 1 who has had one previous pregnancy Margaret H is a 26 year old Para 1 who has had one previous pregnancy. This was obstetrically normal. She is healthy and a non smoker. She has been trying to conceive for about 6 months and she presents at 6 - 7 weeks after her LMP with symptoms of pregnancy and some dark vaginal bleeding.

A patient with 6-7 weeks amenorrhoea and PV bleeding Do you require further history Do you examine this patient What tests do you request

A patient with 6-7 weeks amenorrhoea and PV bleeding Further history that is desirable Was the LMP a normal period Usual cycle length Has pregnancy been confirmed Any pain Pregnancy symptoms still? Risk factors for ectopic

Risk Factors for Ectopic Pregnancy Previous ectopic Previous tubal surgery Includes tubal ligation And re anastomosis PID Infertility Assisted conception IUCD for contraception

Risk Factors for Miscarriage Maternal age 10% of pregnancies at age 25 But 33% of pregnancies for age >40 Previous miscarriage Family history of miscarriages Systemic disease E.g. Diabetes, Hypertension, Renal, Autoimmune Smoking Infertility or Assisted conception

A patient with 6-7 weeks amenorrhoea and PV bleeding Examination that is desirable Vital signs Abdominal palpation for mass or tenderness 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 6-7 weeks amenorrhoea and PV bleeding Desirable tests HB, Blood group Urine test for HCG if not done before Ultrasound if >3 weeks from conception Quantified beta HCG if <3w from conception or ultrasound not diagnostic Other routine AN tests may be required

What is the prognosis for this pregnancy Scan report: Intrauterine sac with an identified embryonic echo and evidence of fetal heart motion at a rate of 110/min. A normal decidual reaction is identified and a yolk sac is visible What is the prognosis for this pregnancy

Prognosis for a Pregnancy 10 – 40% embryos transferred after IVF 50% of all embryos that implant 85% of patients with a positive HCG test 95% of those with a fetal heart at 6-8w 98% of those who make it to 12w 99% of those who make it to 20w

A 26 year G2P1, healthy and a non smoker. Bleeding at 6 – 7 w settles A 26 year G2P1, healthy and a non smoker. Bleeding at 6 – 7 w settles. Blood group O Neg. Advise next steps

A 26 year G2P1, healthy and a non smoker. Bleeding at 6 – 7 w settles A 26 year G2P1, healthy and a non smoker. Bleeding at 6 – 7 w settles. Blood group O Neg. Provide anti-D gamma globulin Discuss first trimester tests for chromosomal disorders For all patients The best test is serum markers at 10-12w followed by ultrasound for nuchal translucency at 12 – 13.5w Or Cell-free fetal DNA in maternal plasma Desirable next steps

What do you tell the patient Is this placenta previa Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the developing placenta which appears to reach to the cervical os What do you tell the patient Is this placenta previa When would you repeat the scan The patient requests “a test for spina bifida”. What would you recommend

What do you tell the patient Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the developing placenta which appears to reach to the cervical os What do you tell the patient There is a blood clot in the uterus that may cause some brown PV loss The prognosis for the pregnancy is good Although there is a small statistically increased risk of APH, IUGR and preterm delivery

Is this placenta previa When would you repeat the scan Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the developing placenta which appears to reach to the cervical os Is this placenta previa When would you repeat the scan No A vaginal scan at 18 – 20 weeks is an excellent means of excluding the need for further scans if the placenta does not reach or overlap the internal os A third trimester scan for growth is desirable for this patient

Scan Report: CRL equivalent to 12 weeks of amenorrhoea Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the developing placenta which appears to reach to the cervical os The patient requests “a test for spina bifida”. What would you recommend Maternal serum AFP may be elevated by the earlier bleeding and the haematoma. Most significant spina bifida can be excluded by ultrasound at 18 – 22 weeks given optimal imaging