Exam 3 - Evaluating First Trimester Bleeding Flashcards
What is the first, second, and third steps in evaluating first trimester bleeding?
- Rule out life threatening conditions (e.g. ectopic pregnancy, maternal hemorrhage)
- Determine fetal viability
- Determine origin of bleeding (e.g. vagina, cervix, uterus)
Questions to ask the patient while collecting HPI
- LNMP
- Contraceptive use and history
- Ultrasound findings
- EDD
- Pregnancy test results
- Previous OB history
- Spontaneous abortion or ectopic pregnancy in particular
Questions to ask when collecting history/evaluating a patient with first trimester bleeding
- History of bleeding - when, quantity, color (dark, bright), volume
- Associated pain - cramping (when, where, nature - mild, intense, sharp, dull)
- Other associated symptoms - fever, UTI symptoms
- History of STI or UTI during pregnancy
- Recent intercourse or recent pelvic exam
Components of the abdominal exam when performing a PE to r/o first trimester bleeding
- Palpate for tenderness, pain, fundal height, masses, rebound or CVA tenderness
- Auscultate bowel sounds
- May be diminished with appendicitis
Why would a provider perform a speculum exam for a patient who might have first trimester bleeding?
- Collect specimens to r/o cervicitis, vaginitis, wet prep with KOH
- Note possible dilation of cervix, possible discharge
- Assess for fetal parts or membranes in hourglass formation (bulging sac protruding from cervical os)
- Look for bleeding polyps
What should the provider be concerned about if a pregnant patient has cervicitis?
Suspect infection
- May have increased vascularity d/t irritation from trauma (e.g. recent pap, specimen collection, sex)
- Encourage pelvic rest until symptoms resolve
- Nothing in vagina (including sex, tampons)
Is cervicitis associated with fetal loss?
No
What components of the bimanual exam should the provider include when evaluating a patient with first trimester bleeding?
- Assess size of uterus
- Look for cervical effacement, dilation, cervical motion tenderness, adnexal masses
- Auscultate fetal heart sounds (if patient is >10 weeks)
What lab tests/imaging would you order to evaluate first trimester bleeding?
- CBC for anemia
- Serum hCG
- Serum progesterone
- Ultrasound
- Gonorrhea, chlamydia, trichomoniasis
How often do hCG levels double during pregnancy?
- Every 1.5 days until week 5
- Every 2 days until week 6
- Every 2-2.5 days until week 7
- Start to slow down after week 7
- Plateaus and falls during weeks 8-10
What progesterone level would indicate a viable and abnormal pregnancy?
Viable if >25
Failing or abnormal pregnancy is <5
What should you tell a patient if they are only bleeding from the cervix?
Bleeding from cervix rarely associated with pregnancy loss
- Reassure, monitor closely, encourage pelvic rest until symptoms resolve
What are the two primary differential diagnoses for uterine bleeding?
Spontaneous abortion or ectopic pregnancy
What is a risk factor for spontaneous abortion?
Subchorionic hemorrhage - bleeding between chorion and myometrium (or placenta)
- Often resolves spontaneously with no adverse outcome
How can a transvaginal ultrasound be beneficial in diagnosing first trimester bleeding?
- Can reveal gestational sac when hCG levels are <1500
- Identify intrauterine pregnancy, ectopic pregnancy, fetal viability with gestational age within 5 days
- Diagnose molar pregnancy
- Grape-like clusters in honeycomb pattern or snowstorm effect
When should a provider refer a patient out for emergency evaluation for ectopic pregnancy?
Positive pregnancy test and no intrauterine pregnancy identified on ultrasound
How should the provider manage a missed or inevitable abortion?
If patient is stable hemodynamically and emotionally, patient can choose
- Expectant management
- Medical abortion
- Surgical intervention for pregnancy termination via suction dilatation and curettage (D&C)
How often do patients with miscarriage spontaneously expel products of conception?
About 30% will within 7 days
- 60% within 14 days
- 75% by day 45
If a patient has had a missed or inevitable abortion, should they monitor their temperature?
Yes - should monitor daily and report…
- Any fever >100.4, chills
- Bleeding more than saturating one pad an hour
- Passing large clots greater than quarter size
Why should patients who have had a missed or inevitable abortion save their products of conception?
If this is the third occurrence of spontaneous abortion, can save products for genetic studies
- Should offer women genetic counseling and endocrine eval
What to include in follow up visit for patients who have had a missed or inevitable abortion
- Provide support through grieving process
- Counsel to avoid intercourse until bleeding has subsided
- Contraception, future pregnancy planning
- Consider pre-conceptual care if appropriate
- Provide RhoGAM within 72 hours if patient is Rh (-)
