Bleeding 1 (Ectopic)

<img src="/Bleeding1/pain.jpg"/> Mrs. Clara, a 32- year-old P1+1, attends the emergency department with severe lower abdominal pain and mild vaginal bleeding for the past 2 hours. On further questioning, the pain is acute onset, and localized to the right side of her lower abdomen. Her last menstrual period was 6 weeks ago. Her cycles are normally regular. Five years ago, she underwent uterine evacuation for incomplete miscarriage at 8 weeks of gestation. Currently, she has a healthy 3 year-old girl delivered by caesarean section for prolonged labour. Postoperative period was uneventful. She practiced barrier contraception in the first year. Her urine test today is positive for hCG. You are in charge of the emergency department. You have a busy night with many ill and urgent cases to attend to. You need to obtain further quick relevant history in this patient to reach your diagnosis. Which of the following histories is NOT very helpful in this situation? [[1. Characteristics of pain such as nature, onset, severity, site, relieving factors, aggravating factors]] [[2. Anaemic symptoms such as palpitation, shortness of breath, syncope]] [[3. Detailed past obstetric history of her healthy 3 year old girl]] [[4. Gynaecological history such as any pap smear, ovarian cyst, pelvic inflammatory disease]] (track: 'Basic rock 135', 'play') (track: 'Basic rock 135', 'volume', 0.4)

Uhh oh, sorry. Cyanosis is not very relevant here. Your general examination should aim to determine any signs of pallor or sepsis, and assess conscious level. Sorry, try again. (track: 'evil laugh', 'play') (track: 'evil laugh', 'volume', 0.2)

Excellent ! You are absolutely right. You need to do general examination to check pallor and conscious level. You also need to check her vital signs and perform an abdominal examination to check whether it is soft, looking for any tenderness, ragidity, larger-than-date uterus, presence of other masses, free fluid, and bowel sounds. A pelvic examination is needed to check for any active bleeding, assess the amount of bleeding, check whether the cervical os is open or closed, check for presence of products of conception, any grape-like vesicles, cervical excitation tenderness, assess uterus size, and whether the uterus is larger than date. You can now go to the next part below. <image src="/Bleeding1/womanbreathe.jpg"/> What are your differential diagnoses at this juncture? [[1. Molar pregnancy, miscarrige, ovarian tortion, ectopic pregnancy]] [[2. Ectopic pregnancy, acute appendicitis, endometriosis, miscarriage]] [[3. Miscarriage, ectopic pregnancy, hyperemesis gravidarum, ovarian cyst rupture]] (track: 'short success', 'play') (track: 'short success', 'volume', 0.7)

Ohhhh. You are almost right......but...... Cord prolpase will not happen in this first trimester. No worries, try again. (track: 'evil laugh', 'play') (track: 'evil laugh', 'volume', 0.2)

Sorry, you might be wondering why it is wrong. Yes, all the information is correct regarding vital signs, except for deep tendon reflexes. But don't give up. Try again ;-) (track: 'evil laugh', 'play') (track: 'evil laugh', 'volume', 0.2)

You are good! Yes, that's right. Here are the differential diagnoses of lower abdominal pain with vaginal bleeding in early pregnancy: • Molar pregnancy • Miscarrige • Ovarian tortion, rupture with treatened miscarrage • Ectopic pregnancy • Appendicitis with treatened miscarriage • Acute pelvic inflammatory disease with threatened miscarriage Now you can move on to the next [[part]]. (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.2)

Good Try. But endometriosis is less likely to present with acute lower abdominal pain. Try again. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 0.7)

Try again. Hyperemesis gravidarum will not present with lower abdominal pain and per vaginal bleeding. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 0.7)

I got you. Endometrial polyp is not relevant here. Try again ;-) (track: 'error', 'play') (track: 'error', 'volume', 0.2)

Uhh Grrrrr It's disappointing, isn't it? We don't need D-Dimer for this patient. I am sorry. Please try again. (track: 'error', 'play') (track: 'error', 'volume', 0.2)

Detailed history of pain is extremely relevant and you DO need to ask about this. Read the question carefully ;-) Sorry, Try again. (track: 'no', 'play') (track: 'no', 'volume', 0.4)

uh oh...Your patient is bleeding. Detailed history of anaemia IS very important. Read the question carefully ;-) Sorry, Try again. (track: 'no', 'play') (track: 'no', 'volume', 0.4)

Hooray! Yes you made the right choice. This history is the least relevant at this urgent moment. Now try the next question. What physical examination would you perform in this patient? Also, think of your expected findings or reason. <img src="/Bleeding1/womanface.jpg"/> [[1. General examination to check for pallor, cyanosis, cachexia]] [[2. Vital signs such as blood pressure, pulse rate, respiratory rate, deep tendon reflexes]] [[3. Abdominal examination to check tenderness, ragidity, uterus larger than date]] [[4. Pelvic examination to check for any active bleeding, cord prolapse, or products of conception]] (track: 'music box', 'play') (track: 'music box', 'volume', 0.3)

Oh no! That's not the right answer. But your thinking is right, this IS an important history that you should ask her about. You just need to read the question carefully and try again. (track: 'no', 'play') (track: 'no', 'volume', 0.4)

Well done! That is right. Investigations you need are: • Full blood count to check for signs of anemia or infection • Group and crossmatch in case she needs a transfusion. • Pelvic ultrasound to look for free fluid, adnexa mass, empty uterus, and 'snow storm' appearance; also to check the intrauterine sac, fetal pole, and fetal heart activity. Go to [[Next]] (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

Oops. Threatened miscarriage will show an intrauterine gestational sac on the ultrasound. Try again ;-) <img src="/Bleeding1/USSgestsac.jpg"> Image source: https://www.youtube.com/watch?v=xLDoXyOQR3U (track: 'wake up', 'play') (track: 'wake up', 'volume', 0.2)

Uhhh ahhh Molar pregnancy will show a snow storm appearance on the ultrasound. Try again :-) <img src="/Bleeding1/USSsnowstorm.jpg"/> Image source: https://alamhamilblog.com/2014/05/18/kandungan-molar-atau-anggur/ (track: 'wake up', 'play') (track: 'wake up', 'volume', 0.2)

Oh dear. You saved her by timely resuscitation but you killed her by doing the wrong procedure. Luckily you still have a chance here. Try again :-) (track: 'yell', 'play') (track: 'yell', 'volume', 0.2)

Oh dear. You saved her by timely resuscitation but you killed her by waiting for another 48 hours. It is a ruptured ectopic and she is bleeding. Luckily you still have a chance here. Try again ;-) (track: 'yell', 'play') (track: 'yell', 'volume', 0.2)

<h3>Congratulations!</h3> You have saved your patient's life by timely and correct management. I am so proud of you! <img src="/Bleeding1/greys-anatomy-film.jpg"> Here are the reading resources for your case. Please don't forget to read to save patients in real life. And also to pass your exam !!! 1. <a href="/Bleeding1/Diagnosis and management of Ectopic pregnancy RCOG.pdf" target="_blank">Diagnosis and management of ectopic pregnancy (RCOG)</a> 2. <a href="/Bleeding1/Ectopic Gynaecology by 10 Teachers 18th Ed.pdf" target="_blank">Ectopic Pregnancy chapter, Gynaecology by 10 Teachers, 18th edition</a> 3. <a href="/Bleeding1/Ectopic Oxford Handbook of Obstretics & Gyneacology 3rd ed.pdf" target="_blank">Ectopic Pregnancy Problems, Handbook of Obstetrics & Gynaecology, 3rd edition</a> (link: "Restart Game")[(reload:)] Some artwork for this website were generated by the author using AI tools (Ideogram 2.0 and DALL-E) (track: 'happykids', 'play') (track: 'happykids', 'volume', 0.2)

Nah Nah... Twisted ovarian cyst will not show any free fluid on the ultrasound. Try again ;-) (track: 'wake up', 'play') (track: 'wake up', 'volume', 0.2)

You made it! You got the correct diagnosis in no time. Well done! Now, you need to save the patient. <img src="/Bleeding1/patientcartoon.jpg"/> Outline the management options to save your patient. <em>The clock is ticking... tick tock, tick tock</em>. <em>Your patient is deteriorating. Hurry!</em> [[1. Resuscitation, emergency suction and currettage]] [[2. Resuscitation, take an urgent Beta hCG and repeat in 48 hours]] [[3. Resuscitation, emergency salpingectomy]] [[4. Resuscitation, urgent hysteroscopy]] (track: 'cheer', 'play') (track: 'cheer', 'volume', 0.1)

Hey, you're progressing really well but there's more to be done. Hang on! Upon further history taking, Mrs. Clara says that her pain is located in the lower abdomen, but sometimes radiates to her right shoulder tip. She fainted once at home. On examination, she appears very pale. Her BP is 90/60 mmHg, pulse is 110/ min, and she is afebrile. Her abdomen is tense, with tenderness at the right iliac fossa and lower abdomen. Her pelvic examination shows the following: os closed, minimal bleeding, cervical excitaion positive. Uterus is around 6-8 weeks. Her ultrasound reveals the following: empty uterus, free fluid, right adnexa mass <img src="/Bleeding1/USSfreepelvicfluid.jpg"> Image source: https://www.aafp.org/pubs/afp/issues/2009/0601/p985.pdf What is your provisional diagnosis? [[1. Threatened miscarriage]] [[2. Molar pregnancy]] [[3. Twisted ovarian cyst]] [[4. Ruptured ectopic pregnancy]]

<h3>You are about to start your next exciting game.</h3> Read the scenarios and questions carefully, then try your best to answer them. If you make the wrong choice, you can go back and try again. Good luck! Let's [[start->Scenario]]

Choose the relevant investigations with correct justifications that you would request in Mrs Clara, whose LMP was 6 weeks ago and is presenting with lower abdominal pain and vaginal bleeding. [[1. Full blood count to check platelets; Group and crossmatch in case she needs a transfusion; Pelvic ultrasound to rule out endometrial polyp.]] [[2. Full blood count to check for anemia; Group and crossmatch in case she needs a transfusion; Pelvic ultrasound to look for free fluid, adnexa mass, and empty uterus.]] [[3. Pelvic ultrasound to look for a 'snow storm' appearance; D-Dimer and full blood count to rule out anaemia]] [[4. Pelvic ultrasound to look for an empty uterus; D-Dimer and full blood count to look for an infection.]]

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