Vaginal Bleeding in Pregnancy. Evaluation of First Trimester Bleeding. Implantation bleeding FIRST TRIMESTER BLEEDING 9/13/2011

Transcription

1 Vaginal Bleeding in Pregnancy Evaluation of First Trimester Bleeding Jackie Kazik, MA, PA C CME Resources CAPA Annual Conference % of all first trimester pregnancies Etiology often not determined May be normal i.e. implantation bleeding May be unrelated to pregnancy Cervicitis Goal exclude serious pathology Ectopic Molar pregnancy Implantation bleeding Occurs 5 12 days after conception (prior to positive HCG test) Lighter and shorter than normal pg Often mistaken for a period Unrelated to pregnancy outcomes FIRST TRIMESTER BLEEDING SPONTANEOUS ABORTION ECTOPIC PREGNANCY MOLAR PREGNANCY 1

2 Terminology of Abortion Spontaneous abortion Threatened abortion Inevitable abortion Complete abortion Incomplete/missed abortion Blighted ovum (anembryonic pregnancy) Habitual/recurrent abortion Definitions of abortion Threatened Ab Bleeding or cramping with closed cx in first half of pregnancy Inevitable Ab above with dilatation of cx Complete Ab all products have been expelled Incomplete Ab (missed) POC remain in uterus Anembryonic pg blighted ovum Habitual abortion three or more Ab s in succession think SLE, thyroid, etc Definitions of Abortion Missed abortion death of the fetus with no signs or symptoms of pregnancy loss Septic abortion uterine infection with POC in uterus SPONTANEOUS ABORTION Incidence ~20% each pregnancy Pregnancy loss prior to 20 weeks (500gm) PRIOR TO 6 WEEKS Most likely chromosomal abnormality AFTER 8 WEEKS More likely due to maternal factors Prognosis is good after, with 60% of patients having a viable pg next time 2

3 Risk Factors maternally related Age (50% rate > 45 y.o.) Structural anomalies Maternal infections Endocrine problems Autoimmune/coag problems Blood group incompatibility Severe malnutrition Toxins (lead, smoking, ETOH, caffeine>300mg/d), radn, anesthesia Risk factors pregnancy related Gestational age Subchorionic hemorrhage Gestational sac size Yolk sac Fetal cardiac rate HISTORY LMP AMOUNT & QUALITY OF FLOW DATE OF POSITIVE HCG PAIN? PREVIOUS AB S DIAGNOSIS Pelvic exam Cx dilated? Amount of bleeding Uterine size Pain with palpation Adnexal masses Orthostatic changes document if bleeding is heavy LABS shcg quantitative Rh & type Hemogram Progesterone (?) Ultrasound 3

4 Quantitative HCG Serial measurements Doubles q hrs (>66% in 48 hours) doubling? plateau? falling? Correlation with dates LMP/first positive EPT/uterine size Correlation with US findings HCG levels Gestational sac Yolk sac 5000 Cardiac activity 10,000 (?) 15,000 Ultrasound Normal 6 week pregnancy on US Gestational sac IUP? Yolk sac normal or abnormal? Embryo know what to tell the patient Embryo may not be expected If +FHB is seen 90 96% go to term Subchorionic bleeding 4

5 Normal pregnancy on US Anembryonic pregnancy on US TREATMENT Observe ABO Rh If Rh negative, give Rhogam within 72 hours Bleeding precautions D & C Management of the patient Bed rest does not prevent loss Pelvic rest is advised Even though nothing can be done, constant f/u with patient is warranted mainly for psychological reasons Anticipate complications/heavy bleeding 5

6 Incomplete Abortion Prolonged bleeding Check pelvic exam for open os Check CBC/ quant HCG D & C? Expectant management (up to 2 weeks) Followup HCG s Rhogam if Rh negative Recurrent Abortion 3 more consecutive pregnancy losses <20 weeks ~1% of patients Most likely due to Chromosomal factors Uterine abnormalities SLE or other autoimmune problems Thyroid disease ECTOPIC PREGNANCY RISK FACTORS FOR ECTOPIC PREGNANCY 1:250 1:87 15% of all maternal mortality 98% occur in the fallopian tube 2% other portions of cornua, cx, ovary, abd increased incidence with risk factors Risk factor Previous ectopic Tubal surgery BTL IUD Infertility DES exposure Previous STD Previous abd surgery Odds Ratio

7 Clinical Presentation Pelvic/abd pain 100% Tenderness on exam 80% Bleeding 75% Amenorrhea 74% Adnexal mass 50% DIAGNOSIS AWARENESS OF THE POSSIBILITY History Pelvic exam S HCG Ultrasound History High index of suspicion Same as for threatened abortion ALWAYS ask Q s related to risk ALWAYS ask about pelvic pain Physical Examination Orthostatic changes Pelvic exam DOCUMENT Abdominal pain Adnexal masses/pain Cervical motion tenderness Uterine size IF EARLY, exam may be NORMAL 7

8 DIAGNOSIS HCG >1500 with no IUP Pos. HCG/pelvic pain/vag bleeding 5 7 weeks pg HCG not doubling in pt with vag bleeding Potential in any pt with pos. HCG and pelvic pain DIAGNOSIS Ultrasound Evidence of DEFINITIVE intrauterine gestational sac excludes ectopic Pseudosac Empty uterus get HCG for correlation May need to repeat the history/pe daily Serial HCG s and US Normal uterus (no IUP) Decidual ring (and yolk sac) 8

9 Pseudo sac HETEROTOPIC PREGNANCY RARE 1:30,000 ECTOPIC PREGNANCIES HYDATITIDIFORM MOLE or Gestational trophoblastic disease (GTD) 1:1500 1:2000 pregnancies more common in pts >40 y.o. complete vs. partial historically diagnosed later potential for metastases DIAGNOSIS shcg high (hyperemesis common) uterus is large for dates vaginal bleeding Ultrasound typical US presentation Grape clusters 9

10 Ultrasound Findings TREATMENT Surgical evacuation Tissue to pathology Serial HCG s until negative X 1 yr Pregnancy contraindicated x 1 yr No contraindication to OCP use Very slight increased risk of mole again CXR Case One What do you do next? 38 y.o. WF G2 P1 AB0 L1 phones clinic 4/2/02 with c/o bleeding since 3/27/02, increasing in amount in past two days. Urine EPT positive at home. Currently nursing an 8 mo. infant, recalls a single menses 2/2/02. Two days of bleeding on 3/2/02, but very light. PMH noncontributory 10

11 Pelvic Exam Cx is closed, small amount of dark red blood Uterus 6 8 week sized No adnexal fullness, masses or tenderness HCG 30,000 RH & Type AB pos What labs would you order next? What would you like to order next? Ultrasound Findings Case Two PK is a 32 y.o. WF G1 P000 with positive HPT and dark spotting for 3 days. LMP 12/?/05 only menses since stopping ocp s in October no condoms since January PMH hypothyroidism last TSH 9/05, on Synthroid 0.05 mgm. What would you like to do next? 11

12 Abd/Pelvic Exam Abdomen nl BT s, nontender Spec exam cx closed, small amount of dark red blood Pelvic exam 8 weeks sized uterus, nontender, mobile. No adnexal fullness, masses or tenderness What labs do you want to order? Laboratory Results H/H 14.3/42.2 nl indices TSH RH & Type O positive SHCG quant 15, 291 What would you like to order next? Ultrasound Report Uterus measures c/w 6 weeks gestation Intrauterine gestational sac seen Yolk sac slightly enlarged Embryo noted, c/w 5.4 weeks, no evidence of cardiac motion Observation Suction D & C Management/followup After D & C or passage of POC f/u HCG until negative What do you recommend? 12

13 Case Three AB is a 29 y.o. WF G3 P1011 LMP 6 w 6 d by dates (nl menses) c/o RLQ pain since last night Pain is sharp, severe, no radiation Vaginal spotting for 2 weeks, on & off PMH, SHx noncontributory No meds, NKDA OB history NSVD SAb at 6 weeks No STD history No tubal surgery, no previous pelvic sx h/o infertility x 6 years, HSG nl tubal patency 6 years ago What do you do next? What OB history do you want to ask? Abd/Pelvic Exam Abdomen nl BT s, soft, nontender with mild RLQ pain no masses Spec exam closed cx, small amount of dark red blood Biman uterus 4 6 weeks size, firm, mobile no CMT Pos R adnexal tenderness, difficult to assess secondary to guarding WBC 8,400 with nl diff H/H 13.2/38.9 RH & Type O neg SHCG quant 1,280 What do you order next? What labs do you want to do next? 13

14 Ultrasound Findings Ultrasound Report No IU gestational sac noted Moderate free fluid Complex R adnexal mass (5.2 cm) with (+ ) FHB 120 within mass What do you recommend? Salpingostomy vs. Methotrexate Rhogam Followup? Case Four EH is a 22 y.o. WF who phoned our office on 2/11/99 with c/o brown vaginal discharge for 2 d, only following coitus. G 1 P000 LMP 12/28/98 regular 6w3d by dates HPT positive 2/10/99 PMH noncontributory No meds, NKDA What do you want to do next? 14

15 Pelvic exam Cx closed, moderate amount dark brown blood Pelvis 12 week sized globular uterus with soft tissue mass palpable anterior to uterus Ovaries not palpated. No adnexal tenderness on exam What do you want to order next? Labs H/H 14.4/42.8 nl indices RH & type A pos SHCG quant 123,044 What do you order next? Ultrasound Findings Ultrasound Report Uterus enlarged with 23 mm. endometrial complex; no gestational sac seen Multiple fluid collections in grape like clusters Large fluid filled cyst 5.46 x 4.90 cm. anterior to uterus 15

16 What followup does this patient need? D & C CXR HCG weekly until zero: then q. mo. X 1 year 16