Vaginal bleeding in pregnancy (less than 20wks): Difference between revisions
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{{Abortion types}} | {{Abortion types}} | ||
== | ==Clinical Features== | ||
===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 [[First Trimester Abortion|miscarriage]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{VB DDX less than 20}} | {{VB DDX less than 20}} | ||
==Work-Up== | ==Diagnosis== | ||
===Work-Up=== | |||
*[[Beta-HCG Levels|B-hCG (quantitative)]] | *[[Beta-HCG Levels|B-hCG (quantitative)]] | ||
*CBC | *CBC | ||
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*UA | *UA | ||
*[[Ultrasound: Pelvic|Ultrasound]] | *[[Ultrasound: Pelvic|Ultrasound]] | ||
**IUP = | |||
===Evaluation=== | |||
*By US finding: | |||
**+IUP = [[threatened abortion]] | |||
***[[Ectopic]] ruled-out unless on fertility drugs | ***[[Ectopic]] ruled-out unless on fertility drugs | ||
**Empty uterus + free fluid/adnexal mass = [[Ectopic]] | **Empty uterus + free fluid/adnexal mass = [[Ectopic]] |
Revision as of 02:07, 30 August 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
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
- 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
Diagnosis
Work-Up
- B-hCG (quantitative)
- CBC
- T&S (Rh) vs. T&C
- UA
- Ultrasound
Evaluation
- By US 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 - 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