Pain &/or Bleeding in Early Pregnancy

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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