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First Trimester Bleeding

Jenny Beck-Esmay, MD and Neda Frayha, MD
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Vaginal bleeding in the first trimester of pregnancy is one of those topics that seems straightforward but is actually pretty complex. Dr. Jenny Beck-Esmay speaks with our own Dr. Neda Frayha about how to approach first-trimester bleeding in a logical, organized, evidence-based way that’s easy to understand. 

 

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Samuel E. -

Thanks for the topic of first trimester bleeding. I just have 2 comments:
1. You don't really need a bHCG until after the ultrasound. A bHCG in the setting of a normal, viable IUP, does not add anything to your management. So a useful algorithm would be to obtain an ultrasound, then if no IUP, check bHCG, but if there is an IUP, your workup is complete. If there's ultrasound findings concerning for another pregnancy complication (molar pregnancy, heterotopic pregnancy, other rare entities), then further workup may be required. That being said, many radiology departments won't perform the ultrasound until HCG is obtained, out of self-protection.
2. You don't really need a type and screen. A type and screen is a blood bank evaluation, is typically expensive, time consuming, and only needed if you plan to transfuse. Therefore it would be helpful in hemodynamically unstable patients. What you should get is a simple ABORh (not screened for antibodies), or simply an Rh status (+ or -).

Thanks!

Neda F., MD -

Thanks so much, Samuel. You bring up excellent points. Drs. Beck-Esmay and Morrison and I have had a great discussion about your thoughts. In the end, it is often a balance between workup efficiency and resource utilization. At times what we order and when will also depend on patient stability and what we have access to in our specific hospitals. Thanks again for writing in. -- Neda

Margot M. -

How quickly do they need to get an US? We don't have them in our office, so they would need to get referred to a radiology center, which they might not get in to until the next day or even the day after. Labs will take at least 12 hours as well. So, do I need to send them to the ER or UC in case of ectopic pregnancy for any vaginal bleeding? It sounds like ectopic pregnancy is a do not miss diagnosis, and also something that does not really have a lot of symptoms (even hypotension is pretty nonspecific in a young person, I have so many healthy young people who normally have a SBP in the 80s or 90s).
If they are not having symptoms (no lightheadedness, no pain, SBP is above 100, etc.) would outpatient radiology and labs within 24 hours, with a OB referral, and education about when to go to the ER, be ok?

Neda F., MD -

Hi Margot. Here's Dr. Jenny Beck-Esmay's response: "The determining factor on the speed of this work up is whether of not they have previously had an ultrasound confirmed intrauterine pregnancy. If they DO have a documented, previously confirmed IUP, and are relatively asymptomatic, the labs and ultrasound can be done over the course of an outpatient time span and good referral instructions given for worsening symptoms. If they DO NOT, have a documented, confirmed IUP, my recommendation would be to refer directly to the ED for assessment. You are totally right, the presentations can be subtle, but the decompensation can happen quickly. Even the GYN clinics send these patients to the ED for this assessment.

Hope that helps!"

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