First Trimester Vaginal Bleeding



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First Trimester Vaginal Bleeding

Consult GYN

Rh(D) negative?

Inclusion Criteria
  • History of current pregnancy (urine or serum)
  • <12 weeks gestation
  • History of any vaginal bleeding
Exclusion Criteria
  • History of complex GU/GYN surgery/coomorbidities
  • Obvious external cause of bleeding

Patient hemodynamically stable?

Complete speculum pelvic exam

(can be completed prior to US)

Complete speculum pelvic exam

(can be completed prior to US)

Off pathway, treat appropriately

Off pathway, treat appropriately

Emergent GYN consultation, NPO place IVs, complete metabolic panel, consider fluid resuscitation or ordering PRBCs if unstable

Ultrasound result

Beta-HCG > 1500?

Ultrasound criteria for missed abortion:

  • No fetal heart beat with crown-rump length of 7mm
  • No fetal pole with gestational sac 25mm

Missed abortion

  • Consult GYN

Threatened miscarriage

  • Discharge with expectant management
  • Possible follow up transvaginal ultrasound until diagnosis confirmed
  • GYN follow-up within 2 days
  • Nothing per vagina until GYN follow up

Pregnancy of unknown location

  • Outpatient gynecology follow up
  • Serial hCG measurement at 48 hours
  • Return precautions for worsening bleeding, severe pain

Consider OBGYN consultation

Inevitable miscarriage

  • Remove products of conception if present
  • Consult gynecology
  • Possible dilation and curettage

Subchorionic hematoma

  • Risk factor for spontaneous abortion
  • Expectant management only

If serial Beta-HCG does not increase by more than 50% at 48 hours, consult GYN immediately.

  • Aggressive fluid resuscitation
  • Type and cross
  • Consider urgent O- blood transfusion
  • Emergent GYN consultation
  • Consider OR/ICU admission

Physical activity precautions for threatened miscarriage

  • No evidence showing benefit in preventing fetal loss

Complete Blood Count, Serum
Urinalysis with micro, Urine
Ultrasound Pelvis
Type & Screen, Serum
Beta-HCG Quantitative, Serum

Progestins for threatened miscarriage

  • Unclear efficacy, not yet commonly used

anti-D immunoglobulin 50 mcg IM once, counsel patient on the need for antepartum prophylaxis at 28-30 weeks of gestation, don't delay further care to give dose

Anti-D Immunoglobulin



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