Miscarriage

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 ‍pelvic crampingvaginal bleeding

Gestational age: ‍ ‍weeksmonths, last menstrual period on: ‍

Pain rated at ‍012345678910 / 10 ‍

Pain is ‍constantintermittent

Bleeding described as ‍spottinglightmoderateheavy, ‍with smallwith largewithout clots, changing pads/tampons every ‍ hours

Bleeding is ‍constantintermittent

Alleviating factors: ‍none, ‍effectiveineffective



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

‍pelvic cramping

‍vaginal bleeding

‍passing of tissue or clot

‍lower back pain

‍dizziness

‍fainting

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍emotional distress



Contributing factors:

‍advanced maternal age

‍smoking

‍alcohol consumption

‍drug use

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

no risk factors for ‍ectopic pregnancy





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:

‍Miscarriage ‍likelysuspectedpossible

DDx: miscarriage, ectopic pregnancy, gestational trophoblastic disease, cervical changes, implantation bleeding, subchorionic hemorrhage, cervicitis, vaginal infections, trauma, coagulopathy, sexual intercourse-related bleeding





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