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

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 Treatment

Source

UpToDate, Rosen's, Tintinalli

See Also

Vaginal Bleeding (Main)