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
===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
{{Abortion types}}
*Pelvic Ultrasound - can visualize IUP at hCG ~ >1500
 
*Abd Ultrasound - can visualize IUP at hCG ~ >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
==Clinical Features==
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>
===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}}


==Work-Up==
==Evaluation==
#[[Beta-HCG Levels|B-hCG (quantitative)]]
===Work-Up===
#CBC
*[[Beta-HCG Levels|B-hCG (quantitative)]]
#T&S (Rh) vs. T&C
*CBC and BMP
#UA
*Coags
#Ultrasound
*T&S (Rh) vs. T&C
##IUP = Threatened AB
*[[Urinalysis]]
###Ectopic ruled-out unless on fertility drugs
*[[Ultrasound: Pelvic|Pelvic ultrasound]]
##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% = nL IUP
#####Increased < 66% = Ectopic


==Diagnosis==
===Evaluation===
#History
*By [[ultrasound]] finding:
##Previous spontaneous abortion
**+IUP = [[threatened abortion]]
##Extent of bleeding, clots, tissue
***[[Ectopic]] ruled-out unless on fertility drugs
##Presence of cramping
**Empty uterus + free fluid/adnexal mass = [[Ectopic]]
##Light-headedness? Chest pain? Shortness of breath? Palpitations?
**Empty uterus + no free fluid / no mass
#Physical
***[[Beta-HCG Levels|Beta-HCG]]:
##Uterus able to palpated in abdomen ~ 12 weeks
****>1,500 = Presumed [[ectopic]]
##Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
****<1,500 = Indeterminate: follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
##Open OS decreases, but does not rule-out, ectopic
*****Increased >66% = normal IUP
##If find POC send to pathology to rule-out trophoblastic disease
*****Increased <66% = [[Ectopic]]
##Large subchorionic hemorrhage increases chances of a [[First Trimester Abortion|miscarriage]]


==DDX==
===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>===
#[[Ectopic Pregnancy]]
''Values are for IUP visualization, not ectopic visualization''
#[[First Trimester Abortion]]
*Pelvic Ultrasound: hCG >1500
#Non-pregnancy related bleeding
*Abd Ultrasound: hCG >3000<ref>Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside
##Implantation bleeding
Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. [http://emupdates.com/perm/Wang%20Discriminatory%20Zone%202011%20AnnEM.pdf PDF]</ref>
##Gestational trophoblastic disease
###Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
##Fibroids
##Cervicitis


==Treatment==
==Management==
===General===
#[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative
#Assess hemodynamics and need for transfusion if severe anemia or hypotension
#Assess need for transfusion (severe anemia or hypotension)
##[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] if Rh Negative
#Treat specific process:
#OBGYN Consultation for emergency Dilation and Curettage if persistent bleeding
#*[[Ectopic]]
#[[First Trimester Abortion#Management|Miscarriage Treatment]]
#*[[Threatened abortion]]
#*Indeterminate
#**Follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
#**If peritonitis/surgical abdomen, immediate OB/GYN consult for possible [[ectopic]]


===Non-pregnancy related bleeding===
==Disposition==
#Implantation bleeding
*Admit for:
#Gestational trophoblastic disease
**[[Ectopic]]
##Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
**Life threatening bleeding
#Fibroids
**Surgical abdomen
#Cervicitis


==See Also==
==See Also==
{{DDX undifferentiated VB}}
==Videos==
{{#widget:YouTube|id=6cv1VLtcYFA}}
{{#widget:YouTube|id=Jef0dJZ1SGU}}


==See Also==
==References==
[[Vaginal Bleeding (Main)]]
<references/>
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]

Latest revision as of 16:07, 14 April 2022

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 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 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