Gynecology [VAG BLEEDING 2: PREGNANCY]

Pregnancy and Bleeding

Bleeding in pregnancy is normal. There may be spotting in the
first trimester and/or a bloody show in the third trimester. But Positive UPT + Bleeding
bleeding can also be ominous. The goal is to either reassure mom
or identify something more sinister. The process begins with a
Transvaginal
urine pregnancy test (UPT) and is followed up with a
Ultrasound
transvaginal ultrasound. We’ll discuss Ectopic Pregnancy and
Abortion in this lecture. Ectopic IUP

Ectopic Pregnancy ?
An ectopic pregnancy is a potentially life threatening condition;
>1500 <1500
the decision tree is quite complex. The first step is to determine if Too
Beta-Quant
there is indeed an ectopic pregnancy, then to decide what to do Soon
about the diagnosis. Ectopic pregnancies can present with pain,
bleeding, or both. A qualitative UPT will be positive.
Does Not Double Beta-Quant Doubles
When an intrauterine pregnancy is suspected, the first step is a 48 hours
transvaginal ultrasound. If the ultrasound reveals an
intrauterine pregnancy, it’s time to figure out why she’s bleeding
Ectopic No heart tones
(IUP, Abortion, Mole).
Zygote < 3.5cm
+ Ruptured HCG < 5000
If the ultrasound reveals an ectopic pregnancy we have the No Folate
- Ruptured
answer and treatment is needed.
Salpingectomy d Methotrexate
But if the ultrasound reveals neither it’s a conundrum. It’s here
where a Beta-Quant actually matters.

The discriminatory zone is defined as a Beta-Quant between Baby IUP Mole

1500-2000 (the decision is still out). Here, we use 1500. The way
Treat as Suction Curettage
to rectify this problem is <1500 is too soon, >2000 it should
pregnant OCP x 1 year
definitely be seen, and 1500-2000 is a grey zone. I was taught B-HCQ qwk
1500. We’ve heard 1500 on tests so we’re using it. A pregnancy
Abortion
can’t be seen if the Beta-Quant is < 1500. If the beta quant is
>1500 and there’s no IUP, then it’s an ectopic pregnancy. If the Decide
Beta-Quant < 1500 it’s too soon to tell. Watch and wait for 48 (next section)
hours then repeat the Beta-Quant. An intrauterine pregnancy will
double in size in 48 hours while an ectopic will not.

If there’s a doubling of the beta-quant it’s a pregnancy - repeat Ectopic Treatment Methotrexate if:
the ultrasound. If there ISN’T doubling of the beta-quant it’s a. B-HCG < 5000 (maybe 8000 is ok)
ectopic – go find it. b. < 3 cm (maybe 3.5cm is ok)
c. No fetal heart tones
The treatment of an intrauterine pregnancy depends on what it d. No Folate Supplementation
actually is:

1) Live Baby = IUP = See Obstetrics Ectopic Treatment Operative Decision

2) Dead baby = abortion = see below Salpingectomy:
3) Molar pregnancy = see Gyn-Moles - Other tube is normal and fertility desired
- Fertility not desired
The treatment for an ectopic depends on a number of things: Salpingostomy
- Other tube is Abnormal and fertility desired
1) Ectopic without rupture: salpingostomy Methotrexate
2) Ectopic with rupture: salpingectomy - Most fertility sparing option
3) Selective cases: methotrexate. See criteria to the right

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 Gynecology [VAG BLEEDING 2: PREGNANCY]

Abortion IUP à Threatened à Inevitable à incomplete à Complete
One type of reproductive age bleeding is an abortion. Here, mom
was pregnant (so the UPT was positive) and there was a baby Diagnosis Passage of Cervical OS Ultrasound
inside. Mom CAN have an abortion without knowing she is Contents
pregnant and a spontaneous abortion can present with passing of IUP None Closed Live Baby
clots. But, a vignette on the test is going to mention three things Threatened None Closed Live Baby
Inevitable None Open Dead Baby
to help make the diagnosis: passage of contents, state of the os,
Incomplete + Open Retained Parts
and what is found on ultrasound. Complete + Closed No Baby
---------------------------------------------------------------------
Spontaneous Abortion progresses in a definable, predictable Missed None Closed Dead Baby
pattern as shown to the right. A normal Intrauterine Pregnancy
becomes Threatened. That is, if no intervention is made the baby Do an ultrasound after the contents pass
dies. Threatened abortions can be rescued with strict bed rest. Do track Beta-Quant to 0 to screen for trophoblastic disease
Do give IVIG to an Rh- mom at the time of abortion unless
But after that, once the baby dies it becomes inevitable. It hasn’t baby is absolutely known to be Rh –
happened yet, but it will. Nothing will stop it. In this state, mom Do induce a missed abortion (> 24 weeks)
is ready (the os is open) but there’s been no passage of contents Do remove a missed abortion (< 24 weeks)
and so an ultrasound will identify a dead baby.
DON’T give tocolytics
Inevitable becomes incomplete as the contents begin to pass. In
this case, mom is ready (the os is open) and there has been
passage of clots. But mom is not through the abortion yet, so an
ultrasound will show retained parts.

The process finishes with a complete abortion; mom finishes the

process of expelling fetal contents. There will be passage of clots,
but now mom is done (the os is closed) and an ultrasound will
show no parts.

A missed abortion is one in which mom doesn’t realize baby is

dead. There has been NO passage of clots, a dead baby appears
on ultrasound, but the os is closed. A missed abortion will need
to be induced into labor (> 24 weeks) or have the baby removed
with suction curettage (< 24 weeks).

NEVER give tocolytics to an abortion – let the contents pass.

DO get an ultrasound to make sure there are no fetal parts

remaining. If there are, get them out with a D&C.

DO track the Beta-Quant to 0, putting mom on OCPs so she can’t

get pregnant. She has a high risk of developing a gestational
trophoblastic disease. See Gyn, trophoblastic disease.

DO give an Rh – mom IVIG (Rhogam) to prevent

isoimmunization (see isoimmunization lectures).

Misoprostol (1st trimester), oxytocin (induction), or D&C can be

used to help mom along.

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