– History –
- CC: most likely will present as a pregnant lady w\ PV bleeding:
- Onset: first time? When? Sudden\gradual? Continuous\intermittent?
- Characteristics: amount? Color? Clots? Tissue? Smell?
- Associated sx:
- Constitutional: fever, chills, appetite?
- Anemia: dizziness, syncope, headache, palpitations, SOB?
- Labor: abdominal cramps, lower back pain, pelvic pressure, fetal movements?
- Vagina: vaginal bleeding, clear fluid gush\leak, discharge, itching?
- Urinary sx: dysuria, flank pain?
- Preeclampsia: headache, visual changes, epigastric pain, lower limb swelling?
- Obstetric Hx:
- Gravida? Para? Abortions? Living?
- If prev: mode of delivery? Fetal\maternal complications?
- LMP?
- Last US: when? Results? Singleton or multiple gestation?
- Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?
- Gravida? Para? Abortions? Living?
- Gynecological Hx:
- Menstrual Hx: regular periods? Intermenstrual bleeding?
- Contraception use, IUCD?
- Gynecological procedures, IVF\induction of ovulation?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM\GDM, DLP)
- Cardiac, thyroid, SLE
- Hematological (anemia, APS)
- Gyn (PID, fibroids, uterine anomalies)
- Medications: abx, steroids, anticoagulants, folate, herbal
- Surgery, hospitalization, trauma
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs? (exposure to diethylstilbestrol)
- Travel Hx
- Diet, exercise
– Causes –
- Fetal:
- Chromosomal (MC: trisomy 16)
- Congenital anomalies
- Maternal factors:
- Infections (TORCH)
- Endocrine ds
- Thrombophilia (SLE, APS)
- Anatomical abnormalities (septate uterus, Asherman’s)
– Management –
THREATENED | MISSED | INEVITABLE | INCOMPLETE | COMPLETE | |
Clinical features | Minimal PV bleeding ± abd pain | Asymptomatic (usually) | PV bleeding + abd pain ± ROM | Profuse PV bleeding + passage some of POC | Complete passage of POC |
Pelvic exam | Closed cervical OS | Closed cervical OS | Open cervical OS | Open cervical OS | Open\closed cervical OS |
US | Viable | Non-viable | Evidence of POC | Retained tissue | Empty uterus |
Management | Observe | D&C, misoprostol (induces UC)? | Emergency D&C | Emergency D&C | Observe, weekly B-hCG |