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First Trimester Bleed




Hey whats going on guys and welcome to another case presentation.  Today I want to  talk to you about somebody that came in yesterday.  So a little bit about her.  She’s a 24 year old female thats coming in at 8 weeks gestation with a history of spotting for the past 2-3 days.  Now, she did her own pregnancy test at home because of the spotting, and it came back positive.  So, she decided to do a follow up appointment with us as of yesterday.  This is somebody that Iv seen in the past, and she has an interesting history.   This is going to be her fifth pregnancy at 24 years of age.  Now, her first pregnancy ended in a miscarriage at about 6 weeks gestation.  The second pregnancy ended up in gestational hypertension that actually led to pre eclampsia.  The third pregnancy was healthy and viable and lasted the 40 weeks.  Now, the fourth pregnancy that ended in september of 2013, actually ended in one miscarriage and one ectopic.  Its pretty rare for that to happen!  Now, they had to actually remove one of the fallopian tubes because of the ectopic pregnancy.  So as of now, she only has one fallopian tube.

Now theres a couple of things on the differential, theres a couple of things that we need to worry about.  One of those things being an ectopic pregnancy.  The fact that she has had an ectopic pregnancy in her previous pregnancy gives her increased risk of having another ectopic, especially since she only has one fallopian tube.  Because she has had two miscarriages separated by one normal viable pregnancy she isn’t necessarily at an increased risk of having a miscarriage.  However, miscarriages are in themselves very common, so we have to keep this in the differential.  There  are other things that we need to worry about also, such as uterine pathology.  Things like fibroids can cause vaginal bleeding.  Cervical pathology, certainly things like polyps and cervical lesions can cause some vaginal bleeding.  Vaginal lacerations can cause some vaginal bleeding.  Alright so what are we going to do for this patient?

Well, theres three things we need to do.  We need to do a physical exam, an HCG quant, and an ultrasound.  So in the physical exam, you want to note that she doesn’t have any lacerations, whether that be in the vaginal canal or on the cervix itself.  You also want to note any other lesions that are visible that can in them of themselves cause vaginal bleeding.  The second thing you want to do is palpate the fundus, and see if its something you can actually feel, because you want to make sure that her dating is correct.  A lot of pregnant woman actually come in with incorrect dating.  So, normally you wont feel a palpable uterus passed the pubic symphysis until they are about 12 weeks gestation.  Before that you have to do a bi manual exam to get an idea as to how far along she is.  The next thing you want to note is the cervix.  Is the cervix closed, is the cervix open?  Do you see products of conception?  Now, in her case, her fundus was not palpable past the pubic symphysis, meaning she is under 12 weeks gestation.  Her cervical os is closed, which could either signify a non viable pregnancy that is still in the uterus, or this can indicate a threatened abortion, or we still have an ectopic pregnancy on the differential.

Now you want to do a baseline HCG quant and thats for a couple of reasons.  First off, if you order an ultrasound, your not going to see an intra uterine pregnancy until you reach an HCG quant of about 2,000.  After 2000 you should definitely see an intra uterine pregnancy and if you don’t that raises the suspicion for an ectopic pregnancy.  You also want to do serial quants on this patient.  Because if you do serial quants every two to three days you should normally see a doubling of the HCG quant.  So, we did a baseline HCG quant on this patient.  We also sent her out for ultrasound.  We had ultrasound there in the office, so we had a trans abdominal ultrasound done.  Ideally, you want to do a transvaginal, but we only had a trans abdominal at that point.  So what were the results of this patient?

She had a gestational sac that measured 6.4 weeks.  Now, there was not a yolk sac and a fetal heart rate was not identified.  Normally on transvaginal ultrasound you should start to see a sac at around 5-6 weeks and about 7 weeks you should definitely see a fetal heart rate and definitely see a yolk sac.  Now trans abdominal ultrasound can lag by about one to two weeks so this is still constant with a normal viable pregnancy, probably.  Because she has a closed cervical os and a gestational sac, then we can  safely rule out a complete abortion and can safely rule out an ectopic pregnancy.  So what are we going to do for this patient? Were going to do serial quants like we stated earlier.  She’s going to come in every 2-3 days and we want to make sure that her quants are at least doubling.  Doubling means that she has a normal viable pregnancy and we simply did the ultrasound to soon.  If its not increasing the way it should, then this is indicative of a failing pregnancy.  So were going to do a repeat quant every 2-3 days and see her back in 2 weeks for repeat ultrasound.  Now at that point if we don’t see a fetal heart rate, then this is an indication that she is going through a miscarriage.  So, these are the things we want to worry about.

Now as far as bed rest.  Bed rest does not change the outcomes as far as first trimester bleeding.  So don’t place your patients on bed rest.  The only thing this does is increase the risk of DVT because pregnancy increases the risk of DVT.  Bed rest leads to immobility which is a component of virchows triad.  So, don’t place these patients on bed rest.  Theres not a lot we can do for these patients at this point, and by placing these patients on bed rest, your really treating your own ego as opposed to treating the actual patient.  Alright guys so that was the case presentation as of yesterday.  Ill let you know how this goes.  Alright ill see you guys on the next case presentation!


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