View source for 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]]
*US
**Do not use hCG to determine whether [[ultrasound]] should be obtained

{{Abortion types}}

==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 products of conception obtained 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]]

==Differential Diagnosis==
{{VB DDX less than 20}}

==Evaluation==
===Work-Up===
*[[Beta-HCG Levels|B-hCG (quantitative)]]
*CBC and BMP
*Coags
*T&S (Rh) vs. T&C
*[[Urinalysis]]
*[[Ultrasound: Pelvic|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
***[[Beta-HCG Levels|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<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''
*Pelvic Ultrasound: hCG >1500
*Abd Ultrasound: hCG >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>

==Management==
#[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative
#Assess need for transfusion (severe anemia or hypotension)
#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==
{{DDX undifferentiated VB}}

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

==References==
<references/>

[[Category:OBGYN]]