Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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===Background=== | ===Background=== | ||
* Occurs in 20-40% of 1st trimester pregnancies | * Occurs in 20-40% of 1st trimester pregnancies | ||
* Once IUP is confirmed by ultrasound no utility in obtaining B-hCG | * Once IUP is confirmed by ultrasound no utility in obtaining B-hCG | ||
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===DDX=== | ===DDX=== | ||
* Ectopic Pregnancy | * Ectopic Pregnancy | ||
** hCG > 1500 + no IUP | |||
* hCG > 1500 + no IUP | |||
* Miscarriage | * Miscarriage | ||
** Complete Abortion | |||
*** <12 weeks + no IUP | |||
* Complete Abortion | *** Distinguish from ectopic based on decreasing hCG, decreased bleeding | ||
**** Only need to send hCG if unable to examine POC | |||
** Threatened Abortion | |||
* <12 weeks + no IUP | *** Closed os + IUP + cramps and/or bleeding | ||
*** If < 11wks >90% go to term | |||
*** If between 11 and 20 weeks 50% go to term | |||
* Distinguish from ectopic based on decreasing hCG, decreased bleeding | ** Inevitable Abortion | ||
*** Open os + contractions/cramps | |||
** Incomplete Abortion | |||
* Only need to send hCG if unable to examine POC | *** >12 wks + passage of only portion of POC | ||
** Missed Abortion | |||
*** <20 wks + no cardiac activity | |||
* 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 | * Non-pregnancy related bleeding | ||
* Cancer | ** Cancer | ||
** Fibroids | |||
** Cervicitis | |||
* Fibroids | |||
* Cervicitis | |||
===Evaluation=== | ===Evaluation=== | ||
* History | * History | ||
* Previous spontaneous abortion? | ** Previous spontaneous abortion? | ||
* Extent of bleeding, clots, tissue | ** Extent of bleeding, clots, tissue | ||
* Presence of cramping | ** Presence of cramping | ||
* Light-headedness? | ** Light-headedness? | ||
* Risk Factors for Ectopic | ** Risk Factors for Ectopic | ||
* PID | *** PID | ||
* IUD | *** IUD | ||
* Adnexal surgery | *** Adnexal surgery | ||
* Physical | * Physical | ||
* Uterus able to palpated in abdomen ~ 12 weeks | ** Uterus able to palpated in abdomen ~ 12 weeks | ||
* Uterus able to visualzed by abdominal ultrasound ~ 10 weeks | ** Uterus able to visualzed by abdominal ultrasound ~ 10 weeks | ||
* Open OS decreases, but does not rule-out, ectopic | ** Open OS decreases, but does not rule-out, ectopic | ||
* If find POC send to pathology to rule-out trophoblastic disease | ** If find POC send to pathology to rule-out trophoblastic disease | ||
===Work-Up=== | ===Work-Up=== | ||
* B-hCG (quant) | * B-hCG (quant) | ||
* CBC | * CBC | ||
| Line 181: | Line 55: | ||
* RhoGAM if indicated | * RhoGAM if indicated | ||
* Hemabate/Pitocin if indicated | * Hemabate/Pitocin if indicated | ||
* Ultrasound | * Ultrasound | ||
* IUP | ** IUP = Threatened AB | ||
* Ectopic ruled-out unless on fertility drugs | *** Ectopic ruled-out unless on fertility drugs | ||
* Empty uterus + free fluid/adnexal mass = Ectopic | ** Empty uterus + free fluid/adnexal mass = Ectopic | ||
* Empty uterus + no free fluid / no mass: | ** Empty uterus + no free fluid / no mass<nowiki>:</nowiki> | ||
* BHC-G: | *** BHC-G: | ||
* >6,000 = Ectopic | **** >6,000 = Ectopic | ||
* 1,000 - 1,500 = indeterminante | **** 1,000 - 1,500 = indeterminante (?D&C if undesired) | ||
* <1,500 = follow serial B-HCG levels (x 48hrs) | **** <1,500 = follow serial B-HCG levels (x 48hrs) | ||
* Increased >66% = nL IUP | ***** Increased >66% = nL IUP | ||
* Increased < 66% = Ectopic | ***** Increased < 66% = Ectopic | ||
===Source=== | ===Source=== | ||
UpToDate, Rosen's | UpToDate, Rosen's | ||
[[Category:OB/GYN]] | [[Category:OB/GYN]] | ||
Revision as of 00:27, 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
- "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
- Do not use hCG to determine whether ultrasound should be obtained
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
- Complete Abortion
- 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
- BHC-G:
- IUP = Threatened AB
Source
UpToDate, Rosen's