Vaginal bleeding in pregnancy (less than 20wks)
Background
- Occurs in 20-40% of 1st trimester pregnancies
- Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
- Ultrasound
- Do not use hCG to determine whether ultrasound 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
- Ectopic Pregnancy
- hCG > 1500 + no IUP
- Miscarriage
- 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 + cramps and/or bleeding
- If < 11wks >90% go to term
- If between 11 and 20 weeks 50% go to term
- Inevitable Abortion
- Open os + contractions/cramps
- Incomplete Abortion
- >12 wks + passage of only portion of POC
- Missed Abortion
- <20 wks + no cardiac activity
- Non-pregnancy related bleeding
- Cancer
- Fibroids
- Cervicitis
Evaluation
- History
- Previous spontaneous abortion?
- Extent of bleeding, clots, tissue
- Presence of cramping
- Light-headedness?
- Risk Factors for Ectopic
- PID
- IUD
- Adnexal surgery
- 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
Work-Up
- B-hCG (quant)
- CBC
- T&S (Rh) vs. T&C
- IVF vs. blood
- UA
- RhoGAM if indicated
- Hemabate/Pitocin if indicated
- Ultrasound
- IUP = Threatened AB
- Ectopic ruled-out unless on fertility drugs
- Empty uterus + free fluid/adnexal mass = Ectopic
- Empty uterus + no free fluid / no mass:
- BHC-G:
- >6,000 = Ectopic
- 1,000 - 1,500 = indeterminante (?D&C if undesired)
- <1,500 = follow serial B-HCG levels (x 48hrs)
- Increased >66% = nL IUP
- Increased < 66% = Ectopic
Source
UpToDate, Rosen's