A case of first-trimester vaginal bleeding with abdominal cramping

Mrs. M, aged 24 years and 11 weeks pregnant, presented to the emergency department (ED) with abdominal cramping and heavy vaginal bleeding and clots. Over the past two days, she had experienced light spotting, which had increased in severity that morning. Mrs. M reported no fever, chills, burning on urination, nausea, or vomiting. Her past obstetric history was gravida 4 para 2 aborta 1. She was sexually active and receiving prenatal care from her obstetrician/gynecologist. The patient was otherwise healthy and had no significant medical problems.

1. Physical examination

Mrs. M's BP was 124/84 mm Hg, heart rate 83 beats per minute without ectopy, respiration rate 18 breaths per minute, oxygen saturation 100% on room air, and temperature 98.3°F. Lungs were clear on auscultation in all fields; S1 and S2 were normal with no murmurs, gallops, or rubs. The patient's abdomen was slightly distended, and mild tenderness was present over her lower pelvic area. During pelvic examination, moderate active bleeding was noted in the vaginal vault with the cervical os open. No cervical motion tenderness or adenexal tenderness was observed. Blood clots or tissue were noted on a peripad. The remainder of the patient's physical examination was unremarkable.

2. Diagnostic workup

Laboratory findings showed WBCs 10,000/uL (normal 4,500-11,000), hemoglobin 13.7 g/dL (normal 12.1-15.1), and hematocrit 39.7% (normal 36%-44%). Chemistries and urinalysis were within normal limits. Mrs. M's blood type was B-positive. Beta-human chorionic gonadotropin (b-hCG) level was 9400.0 mIU/mL, which is elevated and suggests a gestational age of three to four weeks, according to the lab report.

Transvaginal ultrasonography showed what appeared to be an abnormal gestational sac within the cervical canal. The findings were suggestive of a threatened abortion in progress. Transvaginal ultrasonography is very reliable for finding remaining tissue or content of conception with 100% sensitivity and 80% specificity.1 When transvaginal ultrasound shows a vacant uterus and the qualitative b-hCG level is >1,500, an ectopic pregnancy should be considered and ruled out.2

After reviewing the findings of the abnormal gestational sac, it was apparent that Mrs. M did not have an ectopic pregnancy.

3. Diagnosis

First-trimester bleeding has a number of differential diagnoses that must be reviewed along with a complete history and physical examination. The relevant differentials for this case are cervical abnormalities, including excessive friability, malignancy, polyps or trauma; ectopic pregnancy; idiopathic bleeding in a viable pregnancy; infection of the vagina or cervix; molar pregnancy; spontaneous abortion; subchorionic hemorrhage, and vaginal trauma.3

Upon review of her history, physical exam, and diagnostic workup, Mrs. M was diagnosed with incomplete spontaneous abortion. In an incomplete abortion, some (but not all) of the products of conception have been passed. Usually the patient has heavy bleeding and cramping with dilation of the cervix.4

4. Discussion

Spontaneous abortion is the loss of a pregnancy before 20 weeks' gestation. An estimated 15%-20% of recognized pregnancies end in this manner.  Approximately 80% of patients are affected within the first trimester, with a decrease in incidence noted with gestational age. One percent of all couples experience recurrent miscarriages, which is defined as two to three pregnancy losses.4

Some types of spontaneous abortion observed in clinical practices include threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, recurrent spontaneous abortion, and complete abortion (Table 1). The type of abortion guides the treatment options available.3

Genetic abnormalities within the embryo (including chromosomal abnormalities) are the most frequent cause of spontaneous abortion, accounting for approximately 40% of all miscarriages. Other risk factors for spontaneous abortion include advanced maternal age, alcohol use, cigarette smoking, illegal drugs, heavy caffeine intake, chronic maternal diseases, uterine malformation, previous induced abortion, previous miscarriages, and structural abnormalities of the reproductive tract.5

5. Treatment plan and options

Although Mrs. M's hematocrit and hemoglobin were within normal limits, she was given one liter of normal saline to keep her hemodynamically stable, as large amounts of blood were lost in the ED. The patient was also given 2 mg hydromorphone (Dilaudid) IV and 4 mg ondansetron (Zofran) IV to  relieve cramping pain and prevent nausea.

Prior to discharge, Mrs. M's obstetrician/gynecologist was called, and the patient was sent home with prescriptions for methylergonovine (Methergine) (one 0.2-mg tablet every four hours for six doses) and ibuprofen (one 800-mg tablet three times a day for pain).

Expectant management was the treatment chosen. This allows the miscarriage to occur naturally without surgical intervention. It is the treatment of choice for incomplete miscarriages.6 Methergine assists with expectant management by increasing uterine contractions, which helps control blood loss. Mrs. M was instructed to follow up with her obstetrician/gynecologist in three to five days.

Methergine is the only ergot alkaloid medication presently used in obstetrics as a uterotonic.7 It is metabolized in the liver and has a half-life of 0.5-2 hours. Oral ingestion allows for close to absolute absorption and causes uterine contractions; peak plasma concentrations occur within 0.3-2 hours. Methergine is indicated for prevention and treatment of post-abortion hemorrhage caused by uterine atony or subinvolution.8 Because ergot alkaloid agents raise BP, Methergine use is contraindicated in women with pre-eclampsia or hypertension. Nausea and vomiting are other adverse effects.7

In the past, dilatation and curettage was the primary treatment for spontaneous abortion because it allowed prompt removal of any remaining products of conception. The goal of treatment is to decrease or stop bleeding and prevent infection. Today, studies have shown expectant and medical management are effective alternatives to surgery.9

6. Outcome

Mrs. M followed up with her obstetrician/gynecologist as instructed. She reported that her vaginal bleeding was minimal, but she experienced increased cramping while taking the Methergine. This almost completely resolved when the medication was stopped. Her pelvic exam was benign. Since Mrs. M was Rh-positive, no Rho(D) immune globulin (RhoGAM) injection was necessary. If the patient continued to have pain and bleeding, a repeat ultrasound might have been ordered with possible dilatation and curettage to remove any remaining fetal contents. Information on psychological counseling was provided to Mrs. M prior to her leaving the office.

Ms. Hyder is a student in the family nurse practitioner program at the University of North Florida in Jacksonville.

1. Wong SF, Lam MH, Ho LC. Transvaginal sonography in the detection of retained products of conception after first-trimester spontaneous abortion. J Clin Ultrasound. 2002;30:428-432.
2. Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72:1707-1714.
3. Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-1250.
4. Puschek EE, Pradhan A. First-trimester pregnancy loss. Emedicine. Available at www.emedicine.com/med/topic3310.htm. Accessed September 10, 2008.
5. Garcia-Enguidanos A, Calle ME, Valero J, et al. Risk factors in miscarriage: a review. Eur J Obstet Gynecol Reprod Biol. 2002;102:111-119.
6. Moore J. Early pregnancy units and problems in early pregnancy. Curr Obstet Gynaecol. 2006;16:327-332.
7. Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75:875-882.
8. University of Maryland Medical Center. Methylergonovine. Available at www.umm.edu/altmed/drugs/methylergonovine-085300.htm. Accessed September 10, 2008.
9. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure—current management concepts. Obstet Gynecol Surv. 2001;56:105-113.

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