Case 4.3 – Bleeding in Early Pregnancy

Differential Diagnosis: Ectopic pregnancy or miscarriage

Bleeding and pain in early pregnancy can be difficult to differentiate between a miscarriage and ectopic pregnancy. The classic triad is:

• An episode of amenorrhoea
• Vaginal bleeding
• Abdominal pain

Important principle: Every woman who presents with abdominal pain and who is within child bearing age should have a urinary beta HCG performed even if there is no episode of amenorrhoea.

In this case: The absence of adnexal tenderness or cervical excitation makes the diagnosis of ectopic pregnancy unlikely. The most likely diagnosis is a miscarriage (likely threatened or incomplete miscarriage given the ongoing bleeding).

Type of Miscarriage	Clinical Features
Threatened	Bleeding usually painless No pelvic tenderness Live foetus on ultrasound
Incomplete	Pain and episode of heavy bleeding Products of conception may be seen on vaginal examination Retained products of conception on ultrasound
Complete	Episode of heavy bleeding and pain with passage of conceptus Bleeding now scant or absent Normal non-tender uterus Empty uterus on ultrasound
Septic	Usually incomplete miscarriage with sepsis Pain and tenderness Febrile >37.5°C
Missed	Bleeding, usually no pain Enlarged uterus Ultrasound: >6 week embryo and embryonic heart beat absent OR sac greater than 25mm and no embryo seen

Conservative Management

• Needs regular follow-up
• Risk of heavy bleeding and pain - may need evacuation of uterus
• Threatened miscarriage: Bleeding settles with rest and reassurance. Hospitalise if heavy bleeding. May progress to miscarriage
• Incomplete/Missed miscarriage: Wait for spontaneous miscarriage. Risk of pain, heavy bleeding, and transfusion requirement
• Most women with missed miscarriage elect evacuation

Medical Evacuation

• Misoprostol (prostaglandin E1 analogue) taken orally or vaginally as an outpatient
• May not be complete and need surgical evacuation

Surgical Evacuation

• Dilation and Suction uterine curettage
• Necessary if haemodynamically unstable or septic
• Risks: perforation of uterus, Ashermann's syndrome

Important Additional Management

• Anti-D immunoglobulin: Non-sensitised Rhesus-negative women require 250 IU of anti-D within 72 hours of miscarriage
• Counselling: All women should have counselling following a miscarriage about the significant psychological impact. The loss centres around the loss of a child, not just an 8-week foetus. Significant hormonal changes occur with the sudden reduction in oestrogen and progesterone which also have psychological effects

Full History

• Detailed history of bleeding including if products of conception seen
• Obstetric history including previous miscarriages and ectopic pregnancies
• Gynaecological history including:
  • PID (increases risk significantly of an ectopic)
  • Tubal or appendiceal surgery (adhesions increase the risk of ectopic)

Investigations

• Beta HCG: To diagnose pregnancy
• Transvaginal ultrasound: To check correct in utero position and pregnancy viability - foetal heart present. Should be seen at 5 weeks (if bHCG is >1500 IU and no sac seen then very high index of suspicion for ectopic)
• Blood Group: If Rhesus negative will need Anti-D to prevent possible sensitization

Treatment

Management as per question 3, depending on the type of miscarriage diagnosed:

• Conservative management with follow-up
• Medical evacuation with misoprostol
• Surgical evacuation if indicated
• Anti-D if Rhesus negative
• Counselling and psychological support

Definition

A molar pregnancy describes a group of tumours (Gestational trophoblastic disease) that arise from foetal trophoblast. In these tumours the trophoblast proliferates abnormally and is capable of unlimited growth, invasion or metastatic spread. They occur in association with pregnancy.

Classification:

• Benign: Hydatidiform moles
• Malignant: Invasive mole, placental site trophoblastic tumour, and choriocarcinoma

Tumour marker: Beta HCG

Treatment: Malignant tumours are sensitive to chemotherapy

Presentation

• Early or recurrent hyperemesis (related to high beta HCG)
• Early onset preeclampsia or hyperthyroidism
• Uterus large for dates and feels very soft
• Ultrasound: Classic ground glass appearance from multiple vesicular structures +/- large ovarian cysts
• Vaginal bleeding +/- passage of 'grape-like' vesicular structures. Histology to differentiate hydropic degeneration of placenta from trophoblastic disease
• Partial mole particularly diagnosed after examination of evacuated products of conception
• Invasive mole presents with persistent bleeding post evacuation for hydatidiform mole or persistent or rising levels of beta HCG

Management

• Diagnosis is dependent on histological confirmation of gestational trophoblastic disease
• Management of hydatidiform mole involves suction evacuation of uterus
• Follow up with weekly, then monthly beta HCG assays for 6 months
• Reliable contraception is advised for 6 months

Indications for Chemotherapy

Neoplasia is diagnosed and chemotherapy instituted if beta HCG levels:

• Do not decrease by 10% 3 weeks after evacuation
• Increase more than 10% in a 2 week period
• Persist more than 6 months
• Histological evidence of choriocarcinoma

Gynaecological Causes:

• Ectopic pregnancy
• Miscarriage
• Pelvic inflammatory disease (PID)
• Ovarian cyst accident - enlargement, rupture, bleed, torsion

Renal/Urological Causes:

• Cystitis
• Pyelonephritis
• Renal stones

Gastrointestinal Causes:

• Constipation
• Colitis
• Appendicitis

Other Causes:

• Musculoskeletal
• Psychosocial - Drug-seeking behavior, physical and/or sexual abuse