Vaginal bleeding in pregnancy (less than 20wks)
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
- "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
- Pelvic - can visualize IUP at hCG ~ >1500
- Abd - can visualize IUP at hCG ~ >6000
- "Discrimatory Zone" values are for IUP visualization, not ectopic visualization
- Do not use hCG to determine whether US should be obtained
Work-Up
- B-hCG (quantitative)
- CBC
- T&S (Rh) vs. T&C
- UA
- 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:
- >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
- Beta-HCG:
- IUP = Threatened AB
Diagnosis
- History
- Previous spontaneous abortion?
- Extent of bleeding, clots, tissue
- Presence of cramping
- Light-headedness?
- 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
DDX
- Ectopic Pregnancy
- Miscarriage
- Complete Abortion
- <12 weeks + no IUP
- Distinguish from ectopic based on decreasing hCG, decreased bleeding
- Only need to send hCG if unable to examine POC
- Threatened Abortion
- Closed os + IUP + bloody vaginal dischrage or frank bleeding
- If <11wk >90% go to term
- If between 11 and 20wk 50% go to term
- Inevitable Abortion
- Open os + contractions/cramps
- Incomplete Abortion
- >12 wks + passage of only portion of POC
- Missed Abortion
- Fetal death at <20wk w/o passage of any fetal tissue for 4wk after fetal death
- Septic abortion
- Evidence of infection during any stage of abortion
- Most commonly caused by retained products of conception
- Complete Abortion
- Non-pregnancy related bleeding
- Implantation bleeding
- Gestational trophoblastic disease
- Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
- Fibroids
- Cervicitis
Treatment
- General
- IVF vs. blood
- RhoGAM 50-150mcg if indicated
- Hemabate/Pitocin if indicated
- Miscarriage
- Threatened abortion
- D/c home if close f/u is ensured
- Pts should avoid sex and tampons to minimze likelihood of infection
- Incomplete abortion
- Uterus should be evacuated
- Consult w/ OB/GYN regarding medical (misoprostol) versus surgical treatment
- Complete abortion
- D/c after f/u is ensured and bleeding has stopped
- Nonviable fetus
- Either admit or d/c w/ f/u within 1wk
- Septic abortion
- Abx (cover vaginal flora and STI)
- Ampicillin/sulbactam 3gm IV OR (clindamycin 600mg IV + gentamicin 1-2mg/kg IV)
- Abx (cover vaginal flora and STI)
- Threatened abortion
- Gestational trophoblastic disease
- Admit for suction curettage in the hospital setting because of risk of hemorrhage
Source
UpToDate, Rosen's, Tintinalli