Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
Patient Assessment
In a clinically stable patient, a diagnosis of failed pregnancy is not
considered an emergency. Once a failed pregnancy diagnosis has been
confirmed, either watchful waiting or surgical intervention is
medically reasonable.
History
- Recent health
- Menstrual history (Ascertain LMP accurate to within 2 weeks)
- Contraception
- Previous OB/GYN history
Physical Exam
- Do a speculum exam to rule out non-uterine causes; check for cervical dilatation.
- Bimanual exam (Uterine size reliable to within 2 weeks if thin and anteverted and 4 weeks if uterus is retroverted)
- Fetal heart tones by Doppler (heard by 8 to 10 weeks post-LMP). The sensitivity may be increased by elevating the uterus during bimanual exam but may not be heard until 11 to 12 weeks post-LMP.
Diagnostic Study
- Ultrasound: (Vol III—OB2 Ultrasound Use)
- Quantitative beta HCG
Correlates to age of pregnancy and to specific ultrasound findings and is particularly helpful when no gestation sac or empty sac is visible on ultrasound.
Treatment
- Check Rh status. If the patient is Rh-negative, give 50 mg RhoGAM.
- If the patient is 5 to 7 weeks post-LMP, obtain an ultrasound. Depending on the experience of the sonographer and the technical quality of the scan, a normal gestational sac should be visible transabdominally.
- If no gestational sac is visible, check a quantitative HCG. If the HCG is < 1800 m L U/mL IRP, a gestational sac may not yet be seen. Repeat the HCG in 2 to 3 days, knowing that in a normal pregnancy, HCG doubles in this amount of time.
- If the uterus is empty and a BHCG is positive and/or the clinical presentation suggests pregnancy, rule out ectopic pregnancy.
- If the patient is 7 to 8 weeks post-LMP, an embryo will be visible on ultrasound. The gestational sac should measure 25 mm. If the sac is < 25 mm, you can calculate when it will reach 25 mm and repeat the ultrasound. (The sac grows by 1 mm/day.)
- If the patient is bleeding heavily, she needs a dilatation and curettage. Bleeding heavily is defined as > 1 pad/hour for several hours, passing clots > golf ball size, or if retained tissue is suspected (continued bleeding and/or cramping after passing tissue). (Vol III—OB4 Dilatation and Curettage)
- Consider empiric antibiotic treatment prior to D & C as endometritis, intra-abdominal infection, and sepsis can result. Also obtain pre-operative coagulation studies and a type & screen on the patient.