Bleeding in the 2nd trimester pregnancy (12-19+6 weeks)
Vaginal bleeding is common at all stages of pregnancy. Spotting and very small amounts of blood may be harmless but there are certain types of bleeding that
Cases of obstetrics. Part I
Urinary pregnancy test: positive Urinalysis: protein trace; blood negative; 16. Figure 6.2 Transvaginal image of a normal 8-week gestation sac and fetus ...
Frequently Asked Questions in Pregnancy
When should I be concerned about vaginal spotting and cramping? •. Light spotting and mild cramping can be perfectly normal in the first several weeks of
Patterns of vaginal bleeding during the first 20 weeks of pregnancy
20 weeks of nulliparous pregnancy and the presence or absence of vaginal bleeding elevation of blood pressure at the 14–16 weeks SCOPE inter-.
Management of vaginal bleeding presenting to the accident and
3 Accid Emerg Med 1999;16:130-135. CLINICAL MANAGEMENT pregnancy a week although not all present via ... neum
A 28 year old woman gravida 2
at 16 weeks gestation
NG201 Evidence review V
21 août 2021 Evidence reviews underpinning recommendations 1.4.16 to ... present with vaginal bleeding after 13 weeks of pregnancy should be offered ...
OBA OB Booklet - Website
which lifts the pregnant uterus can help reduce pelvic varicose veins. Vaginal spotting occurs in half of all pregnancies
Problems in Early Pregnancy
Is it Normal to have bleeding/spotting in pregnancy before 18 weeks? Spotting or bleeding in early pregnancy can be common. It can occur in about 15 in 100
Safe abortion
2.5 Medical abortion: 12 weeks (or 84 days) of pregnancy what she is likely to experience (e.g. pain and bleeding) and how long the process.
3AccidEmergMed1999;16:130-135
CLINICALMANAGEMENT
Abnormalvaginalbleeding
Non-pregnant
<20MiscarriageEctopicAbno
conceiThreatenedInevitableCompletePregnantor
suspiciousofpregnancy weeks>20weeks irmalAbruptioneptionplacentapraevia nancyismiscarrying,orinarupturedectopic maysuggestpelvicinflammatorydiseasewhichAccepted5September1998
Prepubertal130 on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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Managementofvaginalbleeding
Table1Pointstocoverinhistorytaking
Table2Keypointsonexamination
CardiovascularstatusTachycardia,bradycardia,bloodpressureAbdominalexaminationPalpableuterus/abdominalmassTenderness,rebound,distensionListenforfetalheartbeatPelvicexaminationCervicalosopen/closedSizeofuterus,adnexalmasses,ortenderness131 on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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Buckingham,Fawdry,Fothergill
Table3Keyinvestigations
Figure2Transvaginalultrasoundscanshowingaviable9weekpregnancy(crownrumplength23mm,theyolksacisalsoseenasaclearcircleabovethelowerlimbs).132 on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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Managementofvaginalbleeding
Figure3Exampleofaninformationleaflet tobegiventopatientsbeforeattendinganearlypregnancyassessmentunit.
TREATMENT
Pregnancytestpositive
Inevitable/incomplete
Threatened/missed
RefertogynaecologistHome:GPorearlypregnancyunit*BleedinginearlypregnancyVaginalexaminationandtheuseofultrasoundtodetermineviabilitysignificantlyreducesadmissions(28%to12%),referraltogynae-cologists(44%to22%),andreattendance(15%to4%).'Manycentresnowprovideanearlypregnancyassessmentunitthenextdayifpatientsarestableandectopicpregnancyisunlikely.Thereisgreatvalueinhavinganinformationleafletavailabletothosepatientswhomaybehavingathreatenedmiscarriageiftheyhavetowaituntilthenextdayforascan.Anexampleofaninformationleafletisshowninfig3.Thosepatientswhohaveheavybleedingoronexaminationhaveanopenosdorequirereferraltothegynaecologistforadmission.Ifonexaminationtherearevisibleproductswithintheostheseshouldberemovedastheycancontributetoquitesignificantvasovagalresponse.Surgicalmanagementisnolongertheonly optionfortreatingincomplete/inevitablemiscarriages.Medicalmanagementwithmisoprostolenableswomentohavepromptattentionandavoidstheinevitabledelayboughtaboutfromlimitedemergencyoperatinglists.
Followingthisyouwillbe byseenbyaseniordoctor,whowillexplaintheresultsandarrangeanytreatmentthatisnecessary.Occasionallythescanisinconclusiveandyoumaybeaskedtoreturnforfurtherbloodtests2dayslater,oranotherscan1-2weekslater.
Figure4Managementofbleedinginearlypregnancy.133 on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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Summary
Questionsrelatingtothisarticle(1)Whenwillbeahomepregnancytestfirstindicateapositiveresultforawomanwhohasconceivedwithapreviouslyregular28daymenstrualcycle?(A)Sixweeksafterherlastperiod(B)Threeweeksafterherlastperiod(C)Atthetimeshewouldhaveexpectedtostarthernextperiod,thatisfourweeksafterherlastperiod(2)Awomanpresentswithvaginalspottingat16weeks,thefetalheartispresentandtherearenoothersymptoms.ShecarriesabloodcardindicatingthatherbloodgroupisAnegative.Whatdoseofanti-Dshouldyouprescribeandhowsoonafterthebleedingoccursshouldthisbegiven?(3)Whatfactorsinthehistorywouldleadto ahighindexofsuspicionthata25yearoldpatientpresentingwithvaginalbleedinghadanectopicpregnancy?
KeyreferencesThethreekeyreferencesareGilling-Smithetal,'DepartmentofHealth,'andAmericanCollegeofEmergencyPhysicians.'7134 on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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1EverettC.Incidenceandoutcomeofbleedingbeforethe20thweekofpregnancy:prospectivestudyfromgeneralpractice.BMJ1997;315:32-4.2Gilling-SmithC,ZelinJ,TouquetR,etal.Managementofearlypregnancybleedingintheaccidentandemergencydepartment.ArchEmergMed1988;5:133-8.3DepartmentofHealth.ReportonconfidentialenquiriesintomaternaldeathsintheUnitedKingdom1991-1993.London:HMSO,1996.4LingFW,StovallTG.Updateonthediagnosisandmanage-mentofectopicpregnancy.Advancesinobstetricsandgynae-cology.Chicago:MosbyYearBook,1994:55-83.5RamoskaEA,SacchettiAD,NeppoM.Reliabilityofpatienthistoryindeterminingthepossibilityofpregnancy.AnnEmergMed1989;18:48-50.6MuramD,SanfillipoJS,HerweckSP.Vaginalbleedinginchildhoodandmenstrualdisordersinadolescence.In:SanfilippoJS,ed.Pediatricandadolescentgynaecology.Philadelphia:WBSaunders,1994.7RoyalCollegeofObstetriciansandGynaecologists.Intimateexaminations.Reportofaworkingparty.London:RCOGPress,1997.8OlshakerJS.Emergencydepartmentpregnancytesting.JEmergMed1996;14:59-65.9ChardT.Pregnancytests:areview.HumReprod1992;7:701-10.10CacciatoreB,TiitinenA,StenmanUH,etal.Normalearlypregnancy:serumHCGlevelsandvaginalultrasonographyfindings.BrJObstetGynaecol1990;97:899-903.11FratesMC,LaingFC.Sonographicevaluationofectopicpregnancy:anupdate.AIR1995;165:251-9.12NationalBloodTransfusionServiceImmunoglobulinWorkingParty.Recommendationsfortheuseofanti-Dimmunoglobulin.Prescribersjournal1991;31:137-45.13DepartmentofHealth.ReportonconfidentialenquiriesintomaternaldeathsintheUnitedKingdom1988-90.London:HMSO,1994.14BonnarJ,SheppardBL.Treatmentofmenorrhagiaduringmenstruation:randomisedcontrolledtrialofethamsylate,mefanamicacidandtranexamicacid.BMJ1996;313:579-82.15WestR,DaviesA,FentonT.Accidentalvulvalinjuriesinchildren.BMJ1989;298:1002.16HillNCW,OppenheimerLW,MortonKE.Theaetiologyofvaginalbleedinginchildren:a20yearreview.BrJObstetGynaecol1989;96:467.17AmericanCollegeofEmergencyPhysicians.Clinicalpolicyfortheinitialapproachtopatientspresentingwithachiefcomplaintofvaginalbleeding.AnnEmergMed1997;29:435-58. on July 1, 2023 by guest. Protected by copyright.http://emj.bmj.com/J Accid Emerg Med: first published as 10.1136/emj.16.2.130 on 1 March 19
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