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9. Genito-urinary diseases
Bleeding during the first half of pregnancy
T h e two d iag noses to firstly consid er are ectopic preg nancy and abortion.
Ectopic pregnancy
P reg nancy th at d ev elops outsid e th e uterus, v ery often in a fallopian tube. E ctopic
preg nancy sh ould be suspected in any w om an of reprod uctiv e ag e w ith pelv ic pain
and /or m etrorrh ag ia. T h ere are m any possible clinical presentations and th ese can
m islead d iag nosis toward s append icitis, intestinal obstruction, salping itis or abortion.
T h e m ajor risk of ectopic preg nancy is rupture, lead ing to intra ab d om inal
h aem orrh ag e.
Clinical features and diagnosis
– Am enorrh oea (m ay be absent) or m enstrual irreg ularity.
– Dark slig h t bleed ing or lig h t to h eav y brig h t red bleed ing ; or h aem orrh ag ic sh ock
w ith lig h t bleed ing not correspond ing to th e sev erity of sh ock (intra-abd om inal
h aem orrh ag e).
– P elv ic pain; som etim es d istend ed abd om en, rebound tend erness.
– O n pelv ic exam ination: tend er ad nexal m ass; exquisite pain in th e P ouch of Doug las
(h aem operitoneum ); closed cerv ix.
– T h e d iag nosis of preg nancy is confirm ed by a positiv e rapid preg nancy test (urinary
test) but a neg ativ e urinary test d oes not rule out an ectopic preg nancy.
– If ultrasound is av ailable, th e presence of an intra-uterine preg nancy elim inates th e
d iag nosis of an ectopic preg nancy. If ultrasound sh ow s an em pty uterus tog eth er
w ith intra peritoneal effusion, an ectopic preg nancy is likely, especially if th e
preg nancy test is positiv e.
Management
If in d oubt (neg ativ e preg nancy test, no sig n of rupture and stable h aem od ynam ic
cond itions), h ospitalise th e patient for surv eillance, if possible in a surg ical facility.
O th erwise, refer im m ed iately for em erg ency laparotom y.
Threatened abortion 9
Clinical features
In a context of am enorrh oea: slig h t, brig h t red bleed ing ; pelv ic pain; closed cerv ix.
Management
– Look for foreig n bod ies or v ag inal wound consistent with ind uced abortion; rem ov e
foreig n bod ies, clean th e wound ; upd ate tetanus im m unization (pag e 170).
– T reat pain: paracetam ol or antispasm od ics P O .
– P lace th e patient on rest.
Abortion
Clinical features
S lig h t or sig nificant brig h t red bleed ing ; expulsion of th e em bryo, m em branes or
prod ucts; uterine contractions; open cerv ix.
247
Bleeding during the first half of pregnancy
T h e two d iag noses to firstly consid er are ectopic preg nancy and abortion.
Ectopic pregnancy
P reg nancy th at d ev elops outsid e th e uterus, v ery often in a fallopian tube. E ctopic
preg nancy sh ould be suspected in any w om an of reprod uctiv e ag e w ith pelv ic pain
and /or m etrorrh ag ia. T h ere are m any possible clinical presentations and th ese can
m islead d iag nosis toward s append icitis, intestinal obstruction, salping itis or abortion.
T h e m ajor risk of ectopic preg nancy is rupture, lead ing to intra ab d om inal
h aem orrh ag e.
Clinical features and diagnosis
– Am enorrh oea (m ay be absent) or m enstrual irreg ularity.
– Dark slig h t bleed ing or lig h t to h eav y brig h t red bleed ing ; or h aem orrh ag ic sh ock
w ith lig h t bleed ing not correspond ing to th e sev erity of sh ock (intra-abd om inal
h aem orrh ag e).
– P elv ic pain; som etim es d istend ed abd om en, rebound tend erness.
– O n pelv ic exam ination: tend er ad nexal m ass; exquisite pain in th e P ouch of Doug las
(h aem operitoneum ); closed cerv ix.
– T h e d iag nosis of preg nancy is confirm ed by a positiv e rapid preg nancy test (urinary
test) but a neg ativ e urinary test d oes not rule out an ectopic preg nancy.
– If ultrasound is av ailable, th e presence of an intra-uterine preg nancy elim inates th e
d iag nosis of an ectopic preg nancy. If ultrasound sh ow s an em pty uterus tog eth er
w ith intra peritoneal effusion, an ectopic preg nancy is likely, especially if th e
preg nancy test is positiv e.
Management
If in d oubt (neg ativ e preg nancy test, no sig n of rupture and stable h aem od ynam ic
cond itions), h ospitalise th e patient for surv eillance, if possible in a surg ical facility.
O th erwise, refer im m ed iately for em erg ency laparotom y.
Threatened abortion 9
Clinical features
In a context of am enorrh oea: slig h t, brig h t red bleed ing ; pelv ic pain; closed cerv ix.
Management
– Look for foreig n bod ies or v ag inal wound consistent with ind uced abortion; rem ov e
foreig n bod ies, clean th e wound ; upd ate tetanus im m unization (pag e 170).
– T reat pain: paracetam ol or antispasm od ics P O .
– P lace th e patient on rest.
Abortion
Clinical features
S lig h t or sig nificant brig h t red bleed ing ; expulsion of th e em bryo, m em branes or
prod ucts; uterine contractions; open cerv ix.
247
