Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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==DDX==
==DDX==
#[[Ectopic Pregnancy]]
#[[Ectopic Pregnancy]]
#Miscarriage
#[[First Trimester Abortion]]
##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 + bloody vaginal dischrage or frank bleeding
###If <11wk >90% go to term
###If between 11 and 20wk 50% go to term
##Inevitable Abortion
###Open os + contractions/cramps
##Incomplete Abortion
###>12 wks + passage of only portion of POC
##Missed Abortion
###Fetal death at <20wk w/o passage of any fetal tissue for 4wk after fetal death
##Septic abortion
###Evidence of infection during any stage of abortion
###Most commonly caused by retained products of conception
#Non-pregnancy related bleeding
#Non-pregnancy related bleeding
##Implantation bleeding
##Implantation bleeding

Revision as of 06:57, 26 April 2014

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

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

  1. General
    1. IVF vs. blood
    2. RhoGAM
    3. Hemabate/Pitocin if indicated
  2. Miscarriage
    1. Threatened abortion
      1. D/c home if close f/u is ensured
      2. Pts should avoid sex and tampons to minimze likelihood of infection
    2. Incomplete abortion
      1. Uterus should be evacuated
      2. Consult w/ OB/GYN regarding medical (misoprostol) versus surgical treatment
    3. Complete abortion
      1. D/c after f/u is ensured and bleeding has stopped
    4. Nonviable fetus
      1. Either admit or d/c w/ f/u within 1wk
    5. Septic abortion
      1. Abx (cover vaginal flora and STI)
        1. Ampicillin/sulbactam 3gm IV OR (clindamycin 600mg IV + gentamicin 1-2mg/kg IV)
  3. Gestational trophoblastic disease
    1. Admit for suction curettage in the hospital setting because of risk of hemorrhage

Source

UpToDate, Rosen's, Tintinalli

See Also

Vaginal Bleeding (Main)

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