First Trimester Bleeding

Age: ‍ years old

Gender: female



Gestational Age: ‍ weeks /7, last menstrual period on ‍

G‍01234 P‍01234 A‍01234

Blood type: Rh‍+-

First trimester ultrasound: ‍ ‍normalnot yet performed



HISTORY:

Presents with a ‍-‍day history of first trimester bleeding

Described as ‍spottinglightmoderateheavy, ‍with smallwith largewithout clots

Bleeding is ‍constantintermittent



Associated symptoms: *Try using right-click for negatives*

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍pelvic pain

‍back pain

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍dizziness

‍fainting



Contributing factors:

‍advanced maternal age

‍risk factors for ectopic pregnancy

no history of: ‍previous miscarriages, ‍infertility, ‍previous ectopic pregnancy, ‍blood clotting disorders

no use of: ‍anticoagulants, ‍antiplatelets





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Pelvic:

- External genitalia: ‍normal, ‍rashlesions, ‍inguinal lymphadenopathy

- Vagina: ‍normal, ‍lesions, discharge ‍normal, ‍foul-smelling

- Cervix: ‍normal, ‍, ‍IUD strings visualized

- Bimanual exam: ‍normal, uterus ‍tendernessmass, adnexa ‍tendernessmass ‍on righton left, ‍cervical motion tenderness

- Tests performed: ‍Pap smearHPV test, ‍vaginal culturechlamydia/gonorrhea screeningHSV sample, pH ‍< 4.5 (normal)> 4.5, KOH sniff test ‍negative

- ‍Pelvic exam performed with chaperone 





ASSESSMENT:

‍First trimester bleeding ‍likelysuspectedpossible

DDx: ectopic pregnancy, threatened miscarriage, inevitable miscarriage, gestational trophoblastic disease, cervical changes (polyps, infection, cancer), implantation bleeding, subchorionic hemorrhage, infection, cervical insufficiency, trauma, coagulopathy, sexual assault, foreign body, STI





PLAN:

Investigations:

- Blood work: ‍CBC, ‍βhCG, ‍blood type and Rh, ‍antibody screen

- Pelvic ultrasound

Treatments:

- Rest

- Expectant management

- ‍Misoprostol

- ‍Analgesics

- ‍Rh(D) immune globulin

- Dilation and curettage

Further care:

- Repeat βhCG in ‍ 48 hours

- Referral to obstetrician

- Referral to psychologist

- Follow-up in ‍ ‍weeks

- Return if symptoms worsen, if new symptoms develop such as heavy bleeding or fever, or if emotional distress occurs

- Referral to ER if severe abdominal pain, severe bleeding, or fever occurs