Bleeding in Pregnancy

Ectopic pregnancy

H/O suggestive of ectopic pregnancy :

Abdominal pain
PV bleeding
Amenorrhoea
Previous ectopic pregnancy
IUD in situ
Previous abdominal/pelvic surgery
Previous h/o of PID


Examination :

Pallor
Dehydration
Tachycardia
Hypotension
Tender abdomen
Os is closed
Cervical excitation*

*positive cervical excitation = by moving the cervix sideways, patient complaints of sharp pain

Urgent investigations

FBC
BUSE
PT/INR
Blood grouping and Cross matching - 2 pints
USG abdomen

Management

Insertion of 16G or at least 18G of IV cannula
Fluid resuscitation/Blood transfusion
Nil by mouth

USG report :

a) Intrauterine pregnancy

Booking for Antenatal checkup to be done

b) Missed/Incomplete Miscarriage

Elective removal or products of conception (ERPOC)

c) No gestational sac seen

If haemodynamically stable, symptoms persist :

Perform diagnostic laproscopy
Proceed from here

If haemodynamically unstable :

If tube is extensively damage, where risk of recurrence is high during next pregnancy, perform salpingectomy.

If not, tube can be conserved and only removal of the ectopic is performed : salpingostomy.

Molar pregnancy

Classification

a) Hydatidiform mole (Complete and partial mole)
b) Invasive mole
c) Persistent trophoblastic disease
d) Choriocarcinoma

Histology

Hyperplasia of the trophoblastic tissue with hydropic swelling (grape-like structures)

Incidence

In Malaysia, 1 in 300 pregnancy (0.3%) - rare
Few times more common in Western Countries
Age group : <20 and >40

Clinical features

Amenorrhoea
PV bleeding with/without passage of vesicles
Large for dates
Hyperemesis gravidarum
Hyperthyroidism
PIH <20 weeks of gestation

Investigation :

Diagnosis of Molar pregnancy is by high index of suspicion :

a) B-hCG level : >320,000 IU/L after 14 week of gestation
b) USG findings : Snow-strom appearance, 30% of them associated with Theca Lutein cyst

Differential diagnosis

a) Missed miscarriage
b) Tangential view of placenta
c) Early pregnancy with myoma

Treatment

a) Dilatation of Curettage - removal of products of conception
b) 40 mg of Pitocinin in 500 ml of normal saline given as IV infusion during D & C
c) IM ergometrine if uterus is not well contracted
d) Watch out for complications :

Uterine rupture
Haemorrhage
Pulmonary embolism
DIVC

Work-up/Other investigations :

FBC
BUSE
Coagulation profile
Chest X-ray
Cross match 2 pints of blood

Follow-up :

2 weekly follow-up till b-HCG value is normal.
Then, TCA monthly for 6 months, 2 monthly for 6 month, 3 monthly for 6 month, 6 monthly till 2 completed years without complications

During each follow-up :

a) Full h/o includes amenorrhoea, uterine bleeding, hemoptysis
b) Full physical examination
c) Vaginal examination
d) b-HCG level : if levels are persistently elevated for 2 months interval - discuss with specialist, chemotherapy may be started
e) CXR and USG if indicated
f) Contraceptive counselling : Barrier methods used till b-HCG level is normal, OCP can be taken

Miscarriage

Defined as extraction/expulsion products of conception, weight <500gm before 24 weeks of gestation





For those with :

2 episodes of miscarriages in 1st trimester
OR
1 episode of miscarriage in 2nd trimester

subjected for investigation :

Karyotyping for both parents and fetus
USG pelvis to search for abnormalities
Connective tissue disease screening

Aetiology of miscarriage :

1) Fetal factors

Chromosomal defects - not compatible with live
Structural defects - neural tube

2) Maternal factors

Diabetes
Thyroid dysfunction
Connective tissue disease
Infection - TORCH or Bacterial vaginosis
Smoking
Alcohol intake
Congenital anomalies (biseptate, bicornuate, double uterus, etc)
Submucous myomas that distorts uterus (prevent proper implantation)

Category: Obstetrics Notes