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

DDX

1. Ectopic Pregnancy
   1. hCG > 1500 + no IUP
2. Miscarriage
   1. Complete Abortion
      1. <12 weeks + no IUP
      2. Distinguish from ectopic based on decreasing hCG, decreased bleeding
         1. Only need to send hCG if unable to examine POC
   2. Threatened Abortion
      1. Closed os + IUP + bloody vaginal dischrage or frank bleeding
      2. If <11wk >90% go to term
      3. If between 11 and 20wk 50% go to term
   3. Inevitable Abortion
      1. Open os + contractions/cramps
   4. Incomplete Abortion
      1. >12 wks + passage of only portion of POC
   5. Missed Abortion
      1. Fetal death at <20wk w/o passage of any fetal tissue for 4wk after fetal death
   6. Septic abortion
      1. Evidence of infection during any stage of abortion
      2. Most commonly caused by retained products of conception
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

Evaluation

1. History
   1. Previous spontaneous abortion?
   2. Extent of bleeding, clots, tissue
   3. Presence of cramping
   4. Light-headedness?
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

Work-Up

1. B-hCG (quant)
2. CBC
3. T&S (Rh) vs. T&C
4. IVF vs. blood
5. UA
6. RhoGAM 50-150mcg if indicated
7. Hemabate/Pitocin if indicated
8. 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. BHC-G:
         1. >6,000 = Ectopic
         2. 1,000 - 1,500 = indeterminante (?D&C if undesired)
         3. <1,500 = follow serial B-HCG levels (x 48hrs)
            1. Increased >66% = nL IUP
            2. Increased < 66% = Ectopic

Treatment

1. 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)
2. Gestational trophoblastic disease
   1. Admit for suction curettage in the hospital setting because of risk of hemorrhage

Source

UpToDate, Rosen's, Tintinalli