Medical Evaluation and Management of Threatened Abortions

Show Notes

Background

• Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound
• Occurs in 20-25% of all pregnancies.

Initial Assessment and Management

• Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early
• Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.
• Importance of a detailed history and physical examination.

Diagnostic Approach

• Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.
• Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization
• Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.
• Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.

Patient Counseling and Management

• Open and honest communication about the prognosis of threatened abortion.
• Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.
• Recommendations against bedrest and certain activities
• Lack of evidence supporting restrictions on sexual activity.
• Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.

Follow-up and Precautions

• Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.
• Educating patients on critical warning signs that require immediate medical attention.
• Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.

Take Home Points

1. Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.
2. Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. 
3. Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient. 
4. Approach the interpretation of HCG levels with caution and remember that ectopic pregnancies might not adhere to conventional HCG levels.
5. Established follow up and discharge instructions are crucial.  Manage stable patients with a watchful waiting approach, scheduling subsequent visits for continuous ultrasounds and HCG testing. Clearly outline the importance of immediate medical attention for symptoms such as intense bleeding, significant abdominal pain, fever, or feelings of insecurity at home.
6. Finally, we play an important role wherein we must ensure that the patient is medically stable and psychosocially safe. Here, compassionate communication is crucial when discussing what the diagnosis might entail, alleviate any feelings of blame or shame, and remain vigilant for signs of intimate partner violence or mental health issues.  As emergency medicine physicians, it’s crucial for us to approach these cases with a comprehensive mindset.