First Trimester Bleeding

1
Evaluation of First Trimester Bleeding
Bleeding in desired pregnancy, lt 12 weeks
gestation
Physical exam
Peritoneal signs or hemodynamic instability
Non-obstetric cause of bleeding identified
Products of conception (POCs) visible on exam
Patient stable, no POCs or other cause of
bleeding
Incomplete abortion, treat as indicated
Diagnose and treat as indicated
Transvaginal ultrasound (TVUS)
Transfer to ED
Viable intrauterine pregnancy (IUP)
Ectopic or signs suggestive of ectopic pregnancy
Nonviable IUP
No IUP, no ectopic seen
IUP, viability uncertain
Embryonic demise, anembryonic gestation, or
retained POCs discuss treatment options
Completed abortion expectant management
Threatened abortion repeat TVUS if further
bleeding
Presume ectopic refer for high-level TVUS and/or
treatment
Repeat TVUS in one week and/or follow serial
ß-hCGs
IUP seen on prior TVUS?
Yes
No
Check ß-hCG
ß-hCG lt 2000
?-hCG gt 2000
Ectopic precautions, Repeat ß-hCG in 48 hours
Single ß -hCG gt 2000 and bleeding history
consistent with having passed POCs
Single ß -hCG gt 2000 and bleeding history not
consistent with having passed POCs
Serial ß -hCGs rising and gt 2000
Repeat ß-hCG gt 2000
Repeat ß-hCG lt 2000
Ectopic precautions, repeat ß-hCG in 48 hrs
Repeat ß-hCG fell lt 50, plateaued or rose lt 66
Repeat ß-hCG rose gt 66
Repeat ß-hCG fell gt 50
Repeat ß-hCG fell gt 50
Repeat ß-hCG fell lt50 or rose
Obtain high-level TVUS to differentiate between
ectopic, early IUP, and retained POCs treat as
indicated
Suggests completed abortion ectopic precautions,
follow ß-hCG weekly to zero
Suggests viable pregnancy but not diagnostic
follow ß-hCG until gt 2000 then TVUS for
definitive diagnosis
Suggests early pregnancy failure or ectopic
offer uterine aspiration or high-level TVUS
serial ß-hCGs until definitive diagnosis or
ß-hCG zero
ß-hCG should be followed to zero only in cases
when pregnancy location cannot be confirmed and
the possibility of a spontaneously resolving
ectopic pregnancy has not been excluded ß
-hCG does not need to be followed to zero
following miscarriage of a known intrauterine
pregnancy.