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Basics ⬇

[Section Outline]

Author:

PaulIshimine

Description!!navigator!!

Etiology!!navigator!!

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms!!navigator!!

History

  • Intensity and duration of bleeding:
    • Amount (clots, number of pads)
    • Color (dark or bright red)
    • Painful or painless
    • Watery, blood-tinged mucus
    • Life-threatening conditions may present with only minimal bleeding
  • Last normal menstrual period
  • Passage of tissue
  • Estimated duration of gestation
  • Gravidity/parity
  • Fever
  • Syncope or near-syncope
  • Last intercourse
  • Intrauterine device
  • Previous obstetric-gynecologic complications
  • Use of assisted reproductive technology
  • Spontaneous abortion: Classically crampy, diffuse pelvic pain
  • Ectopic pregnancy: Classically sharp pelvic pain with lateralization
  • Placenta previa: Classically painless bright red hemorrhage
  • Placental abruption: Classically painful dark red hemorrhage

Physical Exam

  • Vital signs:
    • Tachycardia
    • Hypotension
    • Orthostatic changes
    • Signs of hemodynamic instability may be absent due to pregnancy-related physiologic increase in blood volume
  • Fetal heart tones:
    • Fetal cardiac activity seen on transvaginal US at 6.5 wk
    • Auscultated with hand -held Doppler past 10 wk gestation
    • Normal fetal heart rate: 120-160 beats/min
  • Abdominal exam:
    • Uterine size:
      • 12 wk: Palpable in abdomen
      • 20 wk: Palpable at umbilicus
    • Peritoneal signs
    • Firm or tender uterus in late pregnancy suggests abruption
  • Pelvic exam - perform only in early pregnancy:
    • Evaluate source and intensity of bleeding
    • Determine patency of cervical os (only in first trimester):
      • Threatened abortion: Os closed
      • Inevitable abortion: Os open
      • Incomplete abortion: Os open or closed
      • Complete abortion: Os closed
      • Embryonic demise (missed abortion): Os closed
    • Products of conception (POC) may be noted in incomplete or completed abortion:
      • POC in the cervical os can result in profuse bleeding
    • Evaluate uterine size, tenderness
    • Evaluate for uterine fibroids or adnexal masses
    • Late pregnancy: External exam OK, but do not perform pelvic exam unless in controlled OR setting:
      • Severe hemorrhage may ensue
      • Placenta previa or vasa previa must be ruled out by US prior to pelvic exam

Essential Workup!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • CBC:
    • Dilutional “anemia” is a normal physiologic change in pregnancy:
      • Blood volume expand s by 45%
  • Qualitative beta-human chorionic gonadotropin (-hCG)
  • Quantitative -hCG:
    • Imperfect correlation with US findings
    • Detectable 9-11 d following ovulation
  • Blood typing and Rh typing:
    • Cross-match if significant bleeding
  • Disseminated intravascular coagulation (DIC) panel in embryonic demise, placental abruption
  • Blood cultures with septic abortion
  • Suspected POC to lab for identification of chorionic villi

Imaging

  • US:
    • Should be obtained in symptomatic patients with any -hCG level:
      • Confirms intrauterine pregnancy (IUP)
      • Detects gestational sac at 5 wk (usually with -hCG ≥1,000-2,000 IU), yolk sac at 6 wk, and cardiac activity at 5-6 wk of gestation
      • Essentially rules out ectopic pregnancy by showing IUP (except in women at high risk for heterotopic pregnancy)
      • Proves ectopic pregnancy by showing fetal pole outside uterus
      • Suggests ectopic pregnancy by detecting free fluid in cul-de-sac or adnexal mass
      • Detects retained POC
      • Demonstrates “snowstorm” appearance within uterus with gestational trophoblastic disease

Diagnostic Procedures/Surgery

  • Culdocentesis:
    • Limited use
    • Identifies free fluid in cul-de-sac
  • D&C or vacuum aspiration:
    • Indicated if suspected incomplete or septic abortion, embryonic demise, gestational trophoblastic disease, or anembryonic gestation to evacuate retained POC
  • Laparoscopy/laparotomy:
    • Indicated for unstable patients
    • Definitive diagnosis and treatment of ectopic pregnancy

Differential Diagnosis!!navigator!!

Treatment ⬆ ⬇

[Section Outline]

Prehospital!!navigator!!

  • Unstable vital signs warrant aggressive resuscitation
  • In late pregnancy, position patient on left side to decrease uterine compression of inferior vena cava (IVC)
  • Consider preferential transport of a woman with late pregnancy to a facility with obstetric capabilities

Initial Stabilization/Therapy!!navigator!!

  • Airway management
  • Oxygen
  • Pulse oximetry
  • Cardiac monitor
  • 2 large-bore IV lines
  • Blood transfusion as indicated
  • Continuous fetal monitoring in later pregnancy

ED Treatment/Procedures!!navigator!!

  • All women with early pregnancy vaginal bleeding must be evaluated for ectopic pregnancy (preferably by transvaginal US)
  • Administer anti-Rh0 (D) immune globulin if patient is Rh-negative
  • Suspected ectopic pregnancy:
    • Unstable: Consider bedside US with emergent OB/GYN consultation for laparoscopy/laparotomy
    • Stable: Perform US:
      • If confirmatory or suggestive of ectopic pregnancy, obtain OB/GYN consultation for surgery or methotrexate therapy
      • If inconclusive, obtain OB/GYN consultation and arrange for repeat -hCG testing in 2 d
  • Threatened abortion:
    • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
    • Arrange OB/GYN follow-up for minimal bleeding
  • Inevitable/incomplete/missed (embryonic demise) abortion:
    • POC in the cervical os can result in profuse bleeding
    • If POC cannot be removed with gentle traction, obtain emergent OB/GYN consultation
    • Arrange OB/GYN follow-up if bleeding minimal
  • Complete abortion:
    • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
    • Arrange OB/GYN follow-up if bleeding minimal
  • Septic abortion:
    • Initiate broad-spectrum antibiotic therapy
    • Emergent OB/GYN consultation for D&C
  • Late pregnancy vaginal bleeding:
    • Hemodynamic stabilization:
      • Fluid resuscitation
      • Positioning of patient onto left side or displacement of uterus laterally to relieve compression on IVC
    • DIC:
      • Associated with late pregnancy bleeding
      • Especially with placental abruption
      • Treated with blood products
    • Immediate obstetric consultation and rapid transfer to obstetric unit

Medication!!navigator!!

First Line

  • Anti-Rh0 (D) immune globulin: <12 wk-50 mcg IM; >12 wk-300 mcg IM
  • Methotrexate:
    • Variable dosing regimens
    • Only recommended for hemodynamically stable women with unruptured ectopic pregnancy with low -hCG
    • Should always consult OB/GYN prior to administration
  • Antibiotics for septic abortion:
    • Multiple acceptable antibiotic regimens
    • Must provide polymicrobial coverage

Second Line

Misoprostol has been used in completed abortion to facilitate uterine evacuation in completed miscarriage

Follow-Up ⬆ ⬇

[Section Outline]

Disposition!!navigator!!

Admission Criteria

  • Early pregnancy vaginal bleeding with:
    • Unstable vital signs or significant bleeding
    • Ruptured ectopic pregnancy
    • Incomplete abortion (open os)
    • Septic abortion
  • All patients with late pregnancy vaginal bleeding need to be admitted to a labor and delivery unit

Discharge Criteria

  • Stable patients with threatened abortion, complete abortion, embryonic demise, or anembryonic gestation
  • Asymptomatic, hemodynamically stable patient with small, unruptured ectopic (or suspected ectopic) pregnancy after OB/GYN consultation
  • Controlled bleeding from vaginal/cervical source

Issues for Referral

  • Patients with embryonic demise, anembryonic gestation, or gestational trophoblastic disease need to be referred for uterine evacuation if D&C not performed in ED
  • Women with threatened, inevitable, complete, or missed (embryonic demise) abortion should have OB/GYN follow-up within 24-48 hr
  • Consult OB/GYN for patients with a pregnancy of unknown location on US

Follow-up Recommendations!!navigator!!

  • Discharge instructions:
    • No strenuous activity, tampon use, douching, or intercourse
    • Seek medical advice for increased pain, bleeding, fever, or passage of tissue
  • All pregnant women with vaginal bleeding during pregnancy who are discharged from the ED require follow-up care
  • Women with threatened abortions, known or suspected ectopic pregnancy require repeat -hCG testing and repeat exams in 2 d

Pearls and Pitfalls ⬆ ⬇

  • Failure to check Rh status in pregnant women with vaginal bleeding
  • Failure to give anti-Rh0 (D) immune globulin in Rh-negative women with vaginal bleeding
  • Failure to obtain pelvic US in symptomatic pregnant women with first-trimester pregnancy regardless of β-hCG level
  • Placenta previa or vasa previa must be ruled out by US prior to pelvic exam in late pregnancy

Additional Reading ⬆ ⬇

  • HahnSA, PromesSB, BrownMD, et al. Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy . Ann Emerg Med. 2017;69(2):241-250.e20.
  • RobertsonJJ, LongB, KoyfmanA. Emergency medicine myths: Ectopic pregnancy evaluation, risk factors, and presentation . J Emerg Med. 2017;53(6):819-828.
  • Tubal ectopic pregnancy. ACOG Practice Bulletin No. 193. American College of Obstetricians and Gynecologists . Obstet Gynecol. 2018;131(3):e91-e103.

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

ICD9

  • 634.90 Spontaneous abortion, without mention of complication, unspecified

  • 640.90 Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not applicable

  • 641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable

  • 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy

  • 641.10 Hemorrhage from placenta previa, unspecified as to episode of care or not applicable

  • 641.20 Premature separation of placenta, unspecified as to episode of care or not applicable

ICD10

  • O03.9 Complete or unspecified spontaneous abortion without complication

  • O20.9 Hemorrhage in early pregnancy, unspecified

  • O46.90 Antepartum hemorrhage, unspecified, unspecified trimester

  • O00.9 Ectopic pregnancy, unspecified

  • O44.10 Placenta previa with hemorrhage, unspecified trimester

  • O45.90 Premature separation of placenta, unsp, unsp trimester

SNOMED

  • 34842007 Antepartum hemorrhage (disorder)

  • 25825004 hemorrhage in early pregnancy (disorder)

  • 17369002 Miscarriage (disorder)

  • 34801009 Ectopic pregnancy (disorder)

  • 198903000 Placenta previa with hemorrhage

  • 415105001 placental abruption (disorder)