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Bleeding and pain in early pregnancy

Bleeding and pain in early pregnancy. May 2012 Judith ten Hof. Bleeding and pain in early pregnancy. Introduction What’s new? Recurrent miscarriage. Bleeding & pain in early pregnancy. Any vaginal bleeding / pain in first trimester Variation in presentation Diagnosis:

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Bleeding and pain in early pregnancy

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  1. Bleeding and pain in early pregnancy May 2012 Judith ten Hof

  2. Bleeding and pain in early pregnancy • Introduction • What’s new? • Recurrent miscarriage

  3. Bleeding & pain in early pregnancy • Any vaginal bleeding / pain in first trimester • Variation in presentation • Diagnosis: • Viable intra-uterine pregnancy • Non viable intra-uterine pregnancy • Ectopicpregancy • Bleeding due to other causes

  4. Bleeding in early pregnancy • 137.000 women in England/yr • 1 in 5 (clinically confirmed) pregnancies • 50-60% successful pregnancy outcome • 25-30% miscarriage • 10-15% ectopic pregnancy • 8-31% location of pregnancy not clear at first assessment

  5. Pregnancy loss • 50.000 in patient admissions in UK annually • 15-20% of confirmed pregnancies end before 13th week • 2003-2005 10 deaths from ectopic pregnancy in UK • (mat mortality rate 0.47-100.000 maternities) • 2/3 substandard care • Significant impact on physical and mental health and emotional wellbeing

  6. What’s ‘new’ • Terminology • Development of early pregnancy units • Increase in ultrasound expertise • Use of -hCG qualitative assessments • Conservative management options • Nice guidance in progress: ‘a clinical guideline on the assessment and initial management, both physical and emotional, of pain and bleeding in the first trimester of pregnancy’

  7. Terminology • Abortion miscarriage • Spontaneous abortion  Spontaneous miscarriage

  8. Early pregnancy units • Clinical and economical benefit • 40% admission avoided, 20% reduction length of stay • Easily accessible • Ultrasound (abdominal and transvaginal) • -hCG quantitative assessments • Management options early pregnancy complications • Chlamydia screening < 25yrs • Anti-D prophylaxis

  9. Ultrasound

  10. Ultrasound

  11. -hCG assessments • Detection of human chorionicgonadotropin • Urine test from hCG25 iu/l (9 days post conception= cycle day 23-25) • Serum test for quantitative assessments • 1000-2000 iu/l visualisation of pregnancy • Serial testing : • Doubling 48-72hrs in 85% normal pregnancies • Suboptimal rise/plateau • Decline >20% complete miscarriage

  12. Management miscarriage • Expectant • Successful 2-6wks in 60-90% of women • Heavy bleeding • FU urine HCG • Medical • Mifepristone + Misoprostol • Succesful in 60-90% of women • Surgical evacuation • Succesful in 95-100% • Suction evacuation

  13. Management ectopic pregnancy • Surgical: • Majority laparoscopic • Salpingotomy salpingectomy • Conservative: • Low and declining -HCG levels (<1000) • Risk tubal rupture • Medical: methotrexate • -HCG levels<3000 IU/l • > 1dose in 14% • Risk tubal rupture (7%) • Pregnancy not advised < 3months

  14. Recurrent miscarriage •  3 consecutive miscarriages • Risk factors/causes: • Maternal & paternal age • Previous miscarriage • Antiphospholipid syndrome: APL antibodies in 15% • Balanced structural chromosomal abnormality: 2-5% • Chromosomal abnormality fetus 30-57% • Uterine abnormality • Cervical weakness • Endocrine disorders: DM, thyroid, PCOS

  15. Recurrent miscarriage • Antiphospholipid antibodies: • To diagnose: 2 pos tests > 12 wks apart • Thrombophiliascreen • Karyotyping: • Both partners • Cytogenetic analysis products of conception • Ultrasound uterus • Recurrent miscarriage clinic

  16. Involvement primary care • Initial presentation • Confirm pregnancy • Triage • If needed: • refer directly to EPAU (not via A&E) • For USS only if >6-8 wks pregnant • Aftercare

  17. Management in primary care AAFP (Am Ac Fam Physician) July 1 2011 Vol. 84 No. 1

  18. Case 1: Ms R, 34 yr old • P2 (1 VD & 1CS) • LMP: 8wks ago, pregn test 3 wks ago • Intermittent brown discharge since 1 wk • Pain RIF since yesterday: ’getting worse’ • O/E: • pregn test +, BP and pulse nl • Abdo soft, painful RIF • P/S: brown discharge, nl cervix • V/E: very tender R adnexa • Plan: • P2 (1 VD & 1CS) • LMP: 8wks ago, pregn test 3 wks ago • Intermittent brown discharge since 1 wk • Pain RIF since yesterday: ’getting worse’

  19. Case 2: Ms W, 28 yrs • G1P0, • LMP: 6 wks ago on COCP. (Stopped pill). • Vaginal bleeding on wiping this morning • No pain • O/E: • pregn test +, • Abdo soft, painful RIF • P/S: brown discharge, nl cervix • V/E: non tender • Plan:

  20. Case 3: JM, 22 yr old • G2P0+1 TOP, planned pregnancy • LMP 10 wks ago • H/O PID • Came 2 days ago with minimal PV bleeding • App USS tomorrow • Bleeding heavier • Collapses in the surgery

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