Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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*US
*US
**Do not use hCG to determine whether US should be obtained
**Do not use hCG to determine whether US should be obtained
===Discrimatory Zone<ref>Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8</ref>===
 
*values are for IUP visualization, not ectopic visualization
==Diagnosis==
*Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
#History
*Abd Ultrasound - can visualize IUP at hCG ~ >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
##Previous spontaneous abortion
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>
##Extent of bleeding, clots, tissue
##Presence of cramping
##Light-headedness? Chest pain? Shortness of breath? Palpitations?
#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
##Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]]
 
==Differential Diagnosis==
{{VB DDX <20}}


==Work-Up==
==Work-Up==
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#####Increased < 66% = Ectopic
#####Increased < 66% = Ectopic


==Diagnosis==
===Discrimatory Zone<ref>Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8</ref>===
#History
*values are for IUP visualization, not ectopic visualization
##Previous spontaneous abortion
*Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
##Extent of bleeding, clots, tissue
*Abd Ultrasound - can visualize IUP at hCG ~ >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
##Presence of cramping
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>
##Light-headedness? Chest pain? Shortness of breath? Palpitations?
#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
##Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]]
 
==DDX==
#[[Ectopic Pregnancy]]
#[[First Trimester Abortion]]
#Non-pregnancy related bleeding
##Implantation bleeding
##Gestational trophoblastic disease
###Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
##Fibroids
##Cervicitis


==Treatment==
==Management==
===General===
===General===
#Assess hemodynamics and need for transfusion if severe anemia or hypotension
#Assess hemodynamics and need for transfusion if severe anemia or hypotension

Revision as of 18:27, 12 September 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

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

Differential Diagnosis

{{VB DDX <20}}

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

Discrimatory Zone[1]

  • values are for IUP visualization, not ectopic visualization
  • Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
  • Abd Ultrasound - can visualize IUP at hCG ~ >3000[2]

Management

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

See Also

Vaginal Bleeding (Main)

Sources

  1. ↑ Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8
  2. ↑ Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. PDF
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