Case 51: Bleeding in early pregnancy

 

Case 51: Bleeding in early pregnancy

CASE 51: BLEEDING IN EARLY PREGNANCY

History

A 23-year-old woman is referred by her GP with vaginal bleeding. She noticed that there was

blood on the toilet paper 2 days ago, and following this she has had bright red spotting intermittently. She has no pain and there are no urinary or bowel symptoms.

Her last menstrual period started 9 weeks and 6 days ago and she has a regular 31-day

cycle. She had a positive home urine pregnancy test 3 weeks ago after she realized she had

missed a period and was feeling very tired. This is her first pregnancy. She had been using

condoms but with poor compliance, so the pregnancy was unplanned but she is now happy

about it.

She is generally well, only having been admitted to hospital once in the past for an appendectomy at the age of 17 years. She takes no medication, does not smoke and drinks minimal

alcohol. She denies any use of recreational drugs.

Examination

The woman is apyrexial. The blood pressure is 120/65 mmHg and heart rate 78/min. The

abdomen is soft and non-tender with no palpable uterus or other masses.

INVESTIGATIONS

Transvaginal ultrasound is shown in Fig. 51.1. The crown–rump length is 25 mm (equivalent

to around 9 weeks’ gestation) and the fetal heartbeat is seen.

Questions

• How would you interpret the ultrasound result?

• What further examination, investigations or management would you like to perform or request?

Figure 51.1 Transvaginal ultrasound scan.100 Cases in Obstetrics and Gynaecology

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ANSWER 51

The ultrasound scan shows a viable single intrauterine pregnancy. The crown–rump length

is compatible with the gestational age by menstrual dates, especially as the woman reports a

long menstrual cycle (3 days longer than normal, therefore gestational age would be 3 days

less than the ‘normal’). Where there is a significant discrepancy with menstrual and ultrasound gestational age estimation (e.g. more than 7 days), one should consider the possibility

of inaccurate reporting of the last menstrual period date, irregular cycles leading to inaccurate estimated ovulation date, or of a possible growth-retarded fetus which may be destined

to miscarry.

In this case, as the ultrasound is reassuring the diagnosis would be of a ‘threatened miscarriage’.

Figure 51.2 shows a three-dimensional image of the fetus, demonstrating the developing

limbs and the physiological midgut herniation which occur at this developmental stage.

Further management

A speculum examination should be performed. The possible findings may be:

• normal appearance

• cervical ectropion (often associated with postcoital bleeding)

• cervicitis (common with chlamydia)

• cervical polyp

• cervical malignancy (rare but should not be missed).

No further investigations are necessary at this stage – the amount of bleeding is unlikely to

have caused anaemia. Rhesus status is irrelevant as anti-D immunoglobulin is only indicated

in a rhesus negative woman where the bleeding occurs after 12 weeks’ gestation or where a

miscarriage has occurred.

Management in this case is simple reassurance. Available evidence suggests that the pregnancy is at less than 5 per cent risk of miscarriage if the fetal heartbeat is normal and the

bleeding resolves. There is no clear evidence for progesterone, bedrest or avoidance of sexual

intercourse with threatened miscarriage. Further assessment should be offered if the bleeding becomes heavier or recurs. Otherwise the woman’s next appointments are likely to be the

antenatal midwife booking visit and the 11–14-week ultrasound scan.

Figure 51.2 Three-dimensional transvaginal ultrasound scan.Case 51: Bleeding in early pregnancy

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KEY POINTS

• Vaginal bleeding in pregnancy is associated with miscarriage in up to 50 per cent

of cases, but the risk is lower if the bleeding is light.

• After a fetal heartbeat has been visualized, the chance of subsequent first-trimester miscarriage is around 5 per cent.

• Threatened miscarriage is managed supportively with reassurance – administration of progesterone and other measures have not yet been proven beneficial.