First Trimester Bleeding

Question 1

What is the DDx of non-pregnancy related causes of first trimester bleeding?

Answer 1

Cervical polyp, cervical erosion (friable cervix), cervical malignancy, vaginal trauma, infection (STIs)

Question 2

What is the DDx of pregnancy related causes of first trimester bleeding?

Answer 2

Ectopic pregnancy, spontaneous abortion (threatened, inevitable, incomplete), implantation bleed, gestational trophoblastic neoplasia

Question 3

What are the 3 main RFs for spontaneous abortion?

Answer 3

Increased maternal age, previous miscarriage (greater than or equal to 3), uterine abnormalities

Question 4

A 24 yr old presents with vaginal bleeding. She is on the OCP and has some mild pelvic pain. What is at the top of your DDX?

Answer 4

Ectopic pregnancy

Question 5

A 24 yr old presents with vaginal bleeding. She is on the OCP and has some mild pelvic pain. She also mentions that she has had some spotting. What is part of your focused physical exam?

Answer 5

Vital signs (orthostatic changes)
Abdominal tenderness and location (R/O an acute abdomen)
Lithotomy and speculum exam (cervix, clots, tissue, lacerations)
Uterine size
FHR Doppler (12 weeks)

Question 6

A 24 yr old presents with vaginal bleeding. She is on the OCP and has some mild pelvic pain. She also mentions that she has had some spotting. What investigations do you order?

Answer 6

beta-hCG
Transvaginal U/S
CBC
Blood type and screen (Rh status); may need WinRho
If considering GTN: CXR

Question 7

What are the RFs for ectopic pregnancy?

Answer 7

Anything that scars the uterine tubes: hx of PID, hx of surgery on tubes, endometriosis
Pregnancy with IUD in place
Hx of ectopic pregnancy

Question 8

What are the requirements for methotrexate in an ectopic pregnancy?

Answer 8

Not ruptured (ie. hemodynamically stable)
<3cm
beta hCG <5000IU/L
No FHR
No liver/kidney disease

Question 9

What type of spontaneous abortion is described? Treatment?

The patient is bleeding and cramping. The cervix is closed and no tissue has passed.

Answer 9

This is a threatened abortion, expectant management is indicated.

Question 10

What type of spontaneous abortion is described? Treatment?

The patient is bleeding and cramping. The cervix is open. No tissue has passed yet.

Answer 10

This is an inevitable abortion. The treatment includes expectant management, D&C and prostaglandins (misoprostol).

Question 11

What type of spontaneous abortion is described? Treatment?

The patient is bleeding and cramping. The cervix is open and there appears to be tissue passing.

Answer 11

This is an incomplete abortion. The treatment includes expectant management, D&C and prostaglandins (misoprostol).

Question 12

What type of spontaneous abortion is described? Treatment?

A patient presents for a 12 week U/S and no FHR is noted. The cervix is closed.

Answer 12

This is a missed abortion. The treatment includes expectant management, D&C and prostaglandins (misoprostol).