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.
- 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.
- How would you proceed with her evaluation?
- How would you counsel her while waiting for results?
- If an ultrasound reveals an intrauterine pregnancy with the presence of fetal cardiac activity, how would you discuss the result?
- 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.
- How would you proceed with evaluation?
- How would you approach her initially with these results? How would you answer her if she asks, “Was this miscarriage my fault?”
- What information would you provide about how this event will this affect her ability to carry subsequent pregnancies to term?
- What other evaluation or management would you initiate? When can she attempt to conceive again? Teaching Points
- 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.
- Is ultrasound needed in this case? How would you assess her without ultrasound?
- 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?
- 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?
- If the EPL is confirmed and completed, what kind of support may be of use to her?