1. Pain and Bleeding in Early Pregnancy Max Brinsmead MB BS PhD February 2015

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

3. Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal pain Do you require further history Do you examine this patient What tests might be useful

4. Sara with 6-8 weeks amenorrhoea, PV bleeding and abdominal pain Further history that is desirable Was the LMP a normal period Exact date More info about the pain Pregnancy symptoms? Risk factors for ectopic Social circumstances, any other pregnancies etc.

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. Sara with 6-8 weeks amenorrhoea, PV 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

8. Sara with 6-8 weeks amenorrhoea, PV 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

9. A patient with 6-8 weeks amenorrhoea, PV bleeding and abdominal pain Examination 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

10. A patient with 6-8 weeks amenorrhoea, PV bleeding and abdominal pain What 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

11. Scan report: No intrauterine sac seen but thickened endometrium consistent with a decidua reaction is identified. There is a 4 – 5 cm echolucency in the right adnexa with some mixed echogenicity. No free fluid in the pelvis. Ectopic pregnancy 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

12. Two days later Sara has no pain or bleeding. Quant ßHCG is 1200 IU/L. HB 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

13. Two weeks later Sara has had no pain or bleeding but says that she “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

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

15. Sara goes home quite upset to think about it. That night she experiences further crampy abdominal pain and PV bleeding. She presents to ED feeling faint and she looks pale. What would you do if you were the ED officer Have we missed an ectopic pregnancy? Vital signs PR 60/min, BP 70/45 PV examination Lots of blood in the vagina, tissue coming through the Cx This was removed and sent for histology

16. Sara recovers rapidly after this and her pain disappears 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

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

18. When Sara returns a week later she wants to know the sex of the baby that she lost and asks 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”

19. Histology of the products of conception from Sara’s pregnancy loss reveals “trophoblastic 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”

20. Any Questions? For copies of this PowerPoint go to www.brinsmead.net.au and follow the links to “Postgraduates”. www.brinsmead.net.au Called “Case of Pain and Bleeding in Pregnancy”