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Bleeding in Early Pregnancy
Bleeding/pain in early pregnancy is the most common gynae emergency
40% of pregnancies will have some bleeding
DDXs
Viable causes
Implantatin bleed – bleeding at tme of implantatonn usually when period would have been due. Painless and
unprovoked. Small amount of spotng. No interventon required.
Genital causes – e.g. STIsn polypsn fbroidsn endometriosis
Non-viable causes
Miscarriage (missedn inevitablen incomplete)
Ectipic pregnancy
Gestatinal triphiblastc disease – a spectrum of abnormal growth and proliferaton of trophoblasts that can
contnue even beyond end of pregnancy e.g. oolar Pregnancy or oalignancy
Diagnosis
Women may be sent to the EPAU (Early pregnancy assessment unit) for investgaton - a specialist unit in the hospital
dealing with common problems in early pregnancy such as:
- Vaginal bleeding
- Abdiminal pain
- Those with previous ectopics
- Those with previous molar pregnancies
- Those with recurrent miscarriages
A doctorn nurse or midwife will arrange an appointment with the EPAU if you ft any of the above criterian have had a
positve pregnancy testn and are 6-16 weeks pregnant.
The visits will last approximately 15 minutes and consist of
o a thiriugh histiry (usually by a nurse)
o an ultrasiund scan (by a specialist nurse or sonographer) - transvaginal if week 6-12n transabdominal if
week 12-16.
o ~Further bliids (hCG +/- prog)
Hx
- Risk factors for causes
- Nature of bleeding
- Associated pain
- Associated bladder or bowel symptoms
Examine
- Basic ibs – haemodynamically stable/unstable?
- Abdi – tenderness? Guarding? Increased uterine size?
- VE & Speculum– Os open/closed? Products of concepton? Cervical excitaton? Adnexal tenderness?
Investgatons
- Urine pregnancy test (hCG)
- FBC
- TVS/TAS USS
o TVS - Can visualise a normal pregnancy at >1500-2000mIU/ml (usually untl ~week 12)
o TAS – Can visualise a normal pregnancy at >6000mIU/ml (better for visualisaton afer week 12)
- Serum hCG monitoring (+/- prog)
o Every 48hrs:
>66% rise = viable IUP
>50% fall = nin-viable
Somewhere in between = IUP if uncertain viability (refer to EPAU within 24 hours).
o Discriminatory level:
= hCG level above which the gestatonal sac (GS) of an IUP should be visible on ultrasound
hCG >1000–1500 IU/L TVS GS visible? (yes = viablen no = non-viable)
hCG >6000 IU/L TAS GS visible? (yes = viablen no = non-viable)
- If uncertain Diagnistc lapariscipy
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