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First Trimester Bleeding

First Trimester Bleeding. Ontario Family Practice Nurses Conference May 4, 2012. Sharon Domb, MD, CCFP, FCFP Medical Director Department of Family & Community Medicine Sunnybrook Health Sciences Centre. Overview. Normal physiology Diagnosing pregnancy Etiology of first trimester bleeding

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First Trimester Bleeding

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  1. First Trimester Bleeding Ontario Family Practice Nurses Conference May 4, 2012 Sharon Domb, MD, CCFP, FCFP Medical Director Department of Family & Community Medicine Sunnybrook Health Sciences Centre

  2. Overview • Normal physiology • Diagnosing pregnancy • Etiology of first trimester bleeding • Management of first trimester bleeding • Red flags

  3. Normal physiology • Conception takes place around time of ovulation (~ day 14 in a 28 day cycle) • Sperm can live for up to 5 days in a woman, egg lives only one day after ovulation • Hard to pinpoint exactly when conception occurred

  4. Conception Implantation on Day 8-9 Fertilization on Day 0

  5. Normal physiology • bhCG produced by the blastocyst, can be detected in maternal blood after implantation • bhCG levels increase rapidly for first 8-10 weeks, then decrease • In viable pregnancy, should increase by at least 66% every 48 hours in the first 8-10 weeks

  6. Question 1 In your office do you diagnose pregnancy by: • Blood test • Urine test • No test

  7. Diagnosing pregnancy • History • Last missed normal period • Symptoms of pregnancy • Change in symptoms of pregnancy • Physical • Uterine size on bimanual exam • Fetal heart sounds by doppler • Laboratory • Qualitative bhCG (blood or urine) • Quantitative bhCG (blood) • Ultrasound

  8. Uterine size on bimanual exam 6 wks 8 wks 10 wks 12 wks

  9. bhCG levels in pregnancy • Significant crossover • Can’t be used for dating pregnancy

  10. Ultrasound of normal pregnancy Deutchman M, Tanner Tubay A, Turok D. Am Fam Physician 2009 Jun 1;79(11):985-992

  11. Ultrasound markers

  12. Question 2 28 year old calls in with bright red spotting, size of two toonies, no pain. LMP 6 weeks ago. Do you advise her to: • Go to nearest ER immediately • Come in to clinic • Wait at home to see what happens

  13. Etiology of first trimester bleeding • Occurs in about ¼ of pregnancies • Risk increases with maternal age • Half of these will miscarry

  14. Etiology of first trimester bleeding • Implantation of pregnancy • Cervical, vaginal or uterine pathology (polyps, inflammation/infection, trophoblastic disease) • Miscarriage (threatened, inevitable, incomplete, complete) – Most COMMON • Ectopic pregnancy – Most SERIOUS

  15. Definitions • Anembryonic pregnancy (aka “blighted ovum”) • Gestational sac > 18 mm without evidence of embryonic tissues (yolk sac or embryo)

  16. Definitions • Ectopic pregnancy • Pregnancy outside the uterine cavity (usually in the tube) • Can occur elsewhere in the abdomen • Embryonic demise (aka “missed abortion”) • Embryo larger than 5 mm without cardiac activity • Gestational trophoblastic disease • Abnormal proliferation of placenta, with or without a fetus • Can metastasize

  17. Definitions • Heterotopic pregnancy • Rare (1/4000) simultaneous intrauterine and ectopic pregnancies • Spontaneous abortion • Complete = passage of all products • Incomplete = passage of some products • Inevitable = bleeding with dilated cervix

  18. Definitions • Subchorionic hemorrhage • U/S finding of blood between chorion and uterine wall, usually with vaginal bleeding • Threatened abortion • Bleeding before 20 weeks in the presence of an embryo with cardiac activity and closed cervix

  19. Definitions • Implantation of pregnancy • Diagnosis of exclusion • Small amount of spotting at time of expected period, related to implantation of fertilized egg • No intervention required

  20. Clinical presentation • Ectopic pregnancy • Lateral pain, bleeding • Embryonic demise (aka “missed abortion”) • Resolution of pregnancy symptoms earlier than expected • Gestational trophoblastic disease • Exaggerated pregnancy symptoms

  21. Clinical presentation • Heterotopic pregnancy • Like ectopic, but U/S shows intrauterine pregnancy as well • Spontaneous abortion • Bleeding • Cramping

  22. Clinical presentation • Subchorionic hemorrhage • Bleeding • Threatened abortion • Bleeding • Sometimes cramping

  23. Clinical presentation • Implantation of pregnancy • Bleeding at time of expected menses • No pain

  24. Be careful… • There is significant overlap in symptoms • Patients don’t present with all of the symptoms

  25. Spontaneous Abortion • Risk factors • Genetic abnormalities • Endocrine • Immunologic • Infection • Occupational chemical exposure • Radiation exposure • Uterine anomalies

  26. Natural history of miscarriage Ankum WM, Wieringa-de Ward M, Bindels PJE. BMJ, 2001;322:1343-1346

  27. Ectopic pregnancy • Occurs in 2% of reported pregnancies • Leading cause of pregnancy-related death in the first trimester • Can cause abdominal pain, vaginal bleeding, syncope and hypotension Lozeau AM, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. 2005 Nov 1;72(9):1707-1714

  28. Ectopic pregnancy • 97% occur in fallopian tube, 3% in abdominal cavity, ovary, cervix • If bhCG > 1500 and transvaginal ultrasound does not show intrauterine gestational sac, ectopic should be suspected • Usually presents around 7 weeks Lozeau AM, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. 2005 Nov 1;72(9):1707-1714

  29. Ectopic pregnancy • Risk factors • Previous tubal surgery • Previous ectopic pregnancy • In utero DES exposure • Previous genital infections • Infertility • Current smoking • Previous IUD use Lozeau AM, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. 2005 Nov 1;72(9):1707-1714

  30. Be careful… • Up to 30% of patients with ectopic pregnancies have no vaginal bleeding • Up to 10% of patients with ectopic pregnancies have negative pelvic examinations • Ruptured and unruptured ectopic pregnancies have been identified with bhCG levels <100 and > 50,000

  31. Abnormal physiology • In viable pregnancy, should increase by at least 66% every 48 hours in the first 8-10 weeks • BUT…. • A normal rise may be seen in up to 15% of ectopics • An abnormal rise may be seen in up to 15% of intrauterine pregnancies

  32. Etiology of first trimester bleeding • Implantation of pregnancy • Cervical, vaginal or uterine pathology (polyps, inflammation/infection, trophoblastic disease) • Miscarriage (threatened, inevitable, incomplete, complete) – Most COMMON • Ectopic pregnancy – Most SERIOUS

  33. Laboratory investigations • bhCG • Produced by trophoblast cells of fertilized ovum • Only detectable after implantation • Urine test picks up bhCG of 25 IU/L • Will be positive by first missed period • Blood test picks up smaller amounts

  34. History • Last normal menstrual period, cycle regularity • Bleeding • Onset and duration • Colour • Light or heavy • Passing clots? Soaking through clothes? • Feel lightheaded? • Intermittent or constant • Painless or painful • Recent intercourse? • Symptoms of pregnancy • Nausea and vomiting • Breast tenderness

  35. Physical • Vitals • Abdominal exam • Midline pain with miscarriage • Lateral pain with ectopic • Uterine size • Fetal heart sounds if >10-12 weeks • Pelvic exam • Speculum exam to look at bleeding origin, quantity, etc. • Bimanual exam to assess uterine size if unable to feel on abdominal exam

  36. Algorithm Feier C. Clinical Emergency Medicine Algorithms: Vaginal Bleeding in Early Pregnancy. Western Journal of Emergency Medicine: IX, No. 1: Jan 2008; 47-51

  37. Algorithm Feier C. Clinical Emergency Medicine Algorithms: Vaginal Bleeding in Early Pregnancy. Western Journal of Emergency Medicine: IX, No. 1: Jan 2008; 47-51

  38. Algorithm Feier C. Clinical Emergency Medicine Algorithms: Vaginal Bleeding in Early Pregnancy. Western Journal of Emergency Medicine: IX, No. 1: Jan 2008; 47-51

  39. Management: Ectopic • Expectant • bhCG <1000 and declining • Ectopic mass < 3 cm, no fetal heart • Reliable • Medical • Methotrexate, various regimens • bhCG <15,000 • Reliable • Surgical Rhogam for Rh negative patients

  40. Management: Spontaneous abortion • Expectant • If bleeding is manageable and patient hemodynamically stable (< 1 pad per hour x 4 hours) • Surgical • D&C or manual vacuum aspiration Rhogam for Rh negative patients

  41. Management: Embryonic demise • Expectant • Success rate 29% by day 7 • Medical • Misoprostol pv (off label), various regimens • Success rate 87% by day 7 • For fetal size < 8 weeks • To ER if bleeding > 1 pad per hour x 4 hours • Surgical • D&C Rhogam for Rh negative patients

  42. Management: Subchorionic hemorrhage • Expectant • Assuming positive fetal heart • Bleeding can continue for weeks • Some will proceed to spontaneous abortion Rhogam for Rh negative patients

  43. Follow up issues • Follow bhCG down • Contraception (if desired) • Folic acid and/or prenatal vitamin • Psychological issues

  44. Psychological issues • Legitimize grief • Dispel guilt • Provide comfort and support • Reassurance about the future • Include partner Deutchman M, Tanner Tubay A, Turok D. Am Fam Physician 2009 Jun 1;79(11):985-992

  45. Resources • Perinatal Bereavement Services of Ontario • www.pbso.ca • Many hospitals have support services as well

  46. Take home points • Always rule out ectopic pregnancy • Urine bhCG is adequate for diagnosing pregnancy • In normal pregnancy, bhCG should increase by at least 66% in 48 hours • Transvaginal ultrasound should show gestational sac when bhCG > 1500 IU/L • Patients who are Rh negative require Rhogam for first trimester bleed • Be suspicious if pregnancy symptoms resolve before 12 weeks

  47. Questions?

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