00:01
Now let's discuss bleeding
in the 1st trimester.
00:06
So the initial assessment.
00:07
One of the first things we want
to do is get the blood type
and the Rh factor for mom.
00:11
No matter what the cause of
bleeding is,
if mom is Rh negative,
she will need Rhogam.
00:17
So we always want to start with
getting the blood type
in the Rh factor.
00:22
Next, we want to get our
quantitative beta-hcg.
00:25
If the beta-hcg is less than
2000, we may or may not see
anything in the uterus.
00:31
If it is greater than 2000, we
should definitely see something
in the uterus.
00:36
That information is going to
help us determine if this is
a normal pregnancy or if
this is ectopic pregnancy.
00:43
The next thing we'll need
is an ultrasound to document
the location and the viability
of the pregnancy.
00:49
Again remember if that beta-hcg
is less than 2000,
we may or may not be able to
determine the location
of the pregnancy.
00:57
However, ultrasound
is very important.
00:59
And the next thing is
the complete blood count.
01:03
We want to able to determine if
mom is hemodynamically stable
or not.
01:06
And we want to know where her
blood count is starting,
when we're going into issues
with 1st trimester bleeding.
01:14
So bleeding in pregnancy prior
to 20 weeks of gestation with
a documented intrauterine
pregnancy constitutes
a type of abortion.
01:22
Now we have many
types of abortions.
01:24
And so we'll go through those
through our next slides here.
01:28
So first is a
threatened abortion.
01:31
Now this is a documented pregnancy.
01:33
Cervix is closed, but mom
is having bleeding.
01:37
Next is incomplete abortion.
01:39
So mom has passed some products
of conception and is bleeding.
01:43
But there's still products of
conception within the uterus.
01:46
Next is inevitable abortion.
01:48
In this situation the
cervix is already dilated.
01:51
And so mom is inevitably
going to lose that pregnancy.
01:55
And then the fourth type of
abortion is a missed abortion.
01:58
So in this situation, this is
a patient who has absolutely
no symptoms, no bleeding,
no pain.
02:05
Quite commonly this is a
diagnosis made in the office
when a doctors goes to listen
to the heart tones for the baby,
no heart tones are found.
02:15
So again this is how we
define missed abortion.
02:18
So let's talk about how
we manage each of these.
02:22
So threatened abortion.
02:23
So our management is
actually expectant.
02:26
A lot of these pregnancies will
go on to be normal pregnancies.
02:29
So we don't want to do anything
that will interfere with that.
02:32
We do advise the mom that if she
has heavy bleeding or she has
increased pain, that she should
seek medical care.
02:39
Because that threatened
abortion maybe going on to
be an incomplete abortion.
02:44
And then remember if mom is
Rh negative, we need to make sure
she gets Rhogam.
02:49
So for incomplete abortions,
we have three ways that we can
manage it.
02:54
Expectant management, medical
management and that's with
misoprostol or surgical management.
03:00
With expectant management we
allow the body to naturally
complete the process of passing
the products of conception.
03:07
With medical management we
give again, misoprostol to help
expedite that process of passing
the products of conception,
whatever is still
left in the uterus.
03:17
And then surgical
options would be D&C.
03:20
Now important to know, if a
patient is hemodynamically
unstable, they must have a D&C.
03:26
So if they are bleeding because
of this incomplete abortion
and have become hemodynamically
unstable, expectant management
and medical management
is not appropriate.
03:36
For inevitable abortion, these
patients can be managed again,
medically, expectantly
or surgically.
03:42
They can be managed
expectantly if they are stable.
03:45
Medically if they are stable.
03:47
But surgically if they are
hemodynamically unstable.
03:52
So missed abortion.
03:53
So again remember this is our
patient that has no symptoms,
no bleeding, no pain.
03:58
And has no fetal heart tones
on ultrasounds or Doppler.
04:02
So this can be
managed expectantly.
04:04
We tell the patients that they
can go home, come back within
a week and we expect that
they will have passed products
of conception.
04:11
If they've not then we need to
progress to our other options
which are medical and surgical.
04:15
And medical is administering
misoprostol
which helps the uterus evacuate
the abnormal products of conception.
04:22
And then surgically,
which is performing a D&C.
04:26
Again if expectant management is
chosen by the patient, they need
to be monitored weekly to make
sure they do indeed pass those
products of conception.
04:34
If the retain them, then they
are at risk for developing
a septic abortion.
04:39
Spontaneous or complete abortion.
04:41
This again means that mom has
passed all of the products
of conception.
04:45
We do need to confirm that
by ultrasound however.
04:48
And we need to do serial
beta-hcg's to make sure our hcg
level falls back to prepregnancy
levels which is less than
5 micrograms per decalitre.
04:58
So here's a case for you.
05:00
Anna is a 27 year old gravida 2
para 0 female that presents
to the emergency room with
complaint of heavy vaginal
bleeding.
05:08
She has a last menstrual
period of 8 weeks and 2 days.
05:11
She had a positive
pregnancy test at home.
05:14
She has a history of ectopic
pregnancy 2 years ago that was
treated with methotrexate.
05:19
She denies any medical
or surgical history.
05:22
On physical exam, vital signs
are stable,
and she is a afebrile.
05:26
On pelvic exam, uterus
is gravid, non-tender.
05:29
And the cervix
admits one finger.
05:33
So based on that, what is
her most likely diagnosis?
A. Is this a normal pregnancy
B. Is it a missed abortion
C. Is it inevitable abortion
or D. Is it a threatened abortion.
05:46
The answer in this case
is inevitable abortion.
05:50
So it's not a normal pregnancy
because she is having bleeding
and her cervix ix already open.
05:55
It's not a missed abortion
because she is having symptoms.
05:58
It is inevitable abortion
because the cervix
is already dilated.
06:02
And it's not a threatened
abortion because her cervix
did not close.