Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions

(Created page with "===Background=== * Occurs in 20-40% of 1st trimester pregnancies * Once IUP is confirmed by ultrasound no utility in obtaining B-hCG * Ultrasound * Do not use hCG to determine ...")
 
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===Background===
* Occurs in 20-40% of 1st trimester pregnancies
* Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
* Ultrasound
** Do not use hCG to determine whether ultrasound should be obtained
*** "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
**** Pelvic - can visualize IUP at hCG ~ >1500
**** Abd - can visualize IUP at hCG ~ >6000
===DDX===
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Ectopic Pregnancy</font></span></font>
** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">hCG > 1500 + no IUP</font></span></font>
* <font face="Arial">Miscarriage</font>
** <font face="Arial">Complete Abortion</font>
*** <font face="Arial"><12 weeks + no IUP</font>
*** <font face="Arial">Distinguish from ectopic based on decreasing hCG, decreased bleeding</font>
**** <font face="Arial">Only need to send hCG if unable to examine POC</font>
** <font face="Arial">Threatened Abortion</font>
*** <font face="Arial">Closed os + IUP + cramps and/or bleeding<br /></font>
*** <font face="Arial">If < 11wks >90% go to term</font>
*** <font face="Arial">If between 11 and 20 weeks 50% go to term</font>
** <font face="Arial">Inevitable Abortion</font>
*** <font face="Arial">Open os + contractions/cramps</font>
** <font face="Arial">Incomplete Abortion</font>
*** <font face="Arial">>12 wks + passage of only portion of POC</font>
** <font face="Arial">Missed Abortion</font>
*** <font face="Arial"><20 wks + no cardiac activity</font>
* <font face="Arial">Non-pregnancy related bleeding</font>
** <font face="Arial">Cancer</font>
** <font face="Arial">Fibroids</font>
** Cervicitis
<font face="Arial">�</font>
===Evaluation===
* History
** <font face="Arial">Previous spontaneous abortion?</font>
** <font face="Arial">Extent of bleeding, clots, tissue</font>
** <font face="Arial">Presence of cramping</font>
** <font face="Arial">Light-headedness?</font>
** <font face="Arial">Risk Factors for Ectopic</font>
*** <font face="Arial">PID</font>
*** <font face="Arial">IUD</font>
*** <font face="Arial">Adnexal surgery</font>
* Physical<font face="Arial">�</font>
** Uterus able to palpated in abdomen ~ 12 weeks<font face="Arial"><br /></font>
** <font face="Arial">Uterus able to visualzed by abdominal ultrasound ~ 10 weeks<br /></font>
** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Open OS decreases, but does not rule-out, ectopic</font></span></font>
** <font face="Arial">If find POC send to pathology to rule-out trophoblastic disease</font><font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000"><br /></font></span></font>
===Work-Up===
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">B-hCG (quant)<br /></font></span></font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">CBC</font></span></font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">T&S (Rh) vs. T&C</font></span></font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">IVF vs. blood</font></span></font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">UA</font></span></font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">RhoGAM</font></span> if indicated</font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Hemabate/Pitocin</font></span> if indicated</font>
* <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Ultrasound</font></span></font><font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000"><br /></font></span></font>
** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">IUP� = Threatened AB</font></span></font>
*** <font face="Arial"><font color="#000000">Ectopic ruled-out unless on fertility drugs</font></font><font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000"><br /></font></span></font>
** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Empty uterus + free fluid/adnexal mass = Ectopic</font></span></font>
** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Empty uterus + no free fluid / no mass</font></span><nowiki>:</nowiki></font>
*** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">BHC-G:</font></span></font>
**** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">>6,000 = Ectopic</font></span></font>
**** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">1,000 - 1,500 = indeterminante �(?D&C if undesired)</font></span></font>
**** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000"><1,500 = follow serial B-HCG levels (x 48hrs)</font></span></font>
***** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Increased >66% = nL IUP <br /></font></span></font>
***** <font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Increased < 66% = Ectopic</font></span></font>
===<font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">Source</font></span></font>===
<font face="Arial"><span class="Apple-style-span" style="line-height: normal; border-collapse: collapse"><font color="#000000">UpToDate, Rosen's<br /></font></span></font>
===Background===
===Background===


Revision as of 00:21, 29 March 2011

Background

  • Occurs in 20-40% of 1st trimester pregnancies
  • Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
  • Ultrasound
    • Do not use hCG to determine whether ultrasound should be obtained
      • "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
        • Pelvic - can visualize IUP at hCG ~ >1500
        • Abd - can visualize IUP at hCG ~ >6000

DDX

  • Ectopic Pregnancy
    • hCG > 1500 + no IUP
  • Miscarriage
    • Complete Abortion
      • <12 weeks + no IUP
      • Distinguish from ectopic based on decreasing hCG, decreased bleeding
        • Only need to send hCG if unable to examine POC
    • Threatened Abortion
      • Closed os + IUP + cramps and/or bleeding
      • If < 11wks >90% go to term
      • If between 11 and 20 weeks 50% go to term
    • Inevitable Abortion
      • Open os + contractions/cramps
    • Incomplete Abortion
      • >12 wks + passage of only portion of POC
    • Missed Abortion
      • <20 wks + no cardiac activity
  • Non-pregnancy related bleeding
    • Cancer
    • Fibroids
    • Cervicitis

�

Evaluation

  • History
    • Previous spontaneous abortion?
    • Extent of bleeding, clots, tissue
    • Presence of cramping
    • Light-headedness?
    • Risk Factors for Ectopic
      • PID
      • IUD
      • Adnexal surgery
  • Physical�
    • Uterus able to palpated in abdomen ~ 12 weeks
    • Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
    • Open OS decreases, but does not rule-out, ectopic
    • If find POC send to pathology to rule-out trophoblastic disease

Work-Up

  • B-hCG (quant)
  • CBC
  • T&S (Rh) vs. T&C
  • IVF vs. blood
  • UA
  • RhoGAM if indicated
  • Hemabate/Pitocin if indicated
  • Ultrasound
    • IUP� = Threatened AB
      • Ectopic ruled-out unless on fertility drugs
    • Empty uterus + free fluid/adnexal mass = Ectopic
    • Empty uterus + no free fluid / no mass:
      • BHC-G:
        • >6,000 = Ectopic
        • 1,000 - 1,500 = indeterminante �(?D&C if undesired)
        • <1,500 = follow serial B-HCG levels (x 48hrs)
          • Increased >66% = nL IUP
          • Increased < 66% = Ectopic

Source

UpToDate, Rosen's


Background

  • Occurs in 20-40% of 1st trimester pregnancies
  • Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
  • Ultrasound
  • Do not use hCG to determine whether ultrasound should be obtained
  • "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
  • Pelvic - can visualize IUP at hCG ~ >1500
  • Abd - can visualize IUP at hCG ~ >6000

DDX

  • Ectopic Pregnancy


  • hCG > 1500 + no IUP
  • Miscarriage


  • Complete Abortion


  • <12 weeks + no IUP


  • Distinguish from ectopic based on decreasing hCG, decreased bleeding


  • Only need to send hCG if unable to examine POC


  • Threatened Abortion


  • Closed os + IUP + cramps and/or bleeding


  • If < 11wks >90% go to term


  • If between 11 and 20 weeks 50% go to term


  • Inevitable Abortion


  • Open os + contractions/cramps


  • Incomplete Abortion


  • >12 wks + passage of only portion of POC


  • Missed Abortion


  • <20 wks + no cardiac activity


  • Non-pregnancy related bleeding
  • Cancer


  • Fibroids


  • Cervicitis



Evaluation

  • History
  • Previous spontaneous abortion?
  • Extent of bleeding, clots, tissue
  • Presence of cramping
  • Light-headedness?
  • Risk Factors for Ectopic
  • PID
  • IUD
  • Adnexal surgery
  • Physical
  • Uterus able to palpated in abdomen ~ 12 weeks
  • Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
  • Open OS decreases, but does not rule-out, ectopic
  • If find POC send to pathology to rule-out trophoblastic disease


Work-Up

  • B-hCG (quant)
  • CBC
  • T&S (Rh) vs. T&C
  • IVF vs. blood
  • UA
  • RhoGAM if indicated
  • Hemabate/Pitocin if indicated
  • Ultrasound
  • IUP = Threatened AB
  • Ectopic ruled-out unless on fertility drugs
  • Empty uterus + free fluid/adnexal mass = Ectopic
  • Empty uterus + no free fluid / no mass:
  • BHC-G:
  • >6,000 = Ectopic
  • 1,000 - 1,500 = indeterminante (?D&C if undesired)
  • <1,500 = follow serial B-HCG levels (x 48hrs)
  • Increased >66% = nL IUP
  • Increased < 66% = Ectopic

Source

UpToDate, Rosen's

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