1. Bleeding in Early Pregnancy
Max Brinsmead PhD FRANZCOG
February 2015

2. 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 weeks after her LMP with symptoms of pregnancy and some dark vaginal bleeding.

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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