Consult GYN
Rh(D) negative?
- History of current pregnancy (urine or serum)
- <12 weeks gestation
- History of any vaginal bleeding
- 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
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
