SIGNS AND SYMPTOMS 
History
- Last menstrual period (LMP)
- Obstetric history:
- Parity
- Risk factors for pregnancy loss
- Prenatal care
- Abdominal pain, cramping
- Vaginal bleeding:
- Duration
- Amount of bleeding (quantify by number of pads used, compare with normal menstrual period for patient)
- Passage of clots
- Dizzy, syncope
Physical Exam
- Determine hemodynamic status of patient:
- Pregnant patients in late 1st trimester have an increased blood volume
- Can lose substantial amount of blood before having abnormal vital signs
- Pelvic exam:
- Determine whether the internal cervical os is opened or closed
- Amount of bleeding
- Presence of POC
- Presence of adnexal tenderness or peritoneal irritation can be consistent with an ectopic pregnancy
- Bimanual exam to determine the size of the uterus:
- Size of an orange: 6–8 wk
- Fundus at the symphysis pubis: 12 wk
- Fundus at the umbilicus: 16–20 wk
ESSENTIAL WORKUP
- Pregnancy test as below
- Imaging as below
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Confirm pregnancy with a urine or serum test:
- Urine pregnancy test: Most are positive at β-hCG levels of 25–50 mIU/mL ~1 wk gestational age and remain positive 2–3 wk after induced or spontaneous abortions
- CBC
- Rapid hemoglobin determination: Type and Rh
- Type and cross-match for woman with low Hct or signs of active blood loss
- Quantitative β-hCG
- Any POC passed should be sent to pathology for confirmation
Imaging
- Transvaginal ultrasound (TVS):
- Gestational sac seen at 5 wk
- Cardiac activity seen at 6.5 wk
- Transabdominal ultrasound (TAS):
- Gestational sac at 6 wk
- Cardiac activity seen at 8 wk
- Discriminatory zone: Level of β-hCG where a normal IUP should be detected:
- 1,500–2,000 for TVS
- 6,500 for TAS
DIFFERENTIAL DIAGNOSIS
- Positive pregnancy test with vaginal bleeding:
- 2nd- and 3rd-trimester vaginal bleeding:
[Outline]
PRE-HOSPITAL
- IV fluids, oxygen, and cardiac monitor
- Monitor vital signs and transport
- Cautions:
- Patients with spontaneous abortion/vaginal bleeding can have severe hemorrhage and present in shock, especially at > 12 wk
- BP drops during the 2nd trimester of pregnancy with an average of 110/70
INITIAL STABILIZATION/THERAPY
- Stable patients:
- Unstable patients:
- Oxygen, IV fluids via 2 large-bore IVs, cardiac monitor
- Transfuse PRBC if patient does not stabilize after 2–3 L of crystalloid
- Gynecologic consultation immediately
- Oxytocin or methylergonovine may be necessary to control hemorrhage
- These patients are at high risk for having ruptured ectopic pregnancies and may need emergent operative intervention
ED TREATMENT/PROCEDURES
- Threatened abortion:
- Pelvic rest, close follow-up with obstetrics
- Patients < 6.5 wk pregnant with no documented cardiac activity by vaginal US need to be followed with serial β-hCG to assess the viability of the fetus and to rule out ectopic pregnancy
- Inevitable and incomplete abortions:
- Expectant management:
- Successful in up to 85%
- Increased risk of unplanned surgical intervention and blood loss as compared to surgical management
- Medical management:
- Misoprostol
- Successful in up to 85%
- Surgical management:
- Dilation and curettage (D&C) or evacuation, removal of POC at the cervical os to help decrease bleeding and cramping
- Less unplanned hospital admissions, curettages, and blood transfusions
- The confirmation of POC by pathology rules out ectopic pregnancy
- Complete abortion:
- May treat with methylergonovine or oxytocin if bleeding is heavy
- If quantitative β-hCG is < 1,000 and the US is negative, may follow-up with obstetrics for serial β-hCG to confirm the levels are decreasing
- Missed abortion:
- These patients are at risk for disseminated intravascular coagulation (DIC), especially if fetus is retained > 4–6 wk
- Obtain CBC, PT/PTT, fibrin-split products (FSP), and fibrinogen levels
- These patients may be followed closely as outpatients if stable with an early, confirmed IUP and no evidence of DIC
- Patients may choose to have a D&C at a later date or miscarry at home with medication or no intervention; this decision should be made in consultation with OB/GYN
MEDICATION
First Line
- RHO immunoglobulin in Rh-negative women:
- 50 µg for women with threatened or complete abortion at < 12 wk
- 300 µg for women with threatened or complete abortion at ≥12 wk
- Patients need RhoGAM administration within 72 hr to prevent future isoimmunization
- Misoprostol 800 µg vaginally if medical management is chosen in consultation with OB/GYN
- Repeat dose required in 48 hr
Second Line
Usually given in consultation with OB/GYN:
- Oxytocin: 20 IU in 1,000 mL of NS at a rate of 20 mIU/min titrated to decrease bleeding; may repeat for a max. dose of 40 mIU/min
- Methylergonovine: 0.2 mg IM/PO QID for bleeding
[Outline]
DISPOSITION
Admission Criteria
- Suspected unstable ectopic pregnancy (see "Ectopic Pregnancy")
- Hemodynamically unstable patients with hypovolemia or anemia
- DIC
- Septic abortions
- Suspected gestational trophoblastic disease
Discharge Criteria
- D&Cs can be done in the ED for incomplete and inevitable abortions, and patients may be discharged home if stable after 2–3 hr
- Some early inevitable miscarriages can be discharged to complete their miscarriages at home without a D&C
- Discharge with pain medications and close OB/GYN follow-up
- Patients with threatened abortions should be told to avoid strenuous activity
- Pelvic rest (i.e., "nothing in the vagina" during active bleeding; may increase risk of infection)
- Patients should be instructed to return to the ED for any increase in bleeding, dizziness, or temperature > 100.4°F
- Patients and their partners should be counseled that early pregnancy loss is common and that it is not anyone's fault
FOLLOW-UP RECOMMENDATIONS
Patients with positive pregnancy tests and vaginal bleeding with or without abdominal pain should be followed by OB/GYN.
[Outline]
- Huancahuari N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30:837–847.
- Martonffy AI, Rindfleisch K, Lozeau AM, et al. First trimester complications. Prim Care. 2012;39:71–82.
- Marx JA, Hockberger RS, Walls RM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
- Prine LW, MacNaughton H. Office management of early pregnancy loss. Am Fam Physician. 2011;84:75–82.
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