This week we discuss bleeding and pain in early pregnancy, and how to diagnose miscarriage.
Take Home Messages:
- Miscarriage occurs in 1 in 5-6 confirmed pregnancies.
- A pregnancy that has not yet been sighted on USS remains a ‘Pregnancy of Unknown Location’ and remains a possible ectopic pregnancy until proven otherwise.
- Serial B-hCGs can be helpful in guiding your clinical decision making, however you cannot ‘locate’ a pregnancy with a blood test alone.
- In the symptomatic patient, a falling, plateauing or rising B-hCG can ALL be associated with an ectopic pregnancy – these must be followed until an ectopic pregnancy can be diagnosed or excluded.
- A rise of B-hCG in 48hrs of > 63% is relatively reassuring for an ongoing intrauterine pregnancy, make sure to confirm it with an USS as soon as you can.
- The ultrasound diagnosis of both a blighted ovum and a missed miscarriage (with a foetal pole) have strict criteria – refer ASUM guidelines below.
References & Resources:
Early Pregnancy Ultrasound Rules and Report Card (LINK) – Ultrasound FOAM from The Sono Cave
First Trimester Bleeding Imaging Pathway (LINK) – Western Australia Health Department Flowchart
Clinical Guideline: Early Pregnancy Loss (PDF) – Queensland Health Guideline
First Trimester Bleeding Algorithm (PDF) – Reproductive Access Project, USA
ASUM Guidelines for Performance of First Trimester Ultrasound (PDF) – Australian Society for Ultrasound Medicine
NICE Guideline: Ectopic Pregnancy and Miscarriage (PDF) – UK Guidelines
How To Treat: Early Pregnancy Bleeding (PDF) – Australian Doctor Magazine, 2009
RANZCOG Guidelines – Anti-D use in Obstetrics (PDF) – Australia & New Zealand
Does speculum examination have a role in assessing bleeding in early pregnancy? (LINK) – Emergency Medicine Journal 2004
Bits & Bumps 
Hi team BnB
Just a quick note: measuring orthostatic hypotension is really quite unhelpful
Check out this short sweet review from dr swaminathan https://vimeo.com/72447198
Asking about syncope, or just standing the patient and observing for syncope is just as good, easier and helps.
Of course, Ultrasound helps – unusual to see syncope without any free fluid on US, unless it is vagally mediated I.e. A clot sitting in the cervix.. So looking there is useful, usually these women are bradycardic, not tachy as you’d expect for serious bleeding
C
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