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EARLY PREGNANCY PAIN AND BLEEDING

EARLY PREGNANCY PAIN AND BLEEDING. Part 1. Early pregnancy problems. Cornerstones of diagnosis are: history and examination hCG transvaginal ultrasound. Human Chorionic Gonadotrophin ( hCG ).

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EARLY PREGNANCY PAIN AND BLEEDING

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  1. EARLY PREGNANCY PAIN AND BLEEDING Part 1

  2. Early pregnancy problems Cornerstones of diagnosis are: • history and examination • hCG • transvaginal ultrasound

  3. Human Chorionic Gonadotrophin (hCG) • Glycoprotein with  and  sub-units linked by disulfide bond ( same in all glycoprotein hormones inc. FSH, LH, TSH;  subunit confers unique biological activity and specificity in radioimmunoassays) • Secreted by syncytiotrophoblast of the chorion • Prevents degradation of the corpus luteum (Corpus luteum produces progesterone and some oestrogen which causes the endometrial glands to prepare for implantation of the blastocyst)

  4. hCG Interpretation Early Pregnancy • Initially rises exponentially and after 6 weeks (>6000-10000 mIU/mL) more slowly • “Doubling time” useful in first 6 weeks • 66% considered to be minimal rise in 48 hours for normal intrauterine pregnancy (85% confidence interval ie. 15% normal pregnancies have less than this rise & 15% ectopics have this rise)

  5. Plateauing hCG suggests ectopic • Falling hCG - rate importantHalf life less than 1.4 days – rarely ectopicHalf life more than 7 days – most predictive of ectopic • Single level – useful only as indication for expected ultrasound findings (depending on quality of ultrasound service) • 3-100 x higher than normal pregnancy levels in gestational trophoblastic disease

  6. Ultrasound Findings (T/V) Early Pregnancy

  7. Gestational sac >13mm without yolk sac or >17mm without embryo means a non-viable pregnancy

  8. Progesterone Assays • Not very useful • >25ng/mL – likely viable intra-uterine pregnancy • <5 ng/mL – abnormal pregnancy but don’t know if intra- or extrauterine • Most between 10 and 20 with early pregnancy bleeding/pain

  9. Early Pregnancy Bleeding • Differential diagnosis:Miscarriage/abortion (intra-uterine pregnancy)Ectopic pregnancyOther – cervical polyps, vaginitis, trauma, foreign body, cervical carcinoma, gestational trophoblastic disease (molar pregnancy)

  10. Abortion

  11. Abortion • Spontaneous:20-30% of all known pregnancies (80% in 1st trimester). If pregnancy failure has occurred, usually before 8 weeks • Threatened:30-40% all pregnanciesSmall PV lossUterine size =datesOs closedFetal heart seen or too early to be seen

  12. Abortion • Missed:Uterine size < datesOs closedMay not have bleeding at firstFetal pole with no fetal heart • Inevitable:Heavy PV loss, usually clotsCervix openInitially no products passed • Incomplete:< 6 weeks usually fetus and placental tissue passed together vs >6 weeks

  13. Causes of Miscarriage • Blighted ovum (fertilised but anembryonic) • Chromosomal anomalies • Embryonic anomalies • Uterine anomalies • IUD • Teratogens (any agent which affects the developing embryo) • Mutagens (any agent which changes the DNA of germ cells) • Maternal disease • Placental abnormalities • Trauma

  14. Management Early pregnancy bleeding • History and examination • hCG +/- ultrasound • (ALWAYS DO A PREGNANCY TEST FOR BLEEDING FEMALE IN REPRODUCTIVE AGE GROUP) • ALWAYS THINK ABOUT ECTOPIC • ALWAYS CHECK BLOOD GROUP

  15. Management options • Threatened – observe • Missed – suction curettage • Inevitable or incomplete – expectant if stable or suction curettage or misoprostil

  16. Ectopic Pregnancy • Next week…

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