Purpose: To practice management of challenging situations in early pregnancy loss, and consider care continuity with one patient.  Note: gender specific language is used for this case.

  1. A 25-year old woman you have been seeing for 5 years presents for an urgent visit. Past history includes irregular periods, which you have managed with OCPs. She reports not having had a period for 7 weeks, and now is having abdominal cramping and moderately heavy bleeding, up to a pad every hour. Her urine hCG is positive.
    1. How would you proceed with her evaluation?
    2. How would you counsel her while waiting for results?
    3. If an ultrasound reveals an intrauterine pregnancy with the presence of fetal cardiac activity, how would you discuss the result?
  2. The same woman comes in one year later. She had a normal delivery following the previous threatened abortion, and never restarted her OCPs. She recently began a new relationship, and has been using condoms intermittently. She began having vaginal bleeding about 5 days ago, and it is now decreasing. Her last menstrual period was 8 weeks ago. Her urine pregnancy test is positive. She brings in tissue and you see gestational sac and chorionic villi.
    1. How would you proceed with evaluation?
    2. How would you approach her initially with these results? How would you answer her if she asks, “Was this miscarriage my fault?”
    3. What information would you provide about how this event will this affect her ability to carry subsequent pregnancies to term?
    4. What other evaluation or management would you initiate? When can she attempt to conceive again?
  3. The same patient presents to you three years later, at age 29. She is now in a long-term relationship, and has been attempting to become pregnant. It has been 5 weeks since her LMP, urine hCG is positive, and she has been spotting for 6 days, without passage of tissue or pain. She is tearful and distraught, as this pregnancy is desired.
    1. Is ultrasound needed in this case? How would you assess her without ultrasound?
    2. On examination, you find a closed cervical os, no gestational tissue, and a nontender uterus consistent with 5-week gestation in size without adnexal tenderness or enlargement. You are able to obtain a transvaginal ultrasound, which shows an intrauterine fluid collection measuring <4mm with no yolk sac present. How do you interpret these results? What are the next steps in her evaluation?
    3. An hCG level drawn at her initial evaluation is 1000. The repeat hCG level drawn two days later is 1300. How do you interpret these results? What are your next steps?
    4. If the EPL is confirmed and completed, what kind of support may be of use to her?


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