Case 47: Bleeding in early pregnancy

 

Case 47: Bleeding in early pregnancy

CASE 47: BLEEDING IN EARLY PREGNANCY

History

A 31-year-old woman presents with vaginal bleeding at 5 weeks 6 days’ gestation. She

has had a previous left uterine tubal ectopic pregnancy managed with laparoscopic salpingectomy. She is certain of her last menstrual period date and has regular cycles. Her

last smear test was normal and she has not used contraception since her last pregnancy 3

years ago.

When she was 21 years she had an episode of pelvic inflammatory disease treated with intravenous antibiotics. She is otherwise not aware of having had any sexually transmitted infections. She has been with her partner for 7 years. She smokes 10 cigarettes per day and does

not drink alcohol. The bleeding is described as very light and she has not been aware of any

pain. She has not felt dizzy or lightheaded and has no shoulder-tip pain.

Examination

She is warm and well perfused. The blood pressure is 136/78 mmHg and heart rate 75/min.

The abdomen is not distended and no tenderness is elicited on palpation. The cervix is closed.

The uterus feels normal size, anteverted and mobile, and there is no cervical motion tenderness. Gentle adnexal examination shows no significant tenderness.

INVESTIGATIONS

Human chorionic gonadotrophin (b-hCG): 691 IU/L

Transvaginal ultrasound scan findings are shown in Figs. 47.1 and 47.2.

Questions

• What is the diagnosis?

• What management options are available and which management would be preferred in this particular case?

Figure 47.1 Transvaginal ultrasound scan

showing a midsagittal view through the uterus.

Figure 47.2 Transvaginal ultrasound

scan showing a transverse view through

the right adnexa.100 Cases in Obstetrics and Gynaecology

122

ANSWER 47

The ultrasound scan images show an empty uterus and an adnexal mass adjacent to the right

ovary. The mass represents an ectopic pregnancy. No gestation sac or fetal pole is visible and

the pregnancy is therefore not considered ‘viable’. However there is still a possibility of rupture if not treated.

! Risk factors for ectopic pregnancy

• Smoking

• Previous pelvic inflammatory disease or chlamydial infection

• History of infertility

• In vitro fertilization

• Previous tubal surgery

• Previous ectopic pregnancy

• Intrauterine contraceptive device (IUCD) or progesterone only pill

Management

Three options might be appropriate to this woman:

• Surgical: laparoscopic excision of the tube (salpingectomy) or salpingotomy to incise

the tube and flush out the ectopic pregnancy.

• Medical: intramuscular methotrexate to destroy the rapidly dividing trophoblast

tissue, with regular hCG follow-up to confirm resolution. As methotrexate is teratogenic, it should be given only once a possible intrauterine pregnancy has been

completely ruled out. In this case, this may be by repeat hCG in 48 h to be certain

that the change is not consistent with a potentially viable pregnancy.

• Expectant: ‘wait and see’ approach, suitable if the hCG at 48 h is decreasing spontaneously and the woman remains asymptomatic.

In this case the woman has previously had a uterine tube removed and surgery might compromise the remaining tube, so methotrexate treatment is preferred. However if the tube is

damaged but preserved, she may be at high risk of further ectopic pregnancy. Prerequisites

for methotrexate are normal full blood count, renal and liver function before treatment,

compliance with the intense follow-up, and understanding the need not to become pregnant

again for at least 3 months due to the potential teratogenic effects. Potential side effects are

abdominal pain (sometimes difficult to distinguish from pain suggestive of tubal rupture),

nausea, diarrhoea and, rarely, conjunctivitis and stomatitis.

KEY POINTS

• Ectopic pregnancies are commonly asymptomatic or associated with atypical

symptoms.

• Surgical, medical or expectant management of ectopic pregnancy depends on

the symptoms, signs and hCG result.

• Methotrexate is effective but follow-up is intensive and sometimes prolonged.

• Methotrexate should never be administered if there is a possibility of a potentially

viable intrauterine pregnancy