Spontaneous Abortion
Age: years old
Gender: female
Gestational Age: weeks /7, last menstrual period on
G P A
Blood type: Rh
First trimester ultrasound:
HISTORY:
Presents with a - history of
Gestational age: , last menstrual period on:
Pain rated at / 10
Pain is
Bleeding described as , clots, changing pads/tampons every hours
Bleeding is
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, up to °, over
, episodes , ,
Contributing factors:
no history of: , , ,
no risk factors for
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , , , bowel sounds , ,
Pelvic:
- External genitalia: , ,
- Vagina: , , discharge ,
- Cervix: , ,
- Bimanual exam: , uterus , adnexa ,
- Tests performed: , , pH , KOH sniff test
-
ASSESSMENT:
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: , , ,
- Pelvic ultrasound
Treatments:
- Rest
- Expectant management
-
-
-
- Dilation and curettage
Further care:
- Repeat βhCG in 48 hours
- Referral to obstetrician
- Referral to psychologist
- Follow-up in
- 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
HISTORY: Associated symptoms: EXAM: Pelvic: ASSESSMENT: PLAN: