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

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===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>===  
===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
''Values are for IUP visualization, not ectopic visualization''
*Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
*Pelvic Ultrasound: hCG >1500
*Abd Ultrasound - can visualize IUP at hCG ~ >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
*Abd Ultrasound: hCG >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>


Revision as of 02:08, 30 August 2015

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

Abortion Types

Classification Characteristics OS Fetal Tissue Passage Misc
Threatened Abdominal pain or bleeding; < 20 weeks gestation Closed No If < 11 weeks (with fetal cardiac activity) 90% progress to term. If between 11 and 20 weeks 50% progress to term
Inevitable Abdominal pain or bleeding; < 20 weeks gestation Open No
Incomplete Abdominal pain or bleeding; < 20 weeks gestation Open Yes, some
Complete Abdominal pain or bleeding; < 20 weeks gestation Closed Yes, complete expulsion of products Distinguish from ectopic based on decreasing hCG and/or decreased bleeding
Missed Fetal death at <20 weeks without passage of any fetal tissue for 4 weeks after fetal death Closed No
Septic Infection of the uterus during a miscarriage. Most commonly caused by retained products of conception Open No, or may be incomplete Uterine tenderness and purulent discharge from the OS may be present

Clinical Features

History

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 miscarriage

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)

Diagnosis

Work-Up

Evaluation

  • By US finding:
    • +IUP = threatened abortion
      • Ectopic ruled-out unless on fertility drugs
    • Empty uterus + free fluid/adnexal mass = Ectopic
    • Empty uterus + no free fluid / no mass
      • Beta-HCG:
        • >6,000 = Ectopic
        • 1,000 - 1,500 = indeterminate (?D&C if undesired)
        • <1,500 = follow serial B-HCG levels (x 48hrs)
          • Increased >66% = normal IUP
          • Increased < 66% = Ectopic

Discrimatory Zone[1]

Values are for IUP visualization, not ectopic visualization

  • Pelvic Ultrasound: hCG >1500
  • Abd Ultrasound: 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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