Can’t Miss Diagnoses
First Trimester Bleeding:
- Miscarriage (formerly known as spontaneous abortion)
- Ectopic pregnancy
- Cervical/vaginal lesions
Points to focus upon
- Last Menstrual Cycle
- Determine if patient has been on fertility treatments, which will elevate their risk of heterotopic pregnancy (a concurrent intrauterine AND ectopic pregnancies) to roughly 1:200 (much more common than normal rates which are closer to 1:10,000).
- Prenatal care & screening, prenatal vitamins
- Screen for other first trimester problems (e.g. nausea and vomiting of pregnancy)
- Social Habits (Pregnancy can be an important time to intervene)
- Screen for sexual and/or domestic violence (first trimester can be a high-risk time).
- Assess volume status and vitals for any suspected Ectopic pregnancy, send type and cross-match early can be life-saving
- Speculum exam to evacuate source of bleeding, presence of clots or tissue.
- Cervical exam to determine if os is open or closed
Point-of-Care Ultrasound (to be done only for those with formal training and/or certification for interpretation):
– Examine for intra-uterine pregnancy
– Examine for free fluid in the abdomen/pelvis
If you diagnose a pregnancy, do not default to giving your congratulations. You do not always know the circumstances of the pregnancy and whether this is a good thing or not. Find a way to safely ask whether this is a planned or safe situation for the patient (consider screening for domestic or sexual violence).
- CBC (Baseline)
- Type & Screen (if blood type NOT known, need to know if Rh negative so that they can receive Rh immunoglobulin)
- Serum beta-HCG
- Formal Ultrasound
Note, about beta-HCG levels in Ectopic Pregnancy:
In a normal pregnancy, the β-HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, β-HCG levels usually increase less. Mean serum β-HCG levels are lower in ectopic pregnancies than in healthy pregnancies
Absence of an intrauterine pregnancy on a scan when the β-HCG level is above the discriminatory zone represents an ectopic pregnancy or a recent miscarriage.
Read more about e beta-HCG discriminatory zone and ultrasounds in suspected ectopic pregnancies here.
For any type of first-trimester bleeding cases, please remember to check Rh status, and provide Rh-immunoglobulin as needed. For first rimester Rh-negative individuals, low dose Rh-immunoglobulin is usually advised (50 mcg IM x 1).
- Unstable ectopic pregnancies should be acutely resuscitations and Obs/Gyne should be contacted to provide definitive surgical care.
- Stable ectopic pregnancies can be managed with either oral or vaginal medicine. Contact Obs/Gyne for advice if this is outside your normal scope of care.
The rate of first trimester bleeding is fairly common – around 25%1 so it is imperative that patients know that it is common, but that it does have some slight correlation with miscarriage. Close observation of symptoms and clear return instructions for what to expect (e.g. If bleeding gets worse, please return to ED) and arranging follow-up as possible. Some cities will have dedicated programs for first trimester bleeding, but access to these may be altered during the COVID-19 outbreak. Consult your obstetrics and gynecology or primary care colleagues as required to figure out the best pathway to arrange follow-up for your patient.
If your patient has a full pregnancy loss, it is important to consider the psychological ramifications of this for your patient (and if involved, their partner). Some key aspects of grief counselling after miscarriage are listed below for your quick reference. However, this should be performed by someone who has experience with this (if possible) to minimize secondary psychological harm to the patient.
Key points to consider when grief counselling during/after a miscarriage, adapted from Deutchman et al. 20091
– acknowledge but attempt to dispel guilt
– acknowledge and validate sense of grief
– reassure patient about future (e.g. usually most worry about future fertility)
– provide advice/counselling on how to discuss with family/friends (Speak plainly, avoid medical details, remember that others may also react emotionally, tell others what you need for support)
– include partner (if in the picture) in psychological care
ALSO, since social distancing procedures at the hospital may preclude a patient’s support network to be there with her, consider inviting the patient to call their loved ones and be on speaker phone may be helpful.
Recommended reading, videos, and podcasts
- EM in 5 video – Vaginal Bleeding in 1st TM Pregnancy
- CRACKCast E034 – Vaginal Bleeding
- CanadiEM – How useful is the beta-HCG discriminatory zone in a suspected ectopic pregnancy
- EM Cases – Ectopic Pregnancy Pitfalls in Diagnosis
- Ectopic Pregnancy Ultrasound
- CRACKCast E177 – Acute Complications of Pregnancy
- CRACKCast E178 – Co-Morbid Medical Emergencies During Pregnancy
- American Family Physician Review Article (CAUTION: American Content)
- 1.Deutchman M, Tubay AT. First Trimester Bleeding. Am Fam Physician. 2009;79(11):985-992. https://www.aafp.org/afp/2009/0601/p985.html.