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A 24-year-old, 11 weeks pregnant, presented to the emergency department with abdominal cramping and heavy vaginal bleeding and clots. 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. 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. What is the next best step?

  • Oral methylergonovine
  • Transvaginal ultrasonography
  • Gram stain on vaginal swab
  • Rho(d) immune globulin injection
  • Dilatation and curettage

Answer Explanation

Transvaginal ultrasonography is very reliable for finding remaining tissue or content of conception with 100% sensitivity and 80% specificity.

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.

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

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

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.