Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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==Background== | ==Background== | ||
*Occurs in 20-40% of 1st trimester pregnancies | *Occurs in 20-40% of 1st trimester pregnancies | ||
*Once IUP is confirmed by | *Once IUP is confirmed by [[ultrasound]] no utility in obtaining [[B-hCG]] | ||
*US | *US | ||
**Do not use hCG to determine whether | **Do not use hCG to determine whether [[ultrasound]] should be obtained | ||
{{Abortion types}} | {{Abortion types}} | ||
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*Previous spontaneous abortion | *Previous spontaneous abortion | ||
*Extent of bleeding, clots, tissue | *Extent of bleeding, clots, tissue | ||
**Often quantified by pads per hour, greater than 1 per hour is concerning | |||
*Presence of cramping | *Presence of cramping | ||
*Light-headedness? [[Chest pain]]? [[Shortness of breath]]? [[Palpitations]]? | *Light-headedness? [[Chest pain]]? [[Shortness of breath]]? [[Palpitations]]? | ||
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*Open OS decreases, but does not rule-out, [[ectopic]] | *Open OS decreases, but does not rule-out, [[ectopic]] | ||
*If find POC send to pathology to rule-out trophoblastic disease | *If find POC send to pathology to rule-out trophoblastic disease | ||
*Can quantify amount of bleeding by number of scopettes of blood on pelvic exam | |||
*Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]] | *Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]] | ||
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{{VB DDX less than 20}} | {{VB DDX less than 20}} | ||
== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*[[Beta-HCG Levels|B-hCG (quantitative)]] | *[[Beta-HCG Levels|B-hCG (quantitative)]] | ||
*CBC | *CBC and BMP | ||
*Coags | |||
*T&S (Rh) vs. T&C | *T&S (Rh) vs. T&C | ||
* | *[[Urinalysis]] | ||
*[[Ultrasound: Pelvic| | *[[Ultrasound: Pelvic|Pelvic ultrasound]] | ||
===Evaluation=== | ===Evaluation=== | ||
*By | *By [[ultrasound]] finding: | ||
**+IUP = [[threatened abortion]] | **+IUP = [[threatened abortion]] | ||
***[[Ectopic]] ruled-out unless on fertility drugs | ***[[Ectopic]] ruled-out unless on fertility drugs | ||
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**Empty uterus + no free fluid / no mass | **Empty uterus + no free fluid / no mass | ||
***[[Beta-HCG Levels|Beta-HCG]]: | ***[[Beta-HCG Levels|Beta-HCG]]: | ||
****> | ****>1,500 = Presumed [[ectopic]] | ||
****<1,500 = Indeterminate: follow serial [[B-HCG]] levels in 48hrs (if no peritonitis) | |||
****<1,500 = follow serial [[B-HCG]] levels ( | |||
*****Increased >66% = normal IUP | *****Increased >66% = normal IUP | ||
*****Increased < 66% = [[Ectopic]] | *****Increased <66% = [[Ectopic]] | ||
===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: hCG >1500 | *Pelvic Ultrasound: hCG >1500 | ||
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#[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative | #[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative | ||
#Assess need for transfusion (severe anemia or hypotension) | #Assess need for transfusion (severe anemia or hypotension) | ||
#OB/GYN | #Treat specific process: | ||
#*[[Ectopic]] | |||
#*[[Threatened abortion]] | |||
#*Indeterminate | |||
#**Follow serial [[B-HCG]] levels in 48hrs (if no peritonitis) | |||
#**If peritonitis/surgical abdomen, immediate OB/GYN consult for possible [[ectopic]] | |||
==Disposition== | |||
*Admit for: | |||
**[[Ectopic]] | |||
**Life threatening bleeding | |||
**Surgical abdomen | |||
==See Also== | ==See Also== | ||
{{DDX undifferentiated VB}} | |||
==Videos== | |||
{{#widget:YouTube|id=6cv1VLtcYFA}} | |||
{{#widget:YouTube|id=Jef0dJZ1SGU}} | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:OBGYN]] |
Revision as of 18:31, 12 January 2021
Background
- Occurs in 20-40% of 1st trimester pregnancies
- Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
- US
- Do not use hCG to determine whether ultrasound 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
- Previous spontaneous abortion
- Extent of bleeding, clots, tissue
- Often quantified by pads per hour, greater than 1 per hour is concerning
- 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
- Can quantify amount of bleeding by number of scopettes of blood on pelvic exam
- Large subchorionic hemorrhage increases chances of a miscarriage
Differential Diagnosis
Vaginal Bleeding in Pregnancy (<20wks)
- Ectopic pregnancy
- Subchorionic hematoma
- First Trimester Abortion
- Complete Abortion
- Incomplete Abortion
- Inevitable Abortion
- Missed Abortion
- Septic abortion
- Threatened Abortion
- Gestational trophoblastic disease
- Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
- Heterotopic pregnancy
- Implantation bleeding
- Molar pregnancy
- Non-pregnancy related bleeding
- Cervicitis
- Fibroids
- Implantation bleeding
Evaluation
Work-Up
- B-hCG (quantitative)
- CBC and BMP
- Coags
- T&S (Rh) vs. T&C
- Urinalysis
- Pelvic ultrasound
Evaluation
- By ultrasound 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
- +IUP = threatened abortion
Discrimatory Zone[1]
Values are for IUP visualization, not ectopic visualization
- Pelvic Ultrasound: hCG >1500
- Abd Ultrasound: hCG >3000[2]
Management
- RhoGAM if Rh Negative
- Assess need for transfusion (severe anemia or hypotension)
- Treat specific process:
- Ectopic
- Threatened abortion
- Indeterminate
Disposition
- Admit for:
- Ectopic
- Life threatening bleeding
- Surgical abdomen
See Also
Vaginal bleeding (main)
- Non-pregnant vaginal bleeding
- Pregnant
Videos
{{#widget:YouTube|id=6cv1VLtcYFA}} {{#widget:YouTube|id=Jef0dJZ1SGU}}
References
- ↑ 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
- ↑ Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. PDF