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A 27-year-old woman attends the emergency department with irregular vaginal bleeding and
abdominal discomfort.
She noticed the bleeding 2 days previously and it is dark red, sufficient for her to need to wear a
sanitary towel, but not heavy. The abdominal discomfort is suprapubic and crampy, slightly more
on the right-hand side. She is systemically well with no fever, change in appetite, nausea or
vomiting. She says that her bowel and urinary habits are normal. Her last menstrual period
commenced 45 days previously and she usually has a slightly irregular cycle, bleeding for 3-5
days every 28-35 days. She has never been pregnant. She has been with her regular sexual
partner for 2 years and they generally use condoms but there are some occasions where they do
not. She had a sexual health screen 6 months ago at the genitourinary clinic where she was told
all her swabs were negative. She has no previous gynaecological history and no significant
previous medical problems.
Clinical case
Examination
The blood pressure is 128/72 mmHg and heart rate is 82/min. The abdomen is soft and non-
distended. There is tenderness on deep palpation in the suprapubic and right iliac fossa regions,
but no rebound tenderness or guarding. Bimanual examination is not performed.
Investigations
Urinary pregnancy test: positive
Transvaginal ultrasound scan is shown in Fig.
Clinical case
The woman is taken for laparoscopy after the
ultrasound scan and Fig. shows the findings.
Questions:
A. Appendicitis
B. Diverticulitis
C. Ectopic pregnancy
D. Ovarian torsion
E. Ruptured ovarian cyst
Practise question
A 26-year-old woman comes to the emergency department because of lower abdominal
pain and vaginal bleeding for the past 24 hours. Her last menstrual period was 7 weeks ago. She
is sexually active with her boyfriend and they use condoms intermittently. Physical examination
reveals mild tenderness in the left lower quadrant and left adnexa. The cervix is closed with
dried blood visible at the os; there is no active bleeding. A quantitative serum B-HCG is 1,500
IU/L. Transvaginal sonography of the patient's right adnexa reveals an extra-uterine gestational
sac with a diameter of 2 cm. ectopic pregnancy
Which of the following is the most appropriate management option for this patient?
A. Laparoscopic salpingectomy
B. Open salpingectomy
C. Methotrexate – IV shrinks the embryo, inhibits rapid dividing cells in entire body* (medical mgt)
D. Suction and curettage
E. Misoprostol
Practise question
A 26-year-old woman comes to the emergency department because of lower abdominal
pain and vaginal bleeding for the past 24 hours. Her last menstrual period was 7 weeks ago. She
is sexually active with her boyfriend and they use condoms intermittently. Physical examination
reveals mild tenderness in the left lower quadrant and left adnexa. The cervix is closed with
dried blood visible at the os; there is no active bleeding. A quantitative serum B-HCG is 1,500
IU/L. Transvaginal sonography of the patient's right adnexa reveals an extra-uterine gestational
sac with a diameter of 2 cm.
Which of the following is the most appropriate management option for this patient?
A. Laparoscopic salpingectomy
B. Open salpingectomy
C. Methotrexate
D. Suction and curettage
E. Misoprostol
Causes of bleeding during early pregnancy MOLAR PREGNANCY
• Serial Quantitative HCG levels every 2 weeks until 3 consecutive levels are
negative
• Then monthly HCG levels for 1 year, watching for recurrence
• No pregnancy for 1 year
• If any significant rise in HCG during the year of observation, methotrexate
therapy
• Hysterectomy is acceptable therapy if no further childbearing is desired.
Practise question
A 25-year-old woman, gravida 1, para 0, comes to the antenatal clinic because
of vaginal bleeding. She is in her first trimester and has felt well during her
pregnancy apart from nausea and the presence of pelvic pressure when asked.
Her blood pressure is 125/80 mm Hg. Physical examination shows an abnormally
large uterus (twin, multiple pregnancy or MOLE) for her gestational age.
Laboratory studies are obtained and show trace amounts of protein and
a hCG concentration of 175,000 mIU/mL. Which of the following is the most likely
diagnosis?
A. Complete molar pregnancy - answer*
B. Eclampsia – convulsion, hyper person
C. Normal pregnancy
D. Partial molar pregnancy – no large fundus
E. Pre-eclampsia - associate HIGH BLOOD PRESSURE, hers fine
Practise question
A 25-year-old woman, gravida 1, para 0, comes to the antenatal clinic because
of vaginal bleeding. She is in her first trimester and has felt well during her
pregnancy apart from nausea and the presence of pelvic pressure when asked.
Her blood pressure is 125/80 mm Hg. Physical examination shows an abnormally
large uterus for her gestational age. Laboratory studies are obtained and show
trace amounts of protein and a hCG concentration of 175,000 mIU/mL. Which of
the following is the most likely diagnosis?
A. Complete molar pregnancy
B. Eclampsia
C. Normal pregnancy
D. Partial molar pregnancy
E. Pre-eclampsia
Vaginal Bleeding in Late Pregnancy – never touch woman* only ultra sound*
The causes of serious vaginal bleeding in the
second half of pregnancy include abruptio
placentae, placenta previa, and vasa previa.
• Classification
• Total, complete, or central previa is found when the placenta completely covers the
internal cervical os. This is the most dangerous location because of its potential for
hemorrhage.
• Partial previa exists when the placenta partially covers the internal os.
• Marginal or low-lying previa exists when the placental edge is near but not over the
internal os.
PLACENTA PREVIA: PRESENTATION
• Consider placental abruption in pregnant women with acute, painful vaginal bleeding
or with acute abdominal/uterine pain.
• Clinical features depend on the degree of placental abruption.
• Mild abruption is characterized by mild uterine tenderness, no or mild vaginal bleeding,
normal maternal vital signs, no coagulopathy, and fetal distress.
• Signs and symptoms of severe abruption are no or heavy vaginal bleeding, fetal distress,
coagulopathy, severe uterine pain or tenderness, continuous or repetitive uterine
contractions, and maternal hypotension or shock. Nausea, vomiting, and back pain may
also be present.
ABRUPTIO PLACENTAE: DIAGNOSIS
• Diagnosis is made by the clinical features.
• Electronic fetal monitoring (cardiotocodynamometry) is very sensitive for
identifying fetal distress as a sign of placental abruption and has a 100% negative
predictive value for adverse outcomes when monitoring is reassuring.
• Transvaginal US is fairly specific for the diagnosis, but is not sensitive for the
detection of retroplacental clot because the appearance of clotted blood evolves
in echotexture over time.
• MRI is diagnostic but requires the transport of a potentially unstable patient out
of the ED or intensive care unit for imaging.
Practise question
A 30-year-old woman, grava 2, para 1, at 36 weeks gestation, comes to
the emergency department because of severe abdominal pain for the past hour.
She describes sudden onset "sharp" and "cramping" pain which began shortly after
she was involved in a motor vehicle accident. She has also noticed a small amount
of vaginal bleeding. Vital signs shows no abnormalities. Physical examination
shows bright-red blood in the vaginal vault and a firm, tender uterus. Tocometer
shows low amplitude regular contractions, approximately every two minutes.
Which of the following is the most likely diagnosis?
A. Placental abruption
B. Placenta accreta
C. Placenta previa
D. Placenta percreta
E. Premature rupture of membranes
Practise question
A 30-year-old woman, grava 2, para 1, at 36 weeks gestation, comes to
the emergency department because of severe abdominal pain for the past hour.
She describes sudden onset "sharp" and "cramping" pain which began shortly after
she was involved in a motor vehicle accident. She has also noticed a small amount
of vaginal bleeding. Vital signs shows no abnormalities. Physical examination
shows bright-red blood in the vaginal vault and a firm, tender uterus. Tocometer
shows low amplitude regular contractions, approximately every two minutes.
Which of the following is the most likely diagnosis?
A. Placental abruption
B. Placenta accreta
C. Placenta previa
D. Placenta percreta
E. Premature rupture of membranes
UTERINE RUPTURE
• Uterine rupture is complete separation of the wall
of the pregnant uterus with or without expulsion of
the fetus that endangers the life of the mother or
the fetus, or both. The rupture may be incomplete
(not including the peritoneum) or complete
(including the visceral peritoneum).