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THE MORNING REPORT

The Best in FOAM Education

  • Erin Mosher, DO

Vaginal Bleeding in the Pregnant Patient

Life Threatening Differential Diagnosis

<20w GA

  • Ruptured ectopic pregnancy

  • Retained products of conception

  • Complication of pregnancy termination

  • Septic abortion

>20w GA

  • Placental abruption

  • Placenta previa

  • Uterine prolapse

  • Postpartum hemorrhage

  • Vasa previa

Other Genital Tract Causes

  • Acute severe menorrhagia

  • Genitourinary trauma

  • Uterine arteriovenous malformations

Emergency department evaluation algorithm for vaginal bleeding



Ectopic Pregnancy

Pathophysiology

  • Implantation occurring outside of uterus

  • Locations

    • Fallopian Tubes (>90%)

    • Abdomen (1%)

    • Cervix (1%)

    • Ovary (1-3%)

    • Cesarean Scar (1-3%)

Risk Factors

  • History of ectopic pregnancy

  • Previous trauma/injury to fallopian tubes (ascending pelvic infections, prior pelvic/uterine/fallopian tube surgeries)

  • Fertility treatment

  • History of infertility

  • cigarette smoking

  • age >35

Presentation

  • History

    • abdominal/pelvic pain

    • vaginal bleeding

    • syncope

  • Physical findings

    • abdominal tenderness to palpation

    • vaginal bleeding

    • hemodynamic instability

      • tachycardia

      • hypotension

      • pallor

Diagnosis

  • Transvaginal ultrasound

    • gestational sac with a yolk sac, embryo, or both is noted in the adnexa

    • Visualization of a definitive intrauterine pregnancy eliminates ectopic pregnancy EXCEPT in the rare case of a heterotopic pregnancy

    • If intrauterine pregnancy is not identified, nor adnexal mass, the results are equivocal and patient should follow-up in two days for a repeat ultrasound and serum hCG



  • Serum hCG level Discriminatory Level

    • hCG value above which the landmarks of a normal intrauterine gestation should be visible on ultrasonography

    • Absence of ultrasound findings of normal intrauterine gestation in the presence of an hCG level above the discriminatory level strongly suggests nonviable gestations (ie early pregnancy loss or an ectopic pregnancy)

    • literature describes discriminatory level ranging between 1500-3500, with cases noted to be even lower

    • average increase of hCG level is approximately:

      • 49% for an initial hCG level <1500

      • 40% for an initial hCG level 1500-3000

      • 33% for an initial hCG level >1500

Treatment

  • Methotrexate

  • Surgical Management

  • RhoGam if patient is Rh negative


References

  • ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy. Obstetrics & Gynecology 131(2):p e65-e77, February 2018. | DOI: 10.1097/AOG.0000000000002464

  • Barnhart KT, Guo W, Cary MS, et al. Differences in Serum Human Chorionic Gonadotropin Rise in Early Pregnancy by Race and Value at Presentation. Obstet Gynecol. 2016;128(3):504-511. doi:10.1097/AOG.0000000000001568

  • Borhart JC. Approach to the adult with vaginal bleeding in the emergency department. UpToDate. Accessed November 3, 2023. https://www.uptodate.com/contents/approach-to-the-adult-with-vaginal-bleeding-in-the-emergency-department.


Erin Mosher, DO

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