Approach to the First Trimester
Patient with Vaginal Bleeding
or Pelvic Pain
Eric R. Swanson, MD, FACEP
Associate Professor, Division of Emergency Medicine
Medical Director, AirMed
University of Utah Health Sciences Center
AirMed
Objectives
• Provide and evidence based approach to the
ED patient with vaginal bleeding and
abdominal or pelvic pain
• Discuss the diagnostic role of technology
(hormonal assays and US)
• Provide a guideline algorithm for managing
these patients
Case Study
• HPI: 28 yo female presents to the ED with vaginal
bleeding and cramping lower abdominal pain. Onset
of pain was gradual & bleeding started as spotting
yesterday and became heavy today. LMP 5 weeks
ago.
• ROS: + Nausea, No fever, chills or urinary symptoms
• Exam: BP 128/80 HR 76 RR 16 T 37.5 Abdomen
is soft with bilateral lower quadrant and suprapubic
tenderness. No CVAT. Pelvic - Os closed, blood is
coming from the uterus
• What information would be useful to you now?
ß-HCG
• The nurse informs you that a ß-HCG
was not obtained because….
– The pt had her “tubes tied”
– The pt was “not sexually active”
– The pt was “on her period”
ß-HCG
• Every female patient of reproductive age with
abdominal pain or vaginal bleeding needs to
have a pregnancy test.
• Pittsburgh study
– Unrecognized Pregnancy in ED patients
• 6.3% Overall
• 13% in women with abd or pelvic complaints
• 2.5% with other complaints
• What are you worried about in this patient?
What are you worried about in
this patient?
• Ectopic pregnancy
• Spontaneous abortion
Ectopic Pregnancy
• Incidence
– Historically 4.5/1000, Current incidence is 20/1000
– Mortality has decreased 90% but still the leading cause of first
trimester mortality
• Risk Factors
– Infertility, history of PID, previous tubal surgeries, previous ectopic
and IUD use. Risk factors are present in less than 50% of patients.
• Clinical Presentation (Variable)
– Abdominal pain - 10% have no pain
– Vaginal bleeding - 30% have no bleeding
• Exam (25% "normal" pelvic)
– Abdominal and adnexal tenderness - 50%
– Adnexal mass - 10%
– Varying uterine size
Spontaneous Abortion
• Incidence
– 15 -20 % of all known pregnancies
• Causes
– genetic abnormalities > 50 %
• Clinical presentation
– Most before 8 or 9 weeks, can occur up to 20 weeks
– Spotting proceeding to heavy bleeding with clots or tissue
– Pain is usually midline and cramping
• Exam
– Midline suprapubic tenderness
– Os closed
– Os open
Should a quantitative ß-HCG level influence
the decision to perform pelvic ultrasound?
• You order a pelvic ultrasound but the
radiologist requests a quantitative ß-HCG
first.
Or…
• Radiologist asks if the ultrasound can be
done as an outpatient the next day or so
Should a quantitative ß-HCG level influence
the decision to perform pelvic ultrasound?
• Perspective:
– Vaginal bleeding, abdominal pain, or both in the
first Trimester will result in:
• 60% Normal pregnancy
• 10% Ectopic
• 30% Miscarriage
– 50% of ectopic pregnancies that present to an emergency
department are not diagnosed at the first visit, yet 70% to
80% are detectable using a combination of transvaginal
ultrasound and quantitative ßHCG
Discriminatory level of ß-HCG
• ß- HCG = 2,000
• Sensitivity 100%, Specificity 98%
• PPV 98%, NPV 100%
• Radiologist asks why you are getting the
US if the ß- HCG is less than 2,000.
Literature
• Barnhart, Obstet Gynecol 1994:
– 59% of ectopics never exceed ß-HCG > 1,500
• Brennan, Acad Emerg Med 1995:
– 15% of ectopics will rupture prior to missed
menses.
– 83% of ectopics will never exceed ß-HCG of 2,000
• (range <100 to > 50,000).
– 36% to 50% will have a lower ß-HCG on serial
testing
Literature
• Kaplan, Ann Emerg Med 1996:
– Subgroup of patients with ß-HCG < 1,000 had 4X
risk of ectopic.
– One third of this subgroup were already ruptured.
– Initial ED work-up was diagnostic in 79% of
patients overall, and 70% of ectopics.
• Dart, Ann Emerg Med 1997:
– 17% of all patients with ß-HCG < 1,000 have
diagnostic US.
– 40% of patients with an ectopic and ß-HCG <
1,000 have diagnostic initial US.
Clinical Prediction Rule
• Buckley, Ann Emerg Med 1999
– Prospective, 915 patients
– FHT’s or tissue in os: Never had an ectopic
– High Risk: Peritoneal signs, definite CMT
• 29% had ectopic
– Intermediate Risk: Non-midline pain or tenderness,
no FHT’s, no tissue in os.
• 7% had ectopic (most patients in this group - 70% of total)
– Low Risk: All others
• 0.5% (1 of 196 patients) had ectopic (only 20% of total were
low risk)
• Retrospective, 730 ED pts, Quant ß-HCG & formal US
• ß-HCG < 1,500 more than doubled the odds of ectopic
• ß-HCG < 1,500 more than 5 times risk of abnormal
pregnancy
• 158 (22%) had ß-HCG < 1,500,
– 25% had ectopic
– 16% had normal IUP
So…….
• High incidence of ectopic in symptomatic first
trimester pts in the ED (around 10%)
• Exam is generally not helpful
– Exceptions are peritoneal signs (ectopic) or
presence of tissue (SAB) or FHT’s (Live IUP)
• Low ß-HCG doesn’t mean low risk
– In fact ß-HCG < 1,500 is 2-4 times risk for ectopic
In the Era of ED Ultrasound
• Prospective, 1,490 1st trimester ED US
– IUP 1,037 (70%)
– Demise 127 (8%)
– Definite ectopic 24 (2%)
– Molar Pregnancy (<1%)
– Indeterminate 300 (20%)
• 300 Indeterminate Ultrasounds
– Demise 158 (53%)
– IUP 88 (29%)
– Ectopic 44 (15%)
American Journal of Emergency Medicine (2007) 25, 591 – 596
Female pt with abdominal pain
and/or vaginal bleeding
Stable
Unstable
2 IV's
B-HCG, HCT, Type & Cross
FAST Exam
Ob/Gyn or Surgery consult
B-HCG
from triage
Clinical
Assesment
Neg
Pos
Pelvic exam
Os Open
Tissue present
Excessive bleeding
Os Closed
Quant BHCG
Type & Rh
HCT if indicated
IV, HCT, Type & Rh
consult OB/Gyn
Rhogam if indicated
ED US indeterminate
or
No ED US done
Quant < 2,000
No IUP
Quant > 2,000
Formal US
Formal US if anything
other than trivial sx's
US if risk factors
US if clinical suspicion
IUP
Doppler FHT's
or
ED US definite IUP
No IUP or
Ectopic
IUP
Ectopic
D/W Ob/Gyn
Rhogam if indicated
Repeat Quant in 48 hrs
OB/ Gyn Consult
Rhogam if
Indicated
OB/Gyn F/U
Rhogam if
Indicated
Female pt with abdominal pain
and/or vaginal bleeding
Stable
Unstable
2 IV's
B-HCG, HCT, Type & Cross
FAST Exam
Ob/gyn or Surgery consult
B-HCG
from triage
Clinical
Assesment
Neg
Pos
Pelvic exam
Os Open
Tissue present
Excessive bleeding
IV, HCT, Type & Rh
consult OB/Gyn
Rhogam if indicated
Os Closed?
Quant BHCG
Type & Rh
HCT if indicated
ED US indeterminate
Doppler FHT's
or
ED US definite IUP
Os Open
Tissue present
Excessive bleeding
Os Closed?
Quant BHCG
Type & Rh
HCT if indicated
IV, HCT, Type & Rh
consult OB/Gyn
Rhogam if indicated
ED US indeterminate
or
No ED US done
Quant < 2,000
No IUP
Quant > 2,000
Formal US
Formal US if anything
other than trivial sx's
US if risk factors
US if clinical suspicion
IUP
Doppler FHT's
or
ED US definite IUP
No IUP or
Ectopic
IUP
Ectopic
D/W Ob/Gyn
Rhogam if indicated
Repeat Quant in 48 hrs
OB/ Gyn Consult
Rhogam if
Indicated
OB/Gyn F/U
Rhogam if
Indicated
Controversy: Does evidence of IUP on
ultrasound eliminate the possibility of an
ectopic pregnancy?
• In general this is true.
• General population: The risk of heterotopic
pregnancy is 1:30,000 (1948), Now 1:2600 to 1:8000.
• Assisted reproduction: The risk is 1:100 to 1:500
– Ultrasound is misleading due to concurrent IUP.
– Quantitative ß-HCG is not helpful due to normal fetus
making the hormone.
– Expectant management is not indicated.
Controversy: Does evidence of IUP on
ultrasound eliminate the possibility of an
ectopic pregnancy?
• Point: Use extreme care and involve
obstetrics in any pregnant patient with lower
abdominal pain or vaginal bleeding and
assisted reproduction.
Ectopic Pregnancy: Treatment
• Unstable
–
–
–
–
–
–
Oxygen
Volume resuscitation
FAST Exam
Type specific blood
OB/GYN
Laparotomy (possibly Laparoscopy)
• Stable
– Laparoscopy
– Methotrexate
– Expectant
Ectopic Pregnancy: Treatment
ACADEMIC EMERGENCY MEDICINE 2007; 14:755–758
Ectopic Pregnancy: Summary
• Incidence has increased 4 fold since 1970.
• 7% to 13% of pregnant patients presenting to
ED’s with abdominal pain or bleeding have an
ectopic pregnancy.
Ectopic Pregnancy: Summary
• History and physical can be misleading in ectopic
pregnancy:
– 10% no pain
– 50% no risk factors
– 25% "normal" pelvic
30% no bleeding
90% no adnexal mass
50% misdiagnosed initially
• No single test is extremely reliable. An algorithm
utilizing physical exam, early transvaginal ultrasound
and quantitative ß-HCG seems to be the best.
Ultasound Images in Early
Pregnancy
• In this transvaginal view, a 4.0 week size
gestational sac is clearly seen (arrow). The
uterus is outlined with arrowheads.
Ultasound Images in Early
Pregnancy
• Gestational Sac
Ultasound Images in Early
Pregnancy
• 4 to 4.5 weeks
• Double sac sign, with the decidua capsularis (DC)
and decidua parietalis (DP).
Ultasound Images in Early
Pregnancy
• 4-5 weeks
• Yolk Sac
Ultasound Images in Early
Pregnancy
• 5 - 6 weeks
• Fetal Cardiac Activity
• Initially slow (110 bpm), then to 160 at 8 wks,
then decreases through rest of first trimester
Ultasound Images in Early
Pregnancy
• 5.5 - 6.5 weeks
• Embryo elongation into fetal pole
ED US Pitfalls
• Pseudogestational sac is seen in 20-50% of
ectopic pregnancies. Can be confused with
double decidual sign.
ED US Pitfalls
• Pseudogestational sac
ED US Pitfalls
• Pseudogestational sac
ED US Pitfalls
• Twin gestation 7 weeks
ED US Pitfalls
• Threatened SAB with Clot
ED US Pitfalls
• Inevitable abortion
• In this case the endometrial cavity (En) at the
fundus is empty because the gestational sac
(arrowheads) has been pushed into the cervix
(Cx).
Further Reading
Summary
• All women of reproductive age with GI or GU
complaints need a ß-HCG
• 7% to 13% of pregnant patients presenting to ED’s
with abdominal pain or bleeding have an ectopic
pregnancy.
• History and physical can be misleading in ectopic
pregnancy.
• No single test is extremely reliable. An algorithm
utilizing physical exam, early transvaginal ultrasound
and quantitative ß-HCG seems to be the best.
Questions?