First Trimester Bleeding1 What causes First Trimester Bleeding

First Trimester Bleeding(1) What causes First Trimester Bleeding? ● Implantation (normal pregnancy), Miscarriage, Ectopic ● Infection cervicitis, vaginitis ● Subchorionic hemorrhage ● Polyp, large cervical ectropion, trauma, cervical cancer ● Other sources of bleeding - cystitis or hemorrhoids What work-up needs to done in OB Triage? ● Vital signs to assess bleeding/stability - can bleed a LOT! ● Pelvic exam to evaluate bleeding - women can bleed a lot and need emergent MVA, surgery, and/ or tranfusion! ● Abdominal exam to assess for surgical abdomen (ruptured ectopic) ● US to confirm viable IUP, if no IUP seen on US in triage, send to DI US before discharge to rule out ectopic. ● HCG-quant, CBC, Type and Screen, Rhogam if > 8 weeks ● Consider STD amp, Vag DNA, wet mount based on exam. If no IUP noted on U/S and elevated HCG, what’s next? ● If pregnancy is desired, repeat HCG in 48 hours with return precautions/warning signs for ectopic ● Place patient in MCH Beta Book, send PCO message to fellows/Yonke with phone number and one liner. ● If pregnancy is undesired, send adhoc to CRH to discuss MVA. Can also talk with patient about methotrexate. Women can become unstable quickly. Needs DI US if no IUP seen on ultrasound in triage! Call FMOB with any questions about first trimester bleeding or pt high risk for ectopic prior to DC. Updated 4/20

First Trimester Bleeding(2) Ultrasound summary: ● Yolk sac: diagnosis IUP ● Heartbeat: diagnosis viable IUP ● A yolk sac and/or embryo rule out ectopic pregnancy…unless heterotopic pregnancy ● Gestational sac without yolk sac or embryo does not rule out ectopic as it may be a pseudosac Ectopic pregnancy: ● 1 -2% of pregnancies are ectopic ● Consider ectopic pregnancy in women who have pain and bleeding ● Women with history of ectopic pregnancy, tubal surgery or tubal pathology, smokers, and those who underwent IVF are at increased risk ● Treatment is surgery or methotrexate - discuss plan with FMOB. Epidemiology and management pregnancy loss ● 1 in 4 women will experience a miscarriage in their lifetime, 15 -25% of women experience 1 st trimester bleeding ● Treatment is expectant management, procedure, medication (mifepristone + misoprostol) ● Refer to CRH for management. Can start med management in triage. ● Emergent MVAs for hemorrhage are done in OB Triage. Stable patients referred to CRH for procedures. You can give mifepristone in triage for medication management of SAB and prescribe misoprostol. Forms for mifepristone are on OB wiki. Call CRH faculty with questions. Or refer to CRH for follow-up. SAB may follow-up in home clinic like IHS or FC if they have ability to follow with either US or h. CG. For procedure, send to CRH.