Case Study Reports: Bleeding and Pain in Early Pregnancy

BLEEDING AND PAIN IN EARLY PREGNANCY

History

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 preg- nant. She has been with her regular sexual partner for 2 years and they generally use con- doms 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.

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.

Questions

·              What is the diagnosis?

·             What are the management options in this case?

·             How would you counsel the woman postoperatively?

ANSWER

The diagnosis is an ectopic pregnancy. This can be seen from the positive pregnancy test, ultrasound confirming a pregnancy in the adnexa (with fetal heart beat present in this case), and laparoscopic confirmation of a distended right uterine tube, showing the typical bluish bulge. There is no evidence of blood in the pouch of Douglas (haemoperitoneum) to suggest rupture of the ectopic pregnancy.

Classic symptoms of ectopic pregnancy are amenorrhoea, iliac fossa pain and dark vaginal bleeding. Ectopic pregnancies are, however, often diagnosed in women with any combination of symptoms from heavy vaginal bleeding with clots to period-type pain, to no symptoms at all. Ectopic pregnancies occur in 1–2 per cent of pregnancies and the majority are diagnosed before rupture but occasionally women still present with collapse and this is a medical emergency – a woman with collapse and a positive pregnancy test should be initially assumed to have a ruptured ectopic pregnancy.

Management options

General ectopic pregnancy management options are:

·              surgical (salpingectomy or salpingotomy)

·              medical (methotrexate injection)

·              expectant (wait and see).

In this case, the only option is surgical in view of the fact that a fetal heart beat is pre- sent, rendering conservative options both dangerous (because of risk of rupture) and unlikely to be successful. The ectopic pregnancy should be removed laparoscopically if possible to minimize hospital stay and postoperative pain and to reduce postoperative complications including adhesions. If the contralateral tube is healthy, then the tube may be removed (salpingectomy). If the other is damaged then salpingotomy (incision into the tube to remove the pregnancy) should be attempted.