Vaginal bleeding in pregnancy (less than 20wks)

Background

• Occurs in 20-40% of 1st trimester pregnancies
• Once IUP is confirmed by US no utility in obtaining B-hCG
• US
  • Do not use hCG to determine whether US 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

Work-Up

1. B-hCG (quantitative)
2. CBC
3. T&S (Rh) vs. T&C
4. UA
5. Ultrasound
   1. IUP = Threatened AB
      1. Ectopic ruled-out unless on fertility drugs
   2. Empty uterus + free fluid/adnexal mass = Ectopic
   3. Empty uterus + no free fluid / no mass
      1. Beta-HCG:
         1. >6,000 = Ectopic
         2. 1,000 - 1,500 = indeterminate (?D&C if undesired)
         3. <1,500 = follow serial B-HCG levels (x 48hrs)
            1. Increased >66% = nL IUP
            2. Increased < 66% = Ectopic

Diagnosis

1. History
   1. Previous spontaneous abortion
   2. Extent of bleeding, clots, tissue
   3. Presence of cramping
   4. Light-headedness? Chest pain? Shortness of breath? Palpitations?
2. Physical
   1. Uterus able to palpated in abdomen ~ 12 weeks
   2. Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
   3. Open OS decreases, but does not rule-out, ectopic
   4. If find POC send to pathology to rule-out trophoblastic disease
   5. Large subchorionic hemorrhage increases chances of a miscarriage

DDX

1. Ectopic Pregnancy
2. First Trimester Abortion
3. Non-pregnancy related bleeding
   1. Implantation bleeding
   2. Gestational trophoblastic disease
      1. Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
   3. Fibroids
   4. Cervicitis

Treatment

General

1. Assess hemodynamics and need for transfusion if severe anemia or hypotension
   1. RhoGAM if Rh Negative
2. OBGYN Consultation for emergency Dilation and Curettage if persistent bleeding
3. Miscarriage Treatment

Non-pregnancy related bleeding

1. Implantation bleeding
2. Gestational trophoblastic disease
   1. Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
3. Fibroids
4. Cervicitis

Source

UpToDate, Rosen's, Tintinalli

See Also

Vaginal Bleeding (Main)