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 US no utility in obtaining [[B-hCG]]
*Once IUP is confirmed by [[ultrasound]] no utility in obtaining [[B-hCG]]
*US
*US
**Do not use hCG to determine whether US should be obtained
**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}}


==Diagnosis==
==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
*UA
*[[Urinalysis]]
*[[Ultrasound: Pelvic|Ultrasound]]
*[[Ultrasound: Pelvic|Pelvic ultrasound]]


===Evaluation===
===Evaluation===
*By US finding:
*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]]:
****>6,000 = [[Ectopic]]
****>1,500 = Presumed [[ectopic]]
****1,000 - 1,500 = indeterminate (?D&C if undesired)
****<1,500 = Indeterminate: follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
****<1,500 = follow serial [[B-HCG]] levels (x 48hrs)
*****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 consultation for emergency Dilation and Curettage if persistent bleeding
#Treat specific process:
#[[First Trimester Abortion#Management|Miscarriage Treatment]]
#*[[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==
[[Vaginal Bleeding (Main)]]
{{DDX undifferentiated VB}}
 
==Videos==
{{#widget:YouTube|id=6cv1VLtcYFA}}
{{#widget:YouTube|id=Jef0dJZ1SGU}}


==Sources==
==References==
<references/>
<references/>


[[Category:OB/GYN]]
[[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)

Evaluation

Work-Up

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
      • Beta-HCG:
        • >1,500 = Presumed ectopic
        • <1,500 = Indeterminate: follow serial B-HCG levels in 48hrs (if no peritonitis)
          • 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

  1. RhoGAM if Rh Negative
  2. Assess need for transfusion (severe anemia or hypotension)
  3. Treat specific process:

Disposition

  • Admit for:
    • Ectopic
    • Life threatening bleeding
    • Surgical abdomen

See Also

Vaginal bleeding (main)

Videos

{{#widget:YouTube|id=6cv1VLtcYFA}} {{#widget:YouTube|id=Jef0dJZ1SGU}}

References

  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