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INTRODUCTION

KEY QUESTIONS

  • What causes vaginal bleeding in the first trimester of pregnancy?

  • How common is miscarriage in the first trimester of pregnancy, and how is it diagnosed?

  • What are first-trimester miscarriage treatment options and success rates?

  • How is ectopic pregnancy diagnosed and treated?

  • What is molar pregnancy, and how is it treated?

CASE 54-1

A 22-y.o. presents to the ED who has registered a 6 out of 10 level of pelvic pain and vaginal bleeding for 3 days. She has a history of irregular menses and was unaware of her pregnancy. Laboratory testing in the ED includes a positive urine pregnancy test, TVUS showing an empty uterus, and serum hCG of 313. The ED resident requests a consult from the OB/GYN hospitalist.

Vaginal bleeding in early pregnancy is a relatively frequent occurrence, with 15% to 28% of pregnant women reporting bleeding in the first trimester.14 Despite the high frequency of this concerning symptom, approximately half of women with bleeding in early pregnancy will continue to have an ongoing pregnancy.3,5 The other half will experience early pregnancy loss (EPL). The term EPL is used in this chapter to describe abnormal intrauterine pregnancies (IUPs) in the first trimester and includes a variety of conditions encompassed by the terms miscarriage or spontaneous abortion (listed in Table 54-1). Like vaginal bleeding in early pregnancy, EPL is common, with miscarriage rates of approximately 15%.6,7 Ectopic pregnancy and molar pregnancy, though rare, also may present with vaginal bleeding in early pregnancy.

TABLE 54-1Spontaneous Abortion Categories

It is not surprising, then, that vaginal bleeding is a common complaint for reproductive-aged women seen in the Emergency Department (ED). One study reports a chief complaint of vaginal bleeding in pregnancy in 1.6% of ED visits.8 In the ED/hospital setting, the overall rate of EPL is 30% for women presenting with bleeding, cramping, or both in early pregnancy.9 While pregnancy viability and diagnosis of pregnancy failure are important, a missed diagnosis of other rare pregnancy complications, such as ectopic pregnancy or hydatidiform molar pregnancy, can have life-threatening consequences. The clinical picture may be complicated further by pregnancy intention ...

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