February 24, 2011 by dailybolusoflr
Threatened abortion is a common diagnosis made in early pregnancy by emergency practitioners.
These patients typically present with vaginal bleeding in the first trimester of pregnancy and are found to have a closed os on vaginal exam.
The following are things to know about these patients:
· All patients with vaginal bleeding should have an Rh sent. (Tomorrow’s Daily Bolus will provide details regarding use of Rhogam)
· If the patient does not have a documented IUP, a quantitative beta HCG should be sent so that ultrasonographic findings can be correlated with the result to help rule out ectopic pregnancy.
· For patients in whom IUPs are noted:
o In patients younger than 35 years of age, an 8 week or greater gestation with cardiac activity noted on us is a very reassuring sign. Less than 5% of patients will go on to spontaneous abortion (SAB).
o In patients older than 35 years of age, the same findings have a slightly greater rate of spontaneous abortion (SAB) – about 8%.
o The most common sonographic abnormality in these patients is a subchorionic hemorrhage or hematoma.
§ This is when blood collects between the uterine wall and the chorionic membrane. It may leak into the cervical canal and cause bleeding.
§ Patients who are found to have small subchorionic hemorrhages on ultrasound have a SAB rate of about 9%.
§ Those with hemorrhages greater than 50% of the size of the gestational sac have increased rates of SAB up to 19%.
· Reassuring these patients that vaginal bleeding occurs in up to 25% of pregnancy patients and that many of those pregnancies go on to deliver normal babies is very important.
· There is no data to suggest that bedrest is indicated in these patients and it is very important to impress upon them that nothing they did or did not do is likely the cause.
Harwood Nuss 678-681
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions