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					Lecture2: Approach to patient with
bleeding in early pregnancy
Differential diagnosis of early pregnancy bleeding:

   1-   Miscarriage
   2-   Ectopic pregnancy
   3-   H.mole
   4-   Other coincidental causes not related to pregnancy( Trauma, fibroid , polyp ,
        ectropion)


Diagnosis:
History:
*The date of last menstrual period: the usual length of her menstrual cycle and the
date of her first positive urinary pregnancy test which should define the likely
gestational age.

* The severity of early pregnancy symptoms, particularly nausea and breast
discomfort, may be of diagnostic value (loss of early pregnancy symptoms may
indicate pregnancy failure and increased severity of early pregnancy symptoms may
be associated with molar and multiple pregnancies).

* The outcome of previous pregnancies is an important indicator of the risk of
miscarriage, ectopic pregnancy, or gestational trophoblastic disease.

* The nature and distribution of associated pain can be helpful. Unilateral pelvic pain
is not necessarily related to an ectopic pregnancy; it may simply be caused by ovarian
capsule distention caused by corpus luteum of pregnancy. Shoulder tip pain suggests
diaphragmatic irritation as a result of intra-abdominal bleeding.

* The extent of first trimester vaginal bleeding provides a useful prognostic value. Is
it associated with passage of clots or pieces of gestation or vesicles of molar
pregnancy.




Examination:
      General examination
      The pulse and blood pressure should be monitored frequently to identify
       development of clinical shock early.
      The abdomen may be distended because of intraperitoneal bleeding or bowel
       dilatation.
      Generalized lower abdominal guarding or rebound tenderness on abdominal
       palpation suggests intraperitoneal bleeding. Localized unilateral iliac fossa
       tenderness may be present with an unruptured ectopic pregnancy or
       physiologic corpus luteum cyst of pregnancy.
      Vaginal examination with a cuscou’s speculum should identify any local cause
       of bleeding due to trauma or cervical bleeding as a result of a polyp or
       physiologic ectropion.
      An open cervical os suggests either incomplete or inevitable miscarriage.
       Blood loss through the cervical os should be noted, including wethre it is
       fresh or old .
      If products of conception are extruding through the cervix, these can be
       removed with spong forceps .
      Bimanual pelvic examination should be done to assess cervical dilation and
       identify cervical excitation tenderness as a clinical sign of an ectopic
       pregnancy.
      The size and shape of uterus should be assessed. If it is larger than expected
       based on menstrual dates, the patient may have a multiple pregnancy, a
       hydatidiformole, or coincidental uterine pathology like fibroids.
      Adnexal palpation may identify a tender mass that may be either an ectopic
       pregnancy or a normal corpus luteum cyst.


Investigation:
   1. Full blood count . Perform clotting screen if coagulopathy is suspected or
      excess blood loss occurs. Cross match blood if excessive blood loss occurs.
   2. Ultrasonography preferabely by vaginal route. Confirmation of an intrauterine
      sac can be made when the yolk sac or fetus becomes visible . Molar pregnancy
      can be visualized by TV USS .
   3. Serum beta hCG concentrations complement the information available from
      TV USS in assessing early pregnancy problems. Levels more than 1500-2000
      IU/L(depending on local laboratory variations). Serial changes in Beta hCG
      are best tested at intervals of 48 hrs or longer . With viable intra uterine
      pregnancy B hCG values should increase by at least 66% in 48 hrs.
   4. CXR if there is suspicion of molar pregnancy.


Initial management:
   1. Resuscitation( if in shock) .
2. It is important to visualize the cervix carefully and remove any product of
   gestation.
3. If the patient is in shock and there are no products of gestation in the cervical
   canal, she should be managed as if a major blood loss has occurred regardless
   of the amount of bleeding seen. Vital signs should be measured frequently,
   and large bore IV access should be established. Blood should be obtained for
   a crossmatch, CBC, and clotting screen. A minimum of 4 units of blood
   should be available for patient in shock.
4. The patient should be assessed rapidly based on her clinical history and
   examination while resuscitation is proceeding. If the assessment suggests
   intraperitoneal bleeding from ruptured ectopic pregnancy,emergency
   laparatomy is indicated.
5. If the patient is not in shock and responds to resuscitation , a careful history
   and examination is arranged.
6. If the diagnosis is made, the management will be accordingly.

				
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posted:3/26/2013
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