2. ➤ Common ED presentation
- 20-40% of pregnancies have 1st trimester bleeding
➤ Wide range of differential diagnoses
➤ Can be life-threatening
➤ Distressing
INTRODUCTION
6. HISTORY
➤ Amount or volume of bleeding and duration
➤ Relation to menstrual cycle
➤ Normal cycle
➤ Other symptoms
➤ Gynae/Obstetric history including IVF
➤ PMH/FH
➤ Drugs
19. UNSTABLE PV BLEEDING
➤ Move to resus
➤ Good IV access x2
➤ FBC, UEC, Crossmatch
➤ Urgent bedside USS
➤ Resuscitate with fluid+/- blood products
➤ Consider cervical shock
➤ Urgent obs & gynae input
20. RHESUS STATUS
➤ Check rhesus status for all pregnant patients
➤ Rhesus negative
- RhD immunoglobulin 250 units IM <20 weeks
- RhD immunoglobulin 625 units IM >20 weeks
- Unclear role if <12 weeks
➤ Prevents maternal formation of antibodies from
isoimmunisation
21. QUANTITATIVE BHCG
➤ Levels increase at least 66% every 48hrs in the first 10 weeks
➤ Serial measurements are more useful
- Falling bHCG consistent with non-viable pregnancy
➤ No discrimination between miscarriage/ectopic
➤ Discriminatory zone is usually >1500 - BHCG level at which
gestational sac visible on TV USS
22. TRANS VAGINAL USS
➤ Most useful tool for determining pregnancy location
- Sensitivity ~98% and specificity 100% for IUP
- Sensitivity ~85% and specificity ~99% for ectopic
23.
24. ➤ Viable intrauterine pregnancy or threatened miscarriage
➤ Miscarriage
➤ Ectopic
➤ Pregnancy of unknown location
25. THREATENED MISCARRIAGE
PV bleeding +/- abdominal cramping with a viable foetus inside
the uterine cavity with a closed cervix
➤ Can affect up to 20% of pregnancies <20 weeks
➤ 17% go on to have further complications
Management
➤ RhD immunoglobulin if rhesus -ve
➤ Discharge with advice
➤ Follow up in EPAS clinic
26. MISCARRIAGE
Pregnancy loss before the 20th week of gestation
➤ 8-20% of pregnancies
➤ Most common in 1st trimester
➤ Risk factors include - advancing maternal age, previous
miscarriage and smoking
28. INEVITABLE MISCARRIAGE
Spontaneous miscarriage than can’t be stopped
➤ Persistant lower abdominal cramps and heavy PV bleeding
➤ Cervical os open
➤ Products of conception often visible
34. MISSED MISCARRIAGE
Foetal demise picked up on USS
➤ Products of conception retained
➤ Sometimes get an asymptomatic brownish discharge
35. ECTOPIC
Ectopic pregnancy occurs when the developing blastocyst
becomes implanted at a site other than the endometrium of the
uterine cavity
➤ 1-2% of pregnancies but 6-16% of pregnancies that present to
ED with symptoms
➤ High morbidity and mortality - 10-15% of all pregnancy deaths
➤ Risk factors include previous ectopics, previous tubal surgery,
previous PID & smoking
42. PLACENTAL ABRUPTION
Bleeding between the placenta and the uterus lining that causes
partial or complete detachment of the placenta
Risk factors include previous abruption, abdominal trauma, cocaine,
pre-eclampsia and hypertension
➤ History
- PV bleeding with abdominal pain
- Uterine contractions
➤ Examination
- Firm, tender uterus
45. ➤ A patient with PV bleeding is pregnant until proven otherwise
➤ Don’t do a PV examination on a patient with PV bleeding who
is in the third trimester of pregnancy
➤ Don’t forget Rhesus status
➤ All the information you could ever possibly need is online
46. REFERENCES
KEMH clinical guidelines - http://www.kemh.health.wa.gov.au/development/manuals/
SCGH clinical guidelines - management of 1st trimester pain and bleeding -
http://scghed.com/2015/11/scgh-early-pregnancy-guideline-102015/
eTG Complete - Menstrual disorders - https://tgldcdp-tg-org-
au.smhslibresources.health.wa.gov.au/viewTopic?topicfile=menstrual-
disorders&guidelineName=Endocrinology#toc_d1e84
Approach to vaginal bleeding in the emergency department - https://www-uptodate-
com.smhslibresources.health.wa.gov.au/contents/approach-to-vaginal-bleeding-in-the-emergency-
department?source=search_result&search=vaginal%20bleeding&selectedTitle=1~150
Diagnosis and management - Emergency Medicine - Seventh Edition. Anthony FT Brown and
Michael D Cadogan. CRC Press.
