Clinical Vignettes: First Trimester Bleeding and Abortion

Case Number 1:

A 24 year old woman presents to your office with complaints of spotting dark blood for four days. She is sexually active with one partner in the last 6 months. She is not using contraception because she has been trying to become pregnant. Please discuss your differential diagnosis and the steps you will take to reach your final diagnosis.

  1. What are some of the most important questions to ask?
  2. What are some of the initial lab evaluations you would undertake simultaneous with talking with her about history and physical?

After the history and physical you perform an ultrasound exam.

  1. Can the βhCG results be helpful?
  2. How long does it take for the βhCG to double?
  3. What is the minimum βhCG required to visualize a pregnancy on vaginal ultrasound?

On the ultrasound exam you note a CRL consistent with 8 weeks, but no cardiac motion.

  1. What is the definition of abortion?
  2. What proportion of clinically recognized pregnancies will end in spontaneous abortion?
  3. What proportions of spontaneous abortions are due to chromosomal abnormalities?
  4. What are some of the non-chromosomal etiologies of spontaneous abortion?
  5. What are the advantages of manual vacuum aspiration (MVA) compared to electric vacuum aspiration (EVA)?
  6. What are the advantages of EVA compared to MVA?
  7. What are the advantages of medication management compared to surgical management (vacuum aspiration)?

Case Number 2:

A 24 year-old woman comes into your office because she is one week late for her period, she did a home pregnancy test and it was positive. She wants an abortion. She has known she would have an abortion should she become pregnant when she didn’t want to since she first became sexually active.

  1. Where would you refer her?
  2. What proportion of induced abortions occurs before 12 weeks?
  3. What is the chance of death if terminating a pregnancy before 9 weeks?
  4. What is the chance of death from giving birth?

Case Number 3:

A 38 year-old woman well known to you comes in because you are her family physician. She is pregnant and was seeing her Ob/Gyn and they have now diagnosed her fetus with a genetic anomaly and she desires pregnancy termination.

  1. Where would you refer her?
  2. What are her options?

Updated November 1, 2010