Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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==Work-Up== | ==Work-Up== | ||
*[[Beta-HCG Levels|B-hCG (quantitative)]] | |||
*CBC | |||
*T&S (Rh) vs. T&C | |||
*UA | |||
*[[Ultrasound: Pelvic|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 | |||
***[[Beta-HCG Levels|Beta-HCG]]: | |||
****>6,000 = [[Ectopic]] | |||
****1,000 - 1,500 = indeterminate (?D&C if undesired) | |||
****<1,500 = follow serial [[B-HCG]] levels (x 48hrs) | |||
*****Increased >66% = normal IUP | |||
*****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>=== | ||
Revision as of 06:33, 20 February 2015
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
Diagnosis
- History
- Previous spontaneous abortion
- Extent of bleeding, clots, tissue
- 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
- 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
Work-Up
- B-hCG (quantitative)
- CBC
- T&S (Rh) vs. T&C
- UA
- Ultrasound
Discrimatory Zone[1]
- values are for IUP visualization, not ectopic visualization
- Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
- Abd Ultrasound - can visualize IUP at hCG ~ >3000[2]
Management
General
- Assess hemodynamics and need for transfusion if severe anemia or hypotension
- RhoGAM if Rh Negative
- OBGYN Consultation for emergency Dilation and Curettage if persistent bleeding
- Miscarriage Treatment
- Implantation bleeding
- Gestational trophoblastic disease
- Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
- Fibroids
- Cervicitis
See Also
Sources
- ↑ 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