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First Trimester Bleeding Update

Nadia Huancahuari,MD and Mizuho Spangler, DO
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EM:RAP October 2013 Written Summary 2 MB - PDF

In important and engaging segment on emergencies in early pregnancy. Nadia also discusses her role in caring for the injured after the recent Boston marathon bombing.

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Carole E., MD -

what about the incomplete ab's that ob/gyn doesn't want to do much more about, and they still have some bleeding? send home with any methergine? also, when do you give a course of doxycycline, just for post suction curettage?

Rabbott -

1. Determination of open cervix: I would contend that a sterile ring forceps passed through an open "jaws of life" will carry fewer vaginal bacteria into the uterine cavity than would a palpating finger. Then again, if the cervical canal is open, the uterine cavity is unlikely to be still sterile anyway - and if the cervical internal os is closed, neither the finger nor the ring will reach it. The ring forceps is certainly easier, as long as you can visualize the cervix. Uterine injury is a theoretical issue for the overenthusiastic use of the ring forceps - don't push hard.

2. Management of heavy bleeding: A substantial proportion of those really heavy bleeders will be found, on exam, to have POC still within the the cervical canal. These can be removed by the EP with gentle traction with a ring forceps. Often, bleeding will abate shortly thereafter.

Continued life threatening heavy bleeding can sometimes be managed with balloon tamponade - just use a foley catheter with a 30 ml balloon (you aren't likely to be able to fill it completely - the 1st trimester uterine cavity may not be that big). Special balloons for this are available, but a foley is quicker to find in the ER. Cut the tip off first. Generally, this is only feasible with the open cervix - but unlikely to be needed with a closed cervix. If needed, confirm intrauterine placement with bedside ultrasound.

Vaginal packing? WTF? That was an 1800's thing.

David L. -

I can see absolutely no reason to do a bimanual pelvic or speculum exam in the stable patient with first trimester bleeding. The exam is invasive, when the patient is already stressed enough, Heaps of evidence shows it has low sensitivity/specificity/repeatability etc etc etc and adds nothing to your assessment. Unless the patient is a primip then the os will always feel open. Ultrasound is the gold standard for finding out what you need to know- i.e. is there an IUP or not, and if so is the foetus viable at present, and if not is there a visible ectopic/evidence of rupture etc. Come on you guys in the US- Get into the 21st century. I used to routinely do pelvic exams in early pregnancy bleeding patients in the early 1990s when I was a resident, but back then ultrasound was not so available and excellent.
Now all that said, in the unstable patient, or whom you think they may have an ectopic/ products in the os its a different story.

David L. -

And PS why do you need to do a "complete metabolic panel"on these patients. Unless its otherwise indicated its a complete waste of everyone's time, money, and won't change management. In the vast majority of patients (i.e.stable ones) all you need is an HCG, blood group (to see if they need anti-D), and maybe an Hb (if there's been significant bleeding)

Mizuho S. -

David, I agree with you on the CMP issue...I don't recall if we casually mentioned that but for the most part...I agree it is not necessary.
Re: the pelvic exam, I believe there is still some utility. In the events of incomplete AB (tissue in the OS) might be easily removed and hence cease the active bleeding. It is also not unheard of to have a pt with a vaginal laceration (due to intercourse or trauma, yes even during pregnancy, I've personally seen 2 pts with this this year alone) identifiable only with a visual pelvic exam...so although I agree US is MOST helpful, I do not believe the pelvic exam is extinct...at least not quite yet :)
Thanks for listening and all the best!

Joshua M. -

Can someone please clarify indications and dosing for Rhogam in first trimester threatened Ab? The ACOG practice bulletin from 1999 says its controversial and no evidence-based recommendation can be made, but that was over a decade ago.

And if it is given, I've seen some sites say that miscarriages should get the 50 mcg but if the fetus is still viable it should get the 300 mcg.

Anyone know???

Shawn S. -

Kinda late, but I would argue there is no purpose for the Quant hcg. I've had OB tell me they had an ectopic with a Quant of 75. Its only purpose, in my mind, is to trend as an outpatient in 48 hours to see if its going up or down. Do the bedside US, if you dont see an IUP or free fluid then order a formal. Disposition should be based on patient's presentation plus/minus presence of free fluid. In my shop a Quant is the last test to come back and i'm not waiting around for it.

Justin K., M.D. -

Are there any guidelines regarding drawing a G&C in these patients? Many of them will have already had it done as part of prenatal screening, but a large portion of them will not have had their initial screen done yet.

john v. -

Anybody have a reference for this?
"o 90% of ruptured ectopics have a beta-hCG of <2000. A low beta-hCG doesn’t mean that you can’t rupture; don’t let your
specialists tell you otherwise."

My radiologists are refusing to have the ultrasound tech come in for quant less than 1000. I've seen ruptured ectopics with a quant of 200, but would like something strong than my anecdotes to argue with.

Dana R., M.D. -

This reference should help with radiology:
Saxon D, Falcone T, Mascha EJ, Marino T, Yao M, Tulandi T. A study of ruptured tubal ectopic pregnancy.
Obstet Gynecol. 1997 Jul;90(1):46-9.
Retrospective review of 693 ectopic pregnancies. Eleven percent of women with a ruptured tube had serum beta-hCG levels of less that 100 IU/L. A brief review of table in paper shows that more than a third ruptured at less than 1000.
Re: Rhogam, refer to the excellent (free) podcast done by Drs. Shreves and Neman on SMARTEM that indicates no evidence for rhogam in early pregnancy.

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Episode 145 Full episode audio for MD edition 218:18 min - 103 MB - M4AEM:RAP Resumen October 2013 Español 97:28 min - 67 MB - MP3EM:RAP 2013 October MP3 266 MB - ZIPEM:RAP October 2013 Written Summary 2 MB - PDFEM:RAP October 2013 Board Review Questions 641 KB - PDFEM:RAP October 2013 Board Review Answers 658 KB - PDF

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