Pain &/or Bleeding in Early Pregnancy

<Presentations>

<Index>

Definition

- Pain &/or vaginal bleeding in early pregnancy up to 14 weeks gestation

Features

- Some pain &/or bleeding is common in 1st trimester

- Must exclude ectopic pregnancy

DDx

- Live pregnancy

- Ectopic pregnancy

- Pregnancy of unkown location (PUL)

- Miscarriage

- Gestational Trophoblastic Disease (Hydatiform mole..)

Associated S/S

- Vaginal bleeding

- Onset/provocation: post-coital/VE (usually small volume)

- Volume: pads, clots

- Abdominal pain/Pelvic pain

- +/- lower back

- Acute abdomen

- Shock

- Ruptured ectopic

- Significant bleeding

Ix

- Beta HCG

- Confirm pregnancy

- Determine pattern

- FBE

- Hb: anaemia

- G&H

- To determine need for Anti-D (unlikely <12 weeks)

- Cross match for Blood Transfusion

- Abdo exam

- Assessment of gravid uterus

- Acute abdomen: Ruptured ectopic

- +/- Urine (first void): Chlamydia

- +/- Speculum exam if heavy bleeding (>2 pads/hr)

- POC: miscarriage

- +/- HVS for Chlamydia

- +/- VE if abdominal/pelvic pain

- Adnexal mass or tenderness: ectopic

- Uterine size: if palpable >14/40

- Cervical excitation

- TV US

- If nil previous US w positive Beta HCG must exclude ectopic & confirm intrauterine pregnancy

- If patient stable & immediate Mx of ectopic not indicated

- If Beta HCG

- <1,500 unlikely to see gestational sac therefore cannot exclude ectopic

- <10,000 unlikely to see foetal heart therefore cannot DDx miscarriage from live pregnancy

- If intra-uterine gestational sac identified

- With foetal pole

- & foetal heart rate detected: live pregnancy

- & foetal heart rate not detected

- Foetal pole >6mm: missed miscarriage

- Foetal pole <6mm: inconclusive (missed miscarriage or early pregnancy)

- Without foetal pole

- & sac >20mm: missed miscarriage

- & sac <20mm: inconclusive (missed miscarriage or early pregnancy)

- If POC passed

- Empty uterus: complete miscarriage

- POC in uterus: incomplete miscarriage

- If no evidence of pregnancy (ectopic or intrauterine) = unsited pregnancy

- POC to histology

- +/- Foetal heart rate doppler

- Indicated if suspected >14/40 &/or uterus palpable abdominally

Mx

- +/- Resuscitation

- IV access

- IV fluids

- +/- Blood Transfusion

- If <6 weeks gestation & Beta HCG <10,000: repeat US + Beta HCG in 48-72hrs

- As per Dx

- Ectopic pregnancy: laparoscopy, laparotomy

- Miscarriage

- Unsited pregnancy

- Repeat Beta HCG in 48hrs

- If doubles repeat US when >1500

- If slow rise, plateau, falls or fluctuates reassess for ectopic & miscarriage

- Assess for Anti-D

- Usually not indicated <14/40 gestation

References

RWH CPG: Pain & Bleeding in Early Pregnancy, 7/10/2010