WIDI - R3) Abdominal pain and vaginal bleeding in a patient with reduced pregnancy symptoms

R3) Abdominal pain and vaginal bleeding in a patient with reduced pregnancy symptoms

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with abdominal pain and vaginal bleeding.
Review the DDx considerations in a patient with abdominal pain and vaginal bleeding.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with abdominal pain and vaginal bleeding.

History

A G2P0 29-year-old woman at 7 weeks gestation presents to her obstetrician due to vaginal bleeding and moderate intermittent cramping abdominal pain that started 3 days ago. She describes the bleeding as slight spotting. During this time, she notes decreased breast tenderness and no longer experiences morning sickness. She denies the passage of tissue or clots.

Physical Exam

BP: 110/65, HR 85, RR 15, Temp 37C, O2 saturation 99%. General: no acute distress. Abdominal exam: Abdomen is soft and nontender. Pelvic exam: Bimanual exam indicates a slightly enlarged and soft uterus. The cervical os is closed. No cervical motion tenderness.

Labs

Beta-hCG: 1850 mIU/mL (normal range at 7-week pregnancy: 3,700 - 160,000 IU/L).

Provisional Diagnosis

Select the Dx you believe is most appropriate

Normal intrauterine pregnancy

Heterotrophic pregnancy

Nonviable intrauterine pregnancy

Molar pregnancy

The patient most likely has a non-viable intrauterine pregnancy (miscarriage) considering the risk factors, (previous miscarriage, first trimester) presentation (vaginal bleeding, abdominal cramping pain with slightly enlarged uterus, lack pregnancy symptoms such as breast tenderness and “morning sickness”) and laboratory findings (low Beta-hCG)

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

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The patient is hemodynamically stable. Therefore, treatment can be planned in a routine, but expedited manner.

First Imaging Study

What is the first imaging study you will order?

Pelvic ultrasound

Transvaginal ultrasound

Abdominal MRI

Pelvic MRI with IV contrast

The transvaginal ultrasound is the best imaging modality to evaluate for a nonviable pregnancy. It does not expose the patient to radiation and can assess for fetal demise.

View ACR Appropriateness Criteria

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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Transvaginal Ultrasound

What best describes the findings on the Crown rump length (CRL) is consistent with a 7-week pregnancy.

Yes

The CRL is 12.7 mm in length (normal CRL for 7-week pregnancy is 11-15 mm).

The fetal heartbeat is present.

Yes

The transvaginal ultrasound indicates no fetal heartbeat.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Pelvic MRI

Abdominal MRI

Pelvic ultrasound

None

No further imaging is needed as the diagnosis is confirmed with the transvaginal ultrasound.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Normal course of pregnancy in first trimester

Nonviable intrauterine pregnancy

This patient has a nonviable intrauterine pregnancy as evidenced by lack of cardiac activity with a CRL ≥ 7 mm.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient can undergo routine management as their condition is not immediately life-threatening.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 29-year-old woman who presents with a nonviable pregnancy in the first trimester. As they are hemodynamically stable, their treatment options include expectant management for spontaneous passage of fetal tissues, medication management with mifepristone and misoprostol regimen, or dilation and curettage. OBGYN will be consulted.

Lessons Learned:
- There is an increased risk of pregnancy loss during the first trimester. The risk is increased with increasing maternal age and previous miscarriages.
- The diagnosis should be suspected in a patient who presents in the first trimester of pregnancy with vaginal bleeding and abdominal cramping, with reduction of pregnancy symptoms such as breast tenderness and hyperemesis gravidarum.
- A transvaginal ultrasound is the imaging modality of choice to diagnose a nonviable pregnancy.
CRL ≥ 7 mm or mean gestational sac diameter of >25 mm without fetal heartbeat confirms definitive pregnancy loss. If these criteria are not met, follow-up interval imaging should be considered.

Socioeconomic Factors:
- Low income levels are associated with increasing risk of spontaneous abortion.
- Environmental exposure to ionizing radiation, lead, arsenic, and air pollution increases the risk of miscarriage.
- Those with poor access to care or those less likely to expect or recognize a pregnancy (adolescents or perimenopausal patients) may be at higher risk for complications from late presentation.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Seyedeh Mehrsa Sadat Razavi, MS2 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator