Haemoglobin	42 g/L
White cell count	8.5 × 10⁹/L
Platelets	160 × 10⁹/L
Urinary pregnancy test	positive
Serum beta hCG	1200 U/L
Cervical PAP smear	no abnormal cells detected; endocervical cells identified
Cervical swab	no evidence of chlamydial infection

Q.4

Interpret these results. What information do they provide? What further investigations may help formulate a diagnosis?

In this instance the pregnancy test was positive, and the complete blood picture, the cervical swab and PAP smear were normal.

On the basis of the positive pregnancy test a pelvic ultrasound examination is arranged (Figure 7.1).

Figure 7.1

Q.5

What does the ultrasound show and what are you going to do now?

Answers

A.1 Further questioning needs to evaluate the extent of the bleeding as compared with a normal period, whether the bleeding occurred after sexual activity, whether there has been any associated pain, whether symptoms of ovulation are usually experienced and whether they were evident during the most recent cycle, and whether there are any symptoms seen consistent with early pregnancy such as more breast enlargement and tenderness than normal, or nausea, or vomiting. When she had her last PAP smear would also be worth defining to evaluate whether the bleeding was likely to be due to a cervical problem.

When taking a history from a woman with abnormal vaginal bleeding the following possible causes need to be considered:

• Is she pregnant and does she have a pregnancy complication? In someone with cycles of variable length, pregnancy is possible so symptoms of pregnancy need to be sought. In someone who has had difficulty conceiving, when a pregnancy is achieved the chance of it being in an ectopic position is increased. You need to ask whether her last menstrual period was of normal volume and duration as it is not uncommon for a ‘period’ to occur in someone who has conceived although the amount of bleeding at the time of the ‘period’ is usually less than normally occurs. If she is pregnant the current 8 days of bleeding could be an indication of the pregnancy being in the Fallopian tube, and not the uterus (an ectopic pregnancy), or that one of the various forms of abortion are occurring (threatened, incomplete, complete or missed abortion).

• If she is not pregnant, the most likely causes are a problem at the level of the cervix, or a disturbance of her oestrogen and/or progesterone levels resulting in irregular shedding of her endometrium (DUB = dysfunctional uterine bleeding).

• Is the bleeding from her cervix? For example, a cervical polyp or carcinoma? Check when her last PAP smear was done, whether PAP smears have ever been abnormal, whether there have been previous episodes of abnormal bleeding and whether she has ever had bleeding after sexual activity. Recurrent bleeding, and especially postcoital bleeding, often has a cervical origin.

• Does she have DUB? This would be suggested by the previous menstrual cycles being irregular, or where the definite symptoms associated with ovulatory menstrual cycles (midcycle mucus change, premenstrual bloating of the abdomen, premenstrual dysmenorrhoea) are absent.

• Abnormal bleeding in a woman with uterine fibroids is generally heavy bleeding at the time of the period. Bleeding between the periods is only likely if one of the fibroids is in the submucosal position and is being extruded.

A.2 The clinical examination is often of limited value in making the correct diagnosis in patients with abnormal vaginal bleeding. Even if this patient was pregnant the uterus is not going to be significantly enlarged. If a cervical cancer was present or a uterine fibroid was being extruded, this should be able to be seen unless it is entirely within the cervical canal. If the bleeding is due to DUB, no abnormality will be able to be detected on clinical examination. In the absence of pain, even if the bleeding was associated with an ectopic pregnancy, it is likely that the pelvic examination findings will be normal. If pain was present it is more likely that there will be bleeding into the pelvic peritoneal cavity, under which circumstances it is likely that there will be adnexal tenderness, cervical excitation and a ‘boggy’ feeling in the pouch of Douglas.

A.3 The investigations required are:

• Complete blood picture, to particularly check the haemoglobin level and the white cell count.

• Pregnancy test, to diagnose or rule out pregnancy.

• Cervical swabs, to exclude chlamydia, although this is unlikely.

• PAP smear, to probably exclude cervical cancer.

A.4 She is pregnant; however, the site of this, and whether it is progressing satisfactorily, are not known. The cause of the bleeding has therefore not been defined.

A vaginal ultrasound examination is required to site the pregnancy and to determine if it is progressing normally. Ideally this should not be performed until the quantitative beta-hCG level is assessed and shown to be at least 1000 IU/L, because even a normal intrauterine gestation sac will not be visible at lower hCG levels. If the hCG level is greater than 1000 IU/L and a gestation sac cannot be seen in the uterus, it is highly likely the diagnosis is an ectopic pregnancy. Sometimes the actual sac containing the fetus can be seen outside the uterus, or a mass of clot and the pregnancy can be seen in one adnexum. The other possible diagnosis if a gestation sac cannot be found under those circumstances is that the whole pregnancy was intrauterine but has been lost (complete abortion).

If the vaginal ultrasound shows the sac is in the uterus, the type of ‘abortion’ then needs to be defined by the ultrasound examination. Types include:

• Threatened abortion with generally a good prognosis: normal sac size, normal fetal size, fetal heart tones present, gestation and estimated due date (EDD) defined.

• Threatened abortion with increased risk of fetal loss: all the above plus a large amount of intrauterine blood clot, or fetal heart rate less than 100 bpm.

• Inevitable abortion: a very small sac, a normal-sized sac with a very small fetus or a sac with no evidence of a fetus (blighted ovum).

• Incomplete abortion: only placental tissue within the uterus.

• Missed abortion: the gestation sac contains the fetus, but the fetus is dead, i.e. no fetal heart tones are present.

A.5 The ultrasound shows an empty uterus, so the diagnosis is either an ectopic pregnancy or complete abortion, providing the beta-hCG level is greater than 1000 IU/L. The hCG level must therefore be checked.

If it is >1000 IU/L, the diagnosis is probably an ectopic pregnancy and laparoscopic assessment to confirm this diagnosis is usually recommended. The other option would be to reassess the beta-hCG level in 2 and 4 days time, as:

• If a complete abortion was the diagnosis the levels should be falling progressively.

• If the levels were increasing progressively and doubling every second day, a normal intrauterine pregnancy missed on the previous ultrasound examination would need to be considered.

• If the levels were constant, not falling significantly nor doubling every second day, an ectopic pregnancy would be likely.

There are a number of therapeutic options once the diagnosis of ectopic pregnancy has been defined and preferably proven by laparoscopy. The most appropriate option would be the administration of a single dose of intramuscular methotrexate (1 mg/kg) along with folinic acid rescue to destroy the ectopic pregnancy. This is associated with a better chance of tubal patency than when any of the surgical options are employed. It is appropriate treatment, if there is no or minimal intraperitoneal bleeding, especially if the beta hCG level is less than 4000 IU/L, the pregnancy sac size is small or not identified, and no fetal heart tones are detected in the ectopic pregnancy itself if it can be seen. Tubal rupture with resulting intraperitoneal bleeding can occur after methotrexate therapy, but is unusual.

Other options include:

• Salpingostomy performed as an open operative procedure or performed laparoscopically.

• Partial salpingectomy performed as an open procedure or laparoscopically (usually the ovary is not removed at the time of removal of the Fallopian tube).

Issues to Consider

• What types of imaging can be used safely in pregnancy?

• What advice would you give to this woman with regard to her further chances of successful pregnancy?

Further Information

, www.advancedfertility.com/ectopfot.htm. Laparoscopic images of ectopic pregnancy

, www.emedicine.com/EMERG/topic478.htm. An article from the eMedicine series on ectopic pregnancy

[/level-membership-for-surgery-category][not-level-membership-for-surgery-category]

Problem 7 A young woman with abnormal vaginal bleeding

Roger J. Pepperell

Q.1

What further information would you like from the history and why?

Q.2

What physical findings would assist in making a correct diagnosis?

Physical examination of the patient is unremarkable. In particular, abdominal and pelvic examination is normal. The vagina and cervix appear healthy.

Q.3

What investigations should you perform to define the likely cause of the bleeding?

The results of the tests you arranged were as follows:

Investigation 7.1 Summary of results

Haemoglobin	42 g/L
White cell count	8.5 × 10⁹/L
Platelets	160 × 10⁹/L
Urinary pregnancy test	positive
Serum beta hCG	1200 U/L
Cervical PAP smear	no abnormal cells detected; endocervical cells identified
Cervical swab	no evidence of chlamydial infection