37, F, 7w pregnant, bleeding 'down below'

Question 1

37, F
PC: 7w pregnant, some bleeding down below
HPC: started last night, initially spotting, now few tablespoons, bright red, lower crampy abdo pain, comes and goes
no d/c, clots, POC.
no fever, diarrhoea, dizziness, breathlessness, falls/trauma
Obs hx: para 0, IVF as trouble conceiving
Gynae hx: regular periods, bleeds 4-5 days on 28-day cycle, not excessively heavy/painful, previous smears all normal
PMH: fit and well, prev lap to investigate infertility
FHx/SHx: lives at home with husband, non smoker, non drinker
ICE: worried about baby + higher miscarriage risk in IVF

DIFFERENTIALS

Answer 1

• miscarriage
• ectopic pregnancy
• molar pregnancy
• cancer (endometrial, cervical)
• PR bleeding causes eg. bowel cancer

Question 2

37, F
PC: 7w pregnant, some bleeding down below
HPC: started last night, initially spotting, now few tablespoons, bright red, lower crampy abdo pain, comes and goes
no d/c, clots, POC.

INVESTIGATIONS

Answer 2

Bedside:
1) ABC - since pt is bleeding
2) BASIC OBS - HR, BP, RR, sats, temp (assess haemodynamic stability) - all normal
3) (ABDO EXAM - no obvious signs of trauma)
4) SPECULUM - examine cervical os - no evidence of foetal tissue, cervical os closed
5) URINE HCG - rule out ectopic

Lab:
1) BLOODS - FBC (anaemia/infection), U&Es (dehydration/renal disturbance), G&S, Rhesus status, serum hCG (rule out ectopic)

Imaging:
1) TV USS - foetal pole consistent w 7w foetus, no foetal cardiac activity

Dx: missed miscarriage

Question 3

37, F
PC: 7w pregnant, some bleeding down below
HPC: started last night, initially spotting, now few tablespoons, bright red, lower crampy abdo pain, comes and goes
no d/c, clots, POC.

MANAGEMENT

Answer 3

Stable patient

1) INVOLVE SENIOR COLLEAGUES
2) DIFF OPTIONS: CONSERVATIVE, MEDICAL, SURGICAL MGX (doesn’t need to decide now, can provide some written info)

CONSERVATIVE:
- watch and wait, may resolve naturally in 7-14 days. Do pregnancy test after 3 weeks.

MEDICAL:
For complete/missed miscarriage:
1) vaginal/oral misoprostol
2) NO mifipristone (not for complete/missed)
3) pregnancy test after 3 weeks

Other types of miscarriage:
1) mifipristone (oral anti-progesterone) –> 2) misoprostol (vaginal prostaglandin) 24/48h later
+ve: pt in control, -ve: more pain/bleeding, multiple visits, may fail

• removal of POC

SURGICAL:
1) Vacuum aspiration (up to ~14-16w) under local anaesthetic in OPD/clinic. Can also be done in theatres under GA.
2) screening for STIs (inc. chlamydia)
(?PV misoprostol 3h prior)

Question 4

Risks of surgical management of miscarriage?

Answer 4

Risks associated with any surgical procedure:
- infection
- bleeding
- risk from anaesthetic

Risks specific to this procedure:
- retained POC –> sepsis - Cervical
incompetence in future pregnancies
- Asherman syndrome

Question 5

Types of miscarriage?

Answer 5

• COMPLETE - all POC expelled
• INCOMPLETE - all POC not expelled
• MISSED - non-viable pregnancy diagnosed on USS but no associated pain or bleeding
• THREATENED - vaginal bleeding in presence of viable pregnancy
• IINEVITABLE - non-viable pregnancy with bleeding and open cervical os, but tissue still in uterus. Will proceed to incomplete or complete miscarriage.
• SEPTIC