Anna Smith, a 24-year-old para 0+1 is brought in to the early pregnancy assessment unit by her husband with fresh vaginal bleeding. Her last period was 6 weeks ago. She is very anxious as she had a similar episode in a previous pregnancy and miscarried.
What should you do on initial assessment?
You need to ensure that Mrs Smith is haemodynamically stable (ổn định huyết động). This initial assessment follows the basic principles of ABC. You must assess her bleeding. If she is bleeding heavily (chảy máu nhiều) and is tachycardic (nhịp chậm) or hypotensive (hạ huyết áp) then IV access should be obtained along with fluid replacement before obtaining a detailed history.
What differential diagnosis immediately comes to mind?
• Miscarriage
• Delayed period
• Ectopic pregnancy
• Molar pregnancy
• Cervical lesion
What would you like to elicit from the history?
History of presenting complaint
1 Bleeding
a. Amount and colour of bleeding
b. History of passage of any fleshy tissues/clots
c. How long she has been bleeding?
2 Pain
a. Is bleeding associated with pain?
b. Site, severity, type and radiation of pain
c. History of shoulder tip pain
3 About menstrual cycle
a. When was her last menstrual period?
b. How regular were the cycles?
c. Was she planning the pregnancy?
d. Has she carried out a pregnancy test?
4 Contraceptive history
5 Previous obstetric history
Outcome of the previous pregnancy (miscarriage, ectopic)
6 Past history
a. Previous pelvic inflammatory disease
b. Sexually transmitted infections
Mrs Smith tells you that she had noticed fresh red blood which was only spotting on wiping herself. It was associated with cramping lower abdominal pain. She describes the pain as mild in intensity, non-radiating and present for the last hour. She has not taken any analgesic as yet. A urine pregnancy test which she did at home 2 days ago was positive. She has a regular κ = 5/30–35 day cycle. Her last period was 6 weeks ago.
Her previous pregnancy was a spontaneous conception 8 months ago. Unfortunately, she had a miscarriage at 7 weeks after an episode of spotting at 6 weeks’ gestation. She is terrified that this is going to happen again. She and her partner have been trying to conceive since her last miscarriage.
What would you look for in physical examination?
General examination
Pallor, tachycardia and hypotension can be found with very heavy bleeding but this is uncommon.
Abdominal examination
After your initial assessment, you need to do an abdominal examination to detect any palpable mass. Any point of tenderness, guarding or rigidity should be elicited. Tenderness and guarding can be present in cases of ectopic pregnancy because of intraperitoneal bleeding.
Molar pregnancy can present with uterine size more than the period of gestation but is now usually diagnosed on ultrasound scan before this stage.
Pelvic examination
Look for signs of bleeding and assess how much she is bleeding. If she is wearing a pad, note if the pad is soaked or if her underwear is stained. You should note if there is active bleeding with blood trickling as this is a sign of a significant bleed.
Speculum examination
• Gently insert the speculum and see if there is bleeding in the vagina
• Use a sponge on sponge holder to see if there is any fresh bleeding
• If bleeding is seen you need to identify if it is heavy
• Check the cervical os: look to see whether the external os is open or closed and look for any products of conception
• Check for any local lesion such as a polyp or cervical erosion
What is the clinical significance of the cervical os and the bleeding?
Inevitable miscarriage -> There is persistent bleeding. Ballooning of the cervix results from products of conception in the cervical canal and the external os is open. The process is inevitable miscarriage and this is irreversible.
Incomplete miscarriage -> There is a history of heavier bleeding with passage of clots or products of conception. The external os is open and products can be removed.
Missed miscarriage (early fetal demise) -> If bleeding is present, it is likely to be a dark brown discharge and the os is closed. This may also be the situation in ectopic pregnancy.
Now review your clinical findings.
She had her last miscarriage when she was on holiday, and no hospital records are available. At present she is haemodynamically stable. She does not look pale and her pulse is 70 beats/minute. She is up to date with her cervical smears and the last one, taken 2 months ago, was reported as normal.
Her uterus is not palpable on abdominal examination.
There is tenderness in the suprapubic area but there is no
guarding or rigidity. The cervical os is closed and there is a
small amount of fresh blood on her pad. No further
bleeding can be seen from the external os. Her cervix is long
with no evidence of ballooning. Bimanual examination does
not reveal any mass or tenderness.
What investigations would you do?
1 Full blood count. A full blood count will assess if she has had a significant blood loss.
2 Blood group and save. Because she had her last miscarriage elsewhere we do not have any records of her blood group. You need to identify if she is rhesus negative as if she has further heavy bleeding she may require transfusion.
To summarize findings so far, Mrs Smith is spontaneously
pregnant for the second time with 6 weeks’ amenorrhoea,
vaginal bleeding and lower abdomen pain. There is no
history of passage of clots or products of conception. Her
pregnancy test is positive. She is haemodynamically stable.
Pelvic examination reveals no active bleeding and a closed
cervical os. There is no abdominal tenderness, guarding or
rigidity.
What will you do next?
An ultrasound scan of her pelvis. This should be transvaginal to obtain a clear view of the uterine cavity and its
contents at her early gestation. You should warn her that
we might not be able to see a pregnancy even with a
transvaginal scan, even if it is intrauterine, because of her
early gestation. Although she gives a history of 6 weeks ’
amenorrhoea, she may be only 5 weeks ’ pregnant as her
cycle length is 30 – 35 days. Explain that transvaginal
ultrasound is not harmful to pregnancy and by itself will
not cause a miscarriage.
Pelvic ultrasound scan
A viable pregnancy can be seen from 5 weeks by transvaginal scan. A pelvic ultrasound scan of the pelvis is
helpful in ruling out ectopic pregnancy. The presence of
an intrauterine pregnancy almost always rules out ectopic
pregnancy. There is a 1 in 40,000 chance of a heterotrophic pregnancy (both an intrauterine and an extrauterine
pregnancy) in a spontaneous conception.
What ultrasound features would you
look for to diagnose a pregnancyrelated cause for her bleeding?
Ectopic pregnancy
If the uterine cavity is empty or if there is no definite sign
of intrauterine pregnancy (presence of at least a yolk sac
or fetal pole), you need to consider ectopic pregnancy. A
pseudogestational intrauterine sac is seen in 10 – 20% of
cases of ectopic pregnancy. There is a collection of fluid
inside the uterine cavity as a result of inflammatory reaction to the pregnancy hormones. There are subtle differentiating signs like contour of the sac, presence of a
double ring and eccentric position which favours the
diagnosis of a true sac rather than a pseudosac. However,
the presence of a yolk sac is a sign of true intrauterine
gestational sac and therefore intrauterine pregnancy.
Other features of ectopic pregnancy on ultrasound are a
complex adnexal cystic mass and free fluid in the peritoneal cavity (Box 1.1 ).
Ultrasound features of a viable pregnancy
In addition to the presence of an intrauterine gestation
sac with yolk sac and fetal pole, there should be presence
of a fetal heart (seen pulsating) to call it a viable
pregnancy.
Ultrasound features of molar pregnancy
The uterus is enlarged in size and reveals the classic
snowstorm appearance of mixed echogenic appearance
indicating hydropic villi and intrauterine haemorrhage.
The β human chorionic gonadotrophin (βHCG) level
can be markedly raised. Large benign theca lutein cysts
(caused by ovarian stimulation with βHCG) are seen in
20% of cases.
Her pelvic ultrasound scan reveals a thickened endometrium.
A very small 2-mm sac is seen which cannot be
differentiated from a pseudosac. There was no evidence of
fetal pole or yolk sac. Her right ovary is normal and the left
ovary shows a 2 × 2.5cm cyst. There is minimal free fluid in
the pouch of Douglas and an ectopic pregnancy cannot be
ruled out.
Can you explain her pelvic
scan findings?
You cannot detect a definite sign of intrauterine pregnancy. It may be that it is a very early pregnancy or an
Figure 1.1 Pelvic ultrasound scan of an intrauterine pregnancy.
Box 1.1 Early embryology
Implantation in the uterine cavity occurs around cycle day
21, once the blastocyst enters the uterine cavity. Once the
blastocyst comes in contact with decidualized
endometrium, the trophoblast proliferates and
differentiates into two layers: cytotrophoblast and
syncytiotrophoblast (cells in contact with endometrium).
Two layers of cytotrophoblast are separated by
extraembryonic mesoderm
Gestational sac
A gestational sac is usually imaged as a round or oval
anechoeic structure and can be seen as early as 20–23
days after ovulation. This develops from isolated spaces in
the extraembryonic mesoderm fusing and forming a simple
fluid-filled cavity that contains amnion, yolk sac and
embryo
Yolk sac
Yolk sac, a spherical structure, develops on cycle day 28,
when the extracoelomic membrane extends completely
around the inner wall of the blastocyst forming a
secondary cavity. It can be seen on transvaginal scan by 5
weeks. When present, the yolk sac confirms the diagnosis
of intrauterine pregnancy
KEY POINT
An empty uterus on scan might represent a complete
miscarriage, very early intrauterine pregnancy or an ectopic
pregnancy
ectopic pregnancy. The cyst in the left ovary is probably
a corpus luteum. Hence you need to investigate further.
What further investigation would you
do now?
Although she has a positive urinary pregnancy test, an
ectopic pregnancy cannot be ruled out on ultrasound and
a serum βHCG is advised.
Explain to her the rationale for
a serum βHCG?
See Box 1.2 .
Now review her test results
βHCG result shows a value of 412IU/L and her blood group
result shows that she is group O rhesus negative. Her full
blood count is normal.
What information do you need to give
to her?
• Despite high resolution ultrasound, you may not be
able to see evidence of intrauterine pregnancy at transvaginal ultrasound scan as the levels of βHCG are less
than 1000 IU/L
• A level of 1000 IU/L is taken as a discriminatory level
to be able to see an intrauterine gestation sac
• A repeat βHCG in 48 hours will help in this case to
determine whether it is an ongoing pregnancy or not
• A single βHCG gives very limited information unless
the levels are high
What is the clinical significance of her
being rhesus negative?
Non - sensitized rhesus - negative women need to receive
anti - D immunoglobulin in the following situations to
prevent the development of anti - rhesus antibodies:
• Ectopic pregnancy
• All miscarriages over 12 weeks ’ gestation (including
threatened)
• All miscarriages where the uterus is evacuated (whether
medically or surgically)
• Threatened miscarriage under 12 weeks ’ gestation only
when bleeding is heavy or associated with pain
• Complete miscarriage under 12 weeks ’ gestation only
when there is formal intervention to evacuate the uterus
Does Anna require anti-D
immunoglobulin?
She does not need anti - D immunoglobulin in her present
situation but once a diagnosis has been made this may
need to be reviewed. She can go home and return after
48 hours.
She returns 48 hours later for a repeat βHCG having had a
further episode of spotting in the morning. The repeat blood
test shows a value of 880IU/L.
Review all your differential diagnoses
Threatened m iscarriage. This is the most likely diagnosis
so far. There is only a small amount of bleeding, the
cervical os is closed and βHCG has doubled in 48 hours.
Inevitable m iscarriage. Incomplete miscarriage means that
the process of miscarriage has started and some products
of conception have been expelled while the rest still
remains. This is unlikely in this case as the os is closed and
bleeding has stopped (apart from one episode of spotting).
In inevitable miscarriage, women continue to experience
cramping abdominal pain as the uterus is contracting and
trying to expel the products. Moreover, the bleeding continues, gradually becoming heavier and you would see an
open os on speculum examination. Although threatened
miscarriage can progress to inevitable miscarriage, at
present in this case there are no such signs.
Box 1.2 β subunit of human chorionic
gonadotrophin
• This is a glycoprotein consisting of α and β subunits
secreted by trophoblast tissue which gives us an idea of
where the pregnancy is
• The βHCG should double in 48 hours in cases of an
ongoing intrauterine pregnancy
• It rises, but less than double, in ectopic pregnancy
(66%)
• If it falls to half in 48 hours it suggests miscarriage
• In 15% of normal intrauterine pregnancy the βHCG will
rise less than double
• In 15% of ectopic pregnancies, a doubling will be seen
in 48 hours
• Failure of βHCG to double in absence of an intrauterine
pregnancy suggests the diagnosis of ectopic pregnancy
• In cases of molar pregnancy, very high levels of βHCG
can be seen
• When considering the test results, the whole clinical
situation must be taken into consideration
Incomplete m iscarriage. This is unlikely as Mrs Smith
does not give a history of passing clots or products of
conception. Moreover, the βHCG has doubled, indicating it is an ongoing pregnancy. In the case of miscarriage
it should decrease, ideally to half in 48 hours. There is a
risk of infection if products are left.
Complete m iscarriage. This could be a possibility as the cervical os is closed and bleeding has stopped. However, there
is no history of passage of clots or products of conception.
Missed m iscarriage. This was a possibility initially but it
was ruled out with the doubling βHCG. As the pregnancy
stops growing, the βHCG levels will reduce. The symptoms of pregnancy may disappear.
Recurrent m iscarriage. This is defined as the loss of three
or more pregnancies consecutively. It affects 1% of women.
In this case there is only one previous miscarriage, hence
investigations for recurrent miscarriage (karyotype of both
partners; lupus anticoagulant; anticardiolipin antibodies;
thrombophilia screen) are not needed.
Ectopic p regnancy. Although initially plausible, this is
unlikely as βHCG is doubled in 48 hours and there are no
risk factors for ectopic pregnancy (previous ectopic, history
of pelvic inflammatory diseases). Moreover, Anna is haemodynamically stable and there is no abdominal guarding
and rigidity. However, it cannot be excluded until an intrauterine pregnancy is demonstrated on ultrasound.
Molar p regnancy. βHCG is too low for it to be a molar
pregnancy, her uterus is not enlarged inappropriately to
the period of gestation and there is no history of passing
vesicles.
Bleeding from a l ocal l esion. This has been excluded as
there no evidence of cervical ectopy or polyp on
examination.
What would you tell this patient?
• You should reassure her because her serum βHCG has
doubled in 48 hours
• It is most likely an early ongoing intrauterine pregnancy as she may be only 5 weeks ’ pregnant considering
her 30 – 35 day cycle
• Ultrasound scan is not useful at present as the values
of βHCG are still less than 1000 IU/L
• She should be advised to come back in a week ’ s time
for an ultrasound scan
• A 24 - hour contact number for the early pregnancy
assessment unit should be given in case she has further
questions
• Further support should be offered as the couple are
very anxious
• You need to explain to her that one miscarriage is very
common. Up to 15 – 20% of pregnancies miscarry
• Investigations for miscarriage are not advised until
a couple has had at least three consecutive
miscarriages
• One miscarriage does not alter the outcome in future
pregnancies
Anna returns in a week and her pelvic ultrasound now
shows a single intrauterine gestation sac with yolk sac and
fetal pole with a heart beat present.
What is the outlook now?
Her scan has confirmed a continuing intrauterine pregnancy. She will need more reassurance at least until her
scan after 8 weeks, which is beyond the gestation of
her last miscarriage. She should have a 24 - hour contact
number in case she bleeds heavily. Approximately
15% of pregnancies are complicated by a threatened
miscarriage.
CASE REVIEW
This case of a very anxious couple is typical of women who
present with very light bleeding in very early pregnancy.
Her reason for anxiety is primarily because of her previous
history of miscarriage. At every stage in history - taking and
examination it is important to remember that she wishes
something to be done to prevent miscarriage happening
again.
Despite her history it is important to rule out other
causes of early pregnancy bleeding. History, examination
and investigations in this case revealed a likely diagnosis of
threatened miscarriage, although ectopic pregnancy could
not be ruled out until the intrauterine pregnancy was demonstrated. Although transvaginal ultrasound can demonstrate intrauterine pregnancy from 5½ weeks onwards,
sometimes dates are mistaken and hence the actual period
of gestation when prior menstrual cycles have been longer
(30 – 35 days in this case).
There is no reason to keep her in hospital and an
outpatient management is justified. Admission will not
prevent the miscarriage if it were to occur again. She has
been given a 24 - hour contact number in case of heavy
bleeding or pain
KEY POINTS
• ABC of resuscitation forms the initial assessment for
bleeding in pregnancy
• Ectopic pregnancy needs to be excluded in women with
pain or bleeding in early pregnancy
• Ectopic pregnancy and miscarriage can present without
the patient even realizing that she is pregnant
• Understand that psychological support is equally
important as the medical management of the condition
• Follow-up for counselling may be required, especially as
this is a repeat episode
• Support groups, a point of contact and follow-up
reassurance scans will be needed
• Investigations for recurrent miscarriages are not warranted
unless there are three consecutive miscarriages
• Even after two miscarriages there is 80% chance of
having a live baby
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