Bleeding in Early Bleeding in Early PregnancyPregnancy

Max Brinsmead PhD FRANZCOGFebruary 2015

Margaret H is a 26 year old Para 1 Margaret H is a 26 year old Para 1 who has had one previous who has had one previous pregnancy. This was obstetrically pregnancy. This was obstetrically normal. She is healthy and a non normal. She is healthy and a non smoker. She has been trying to smoker. She has been trying to conceive for about 6 months and conceive for about 6 months and she presents at 6 - 7 weeks after she presents at 6 - 7 weeks after her LMP with symptoms of her LMP with symptoms of pregnancy and some dark vaginal pregnancy and some dark vaginal bleeding.bleeding.

A patient with 6-7 weeks A patient with 6-7 weeks amenorrhoea and PV bleedingamenorrhoea and PV bleeding

Do you require further history

Do you examine this patient

What tests do you request

A patient with 6-7 weeks A patient with 6-7 weeks amenorrhoea and PV bleedingamenorrhoea and PV bleeding

Further history that is desirable

Was the LMP a normal period

Usual cycle lengthHas pregnancy

been confirmedAny painPregnancy

symptoms still?Risk factors for

ectopic

Risk Factors for Ectopic Risk Factors for Ectopic PregnancyPregnancyPrevious ectopicPrevious tubal surgery

Includes tubal ligation And re anastomosis

PIDInfertilityAssisted conceptionIUCD for contraception

Risk Factors for Risk Factors for MiscarriageMiscarriageMaternal age

10% of pregnancies at age 25 But 33% of pregnancies for age >40

Previous miscarriageFamily history of miscarriagesSystemic disease

E.g. Diabetes, Hypertension, Renal, Autoimmune

SmokingInfertility or Assisted conception

A patient with 6-7 weeks A patient with 6-7 weeks amenorrhoea and PV bleedingamenorrhoea and PV bleeding

Examination that is desirable

Vital signsAbdominal palpation

for mass or tendernessVaginal inspection to

confirm uterine bleeding

Cervical dilatation and excitation are difficult signs to elicit

Any tissue removed from the cervix or vagina requires histology

A patient with 6-7 weeks A patient with 6-7 weeks amenorrhoea and PV bleedingamenorrhoea and PV bleeding

Desirable tests HB, Blood groupUrine test for HCG if

not done beforeUltrasound if >3

weeks from conception

Quantified beta HCG if <3w from conception or ultrasound not diagnostic

Other routine AN tests may be required

Scan report: Intrauterine sac with an identified Scan report: Intrauterine sac with an identified embryonic echo and evidence of fetal heart embryonic echo and evidence of fetal heart motion at a rate of 110/min. A normal decidual motion at a rate of 110/min. A normal decidual reaction is identified and a yolk sac is visiblereaction is identified and a yolk sac is visible

What is the prognosis for this pregnancy

Prognosis for a PregnancyPrognosis for a Pregnancy10 – 40% embryos transferred after IVF

50% of all embryos that implant

85% of patients with a positive HCG test

95% of those with a fetal heart at 6-8w

98% of those who make it to 12w

99% of those who make it to 20w

A 26 year GA 26 year G22PP11, healthy and a non , healthy and a non smoker. Bleeding at 6 – 7 w settles. smoker. Bleeding at 6 – 7 w settles. Blood group O Neg.Blood group O Neg.Advise next

steps

A 26 year GA 26 year G22PP11, healthy and a non , healthy and a non smoker. Bleeding at 6 – 7 w settles. smoker. Bleeding at 6 – 7 w settles. Blood group O Neg.Blood group O Neg.Desirable next

steps

Provide anti-D gamma globulin

Discuss first trimester tests for chromosomal disorders◦ For all patients

The best test is serum markers at 10-12w followed by ultrasound for nuchal translucency at 12 – 13.5w

Or Cell-free fetal DNA in maternal plasma

Scan Report: CRL equivalent to 12 weeks of Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the cm haematoma at the upper edge of the developing placenta which appears to reach to the developing placenta which appears to reach to the cervical oscervical osWhat do you tell

the patientIs this placenta

previaWhen would you

repeat the scanThe patient

requests “a test for spina bifida”. What would you recommend

Scan Report: CRL equivalent to 12 weeks of Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the cm haematoma at the upper edge of the developing placenta which appears to reach to the developing placenta which appears to reach to the cervical oscervical osWhat do you tell

the patient

There is a blood clot in the uterus that may cause some brown PV loss

The prognosis for the pregnancy is good

Although there is a small statistically increased risk of APH, IUGR and preterm delivery

Scan Report: CRL equivalent to 12 weeks of Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the cm haematoma at the upper edge of the developing placenta which appears to reach to the developing placenta which appears to reach to the cervical oscervical osIs this placenta

previaWhen would you

repeat the scan

NoA vaginal scan at 18

– 20 weeks is an excellent means of excluding the need for further scans if the placenta does not reach or overlap the internal os

A third trimester scan for growth is desirable for this patient

Scan Report: CRL equivalent to 12 weeks of Scan Report: CRL equivalent to 12 weeks of amenorrhoea. Normal fetal anatomy. There is a 5 amenorrhoea. Normal fetal anatomy. There is a 5 cm haematoma at the upper edge of the cm haematoma at the upper edge of the developing placenta which appears to reach to the developing placenta which appears to reach to the cervical oscervical osThe patient

requests “a test for spina bifida”. What would you recommend

Maternal serum AFP may be elevated by the earlier bleeding and the haematoma.

Most significant spina bifida can be excluded by ultrasound at 18 – 22 weeks given optimal imaging