What’s the Bleedin’ Problem- 1st trimester bleeding

Dr Emma Young

Consultant in Emergency Medicine

Barts Health NHS Trust

Aims

• Why does it matter to you?

• What causes bleeding?

• Miscarriage and Ectopic

• Diagnostic challenges/ pitfalls

• Anti D

• Shock and mortality – lessons learned and top tips

• Patient experience

Why does this matter to you?

• All EDs see women bleeding in early pregnancy • Women don’t know they are

pregnant • We don’t know they are pregnant

Pitfalls• Extremes of age• Don’t always have ammenorhoea• 10% chance of woman being

pregnant despite them saying it is unlikely

• Women working in ED

Why do women bleed?

• Cervical / vaginal pathology

• Implantation bleed

• Miscarriage• Threatened

• Inevitable miscarriage

• Incomplete/ complete miscarriage

• Ectopic

Miscarriage

Definition

• Spontaneous end of a pregnancy before 24 weeks’ gestation.

Incidence

• 1 in 4

•

Ectopic Pregnancy

= Pregnancy outside the endometrial cavity

Incidence• 1.2/ 100 pregnancies = 12,000/ yr in UK

• Prevalence – 1-2% BUT attending ED with suspicious features = 6-16%

Diagnosis• Usually diagnosed in the first 8 to 9 weeks

• Delayed diagnosis can lead to rupture

Recurrence• Range 4-28 % (average 15%)

Clinical assessment

• Is the patient well/ unwell?

• What is the cause of bleeding?

• What is the diagnosis?

Is there an ectopic pregnancy?

Risk factors for ectopic

High

• Previous ectopic

• Tubal pathology and surgery

Other risk factors

• Pelvic surgery

• IUCD in situ

• Subfertility and Fertility treatment

• Smoking

Clinical signs/ symptoms

• D and V

• Dysuria

• Rectal pressure or pain on defecation

• Shoulder tip pain

• Abdominal pain • Tubal miscarriage V Tubal rupture

• Rebound

• Syncope

• Adenexal tenderness LR 1.9 (CI 1-3.5)

• Adenexal mass LR 2.4 (1.6-3.7)

• Cervical motion tenderness LR 4.9 (CI 1.7-14)

Pitfalls of diagnosing ectopic

• 1/3 have no risk factors

• Pain + vaginal bleeding with no other risk factors = risk of ectopic as high at 39%

• 10-20% no bleeding

• 10% no pain

Ask yourself:

1. Is the patient pregnant?

2. Where is the pregnancy?

3. Has there been rupture?

Is the patient pregnant?

Urine bHCG and Serum HCG

HCG< 5 IU = NOT pregnant

Urine pregnancy tests

• Detect bHCG > 25 IU

• 99.4% sensitivity (not 100!) 4 weeks from LMP

Pitfalls

• Irregular menses, over dilute urine, hydatiform mole

• cases of ruptured ectopic reported with HCG = 10

Serum HCG (quantitative)

• Early diagnosis

• Watch in ectopic / threatened miscarriage

• What should we expect to see on US

Where is the pregnancy?

Transvaginal Ultrasound

• Investigation of choice

• Specificity 94-99%

Stein et al 2010 Metanalysis 2057 EP US (TUV and transabdominal)

• Negative predictive value 99.96 %(CI 99.6 -100%)

Pitfalls

• Person dependent

• Discriminatory zone

• Heterotropic pregnancy

Abdominal ultrasound

- ‘FAST’

Shock and bleeding in early pregnancy

• PV bleeding + shock = Ectopic / inevitable /incomplete miscarriage

• Catheterise / use blood urine test

• Cervical shock - metal sponge holding forceps

• Confirmed IUP + incomplete miscarriage –Consider Misoprostol

Death in early pregnancy MMBRACE 2016

• Higher death rate: recent migrants, asylum seekers, refugees, difficulty reading/ speaking English

• 9 death ectopic pregnancy 2009-2014

• 2/3 substandard care

• 3 anaemic and thrombolysed

• 4 D and V

So:

• Advocate/ translator

• Think ectopic not just PE

• Bedside eFAST = echo for R heart strain in PE and FAST for free fluid in abdomen

When should we give Anti – D in first trimester

RCOG /British Blood Transfusion Society say 250IU in < 12 weeks gestation if:

• Ectopic pregnancy

• Molar pregnancy

• Uterine bleeding where this is repeated, heavy or associated with abdominal pain

NICE 2012

• in ectopic and miscarriage only if surgical intervention

What do patients say:

“I was very ill when I came to A&E. I had collapsed at home and I was bleeding a lot. When I came out from theatre they told me I had to have my tube removed because the baby was growing in the wrong place. The doctors helped me a lot but I still can't forget that I was pregnant one day and then the next day it was gone. This was the second miscarriage I had and I felt as though there must be something wrong with me. I still don't understand why I had another miscarriage”

Thoughts about the patient experience

• Don’t assume that they want to be pregnant

• Its their baby dying

• Silence around miscarriage…..until 2016• Tommy’s #misCOURAGE stories

• Eastenders

• The Archers

Is it my fault?

Talking to patients

• Miscarriage V abortion

• Products of conception V Pregnancy tissues

• Cervical excitation V cervical motion tenderness

• Call the woman by her name not ’mum’

• Include the partner

What the patient wants to know

• Manage expectations

• Is the baby ok?

• Am I having a miscarriage?

• Is there anything can be done?

• What do I do if the bleeding / pain gets worse?

• What should I expect to happen?

• When will I have a scan?

• Where do I get help / support

See NICE guidelines 2012

Take Home Messages

• Think about pre- test probability of ectopic in person you are seeing

• Think ectopic pregnancies with D and V and instead of PE

• PV can add to diagnosis & patient experience

• Urine pregnancy may not be specific enough to rule out if risks high

• Think about feelings (patient and partner and staff)

• Resources: #miscouragestories and Challenging concepts in Emergency Medicine -Rita Das