20-25% pregnancies have PVB› ~50% of these have miscarriage

80% occur in first trimester

Miscarriage - classification› Threatened› Inevitable› Incomplete› Complete› Missed› Blighted ovum› Septic

Ectopic› Fertilized ovum that implants in a location other

than the fundus or body of the uterus› ~2% of pregnancies› Higher incidence in ED pts ~4-13%

Heterotropic› Concomitant intrauterine and extrauterine

pregnancy› Spontaneous pregnancy ~1/30000› High risk pregnancy ~1/300

There is only one Shagging! Things that increase the risk

Never believe a woman who says ‘I can’t be pregnant I use contraception’› See above risk factors

Never believe a woman who says ‘I can’t be pregnant I am not sexually active’› Especially if her mother is in the room

Never be fooled by the LMP All women with abdominal pain and/or PVB are

pregnant until proven otherwise› See above risk factors and rules for any doubt

Never believe a woman!

Pregnancy related› Miscarriage› Ectopic› GTD

Non pregnancy related› Urological› GIT› Gynaecological

?Pregnant If pregnant› ?intrauterine› ?viable› ?Rh status

Unstable› Treat shock

Hypovolaemic Cervical

Stable› History / Examination / Investigations› Specific management

Have they had a previous US Ectopic› Risk factors

PID / previous ectopic / tubal surgery / IUD / IVF / induced ovulation

Heterotropic pregnancy› Risk factors

Induced ovulation / IVF

Do you need to do a PV / speculum?› Yes - If significant pain / bleeding / cervical

shock› Otherwise if US is available then the utility of

PV is questionable› Other considerations

Cervical pathology - ?last PAP

Increases until ~10-12/40› Doubles every 48hrs (min rise 67%)

Serial levels more sensitive for detecting abnormal pregnancy› Decreasing levels indicate non viable pregnancy

Does not differentiate miscarriage from ectopic

› Rising levels decrease chance of miscarriage Risk of ectopic remains

Discriminatory zone› Level at which pregnancy should be visible on US

(different levels for TV and TA)› 1500 (TV) / 6000 (TA)

Traditional teaching› QβhCG <DZ

No US Serial hCG until DZ then US

› Miss ~50% ectopics at first presentation Risk of ectopic actually higher in symptomatic

pts with QβhCG <DZ >70% ectopics have abnormal rise / fall

Current Mx› US is first line investigation

TVUS› Highly accurate for IUP and ectopic

(sensitivities - 98% and 89.9%, specificities - 100% and 99.8%)

Aim to identify› GS location› GA

Mean sac diameter / CRL

› Viability FHR

Patients classified into› IUP

Follow up to assess viability

› Miscarriage Treatment - conservative / misoprostol / D+C

› Ectopic / probably ectopic Treatment – methotrexate / surgery

› Pregnancy of unknown location Early pregnancy not seen Ectopic Complete miscarriage

What now? QβhCG› >DZ – O+G referral› <DZ and pt well

f/u 48hrs for repeat hCG / US

Rhesus status› Rh-ve – anti D

Possibility of heterotropic pregnancy› Require exclusion of ectopic even if IUP

identified› Refer to KEMH

Generally after hours US will not be available (unless US qualified ED Consultant available)

If no previous US› Discuss case with KEMH O+G Reg regarding

appropriate timing of f/u› Worth doing QβhCG primarily for their f/u