Avon CASH Group 9th September 2015.

Case Discussion

Sarah is a 23 year old patient who comes to see you in your GP Surgery complaining of period like vaginal bleeding and cramping pain 10 days after she had a termination of pregnancy.

What should you ask Sarah?

  1. How much bleeding is she getting?
  • How many pads / hour?
  • Is she passing clots / flooding?

NB – if soaking through > 2 pads / hour for 2 consecutive hours needs urgent referral to gynae.

  1. What is the pain like?
  • Location of pain?
  • Radiation?
  1. Controlled by analgesia or not?
  1. Is she feeling unwell?
  • Fever?
  • Malaise?
  1. Type of termination?
  • MTOP or STOP?
  • If MTOP – in Hospital or at home?
  • If Hospital MTOP – did patient pass POC in hospital (confirmed by medical staff)? Or was she sent home before POC passed with a f/u USS arranged (usually arranged for 2 weeks post MTOP)?
  • If Home MTOP (immediate discharge after misoprostol) – did patient pass ? POC / bleed heavily after miso?
  • How many weeks pregnant was patient at time of TOP?
  1. Has the patient started any form of contraception?
  1. Sexual History?
  • LSI? With whom? Regular partner or not? Contraception?
  • Last STI screen - results?
  • Prophylactic antibiotics given / taken at time of TOP?

NB:

Patient should have had STI screen offered at initial PAS appointment.

Patient should be given prophylactic antibiotics (azithro and metz) at time of TOP.

Patient should be advised not to have sex after TOP until bleeding stopped.

  1. What follow up has the patient had / is due to have? Does patient have gynae ward / PAS / Primecare number for follow up problems?

Would you examine Sarah?

Yes you should!

Temp, P, BP.

Speculum – POC at os?

Bimanual examination.

Repeat STI screen if indicated.

What could be the cause of Sarah’s bleeding?

Differential diagnosis:

  • Infection:
  • Endometritis.
  • PID – consider if risk factors for STI.
  • RPOC.
  • Bleeding secondary to SE of contraception.
  • Bleeding secondary to TOP – would normally expect up to approx. 3 weeks of bleeding (heavy for first few days) – gradually getting lighter.

How would you manage Sarah?

If possible RPOC / Endometritis / PID:

  • If STI screen negative / given prophylactic antibiotics at time of TOP – give co-amoxyclav.
  • If risk factors for STI – give ofloxacin and metronidazole.
  • If risk factors for GC (contact of GC / purulent discharge) – ref into GUM.

Review if not improving after 72 hours.

When would you refer Sarah to gynaecology?

  • If systemically unwell with fever / tachycardia / hypotension.
  • If heavy bleeding - > 2 pads / hour for 2 consecutive hours.
  • If POC at os (and you don’t feel happy to remove them yourself).
  • If failure to respond to treatment.

NB – RCOG:

“While ultrasound examination will reliably exclude continuing pregnancy, its routine use in women, suspected of incomplete abortion can be misleading. Ultrasound appearances and measurements of endometrial thickness correlate poorly both with symptoms suggestive of retained products of conception and with later histological examination. Ultrasound appearances are not a clinically useful predictor for the subsequent need for surgical evacuation.The decision to undertake uterine evacuation should be based upon the presence of signs and symptoms.”