Eduovisual
Pregnancy, Childbirth & Puerperium
First trimester bleeding: differential and workup
— Occurs in 20–40% of clinically recognized pregnancies
— About half progress normally; half end in pregnancy loss
— Viable intrauterine pregnancy (IUP) with subchorionic hematoma or implantation bleeding
— Early pregnancy loss (threatened, inevitable, incomplete, complete, missed, septic abortion)
— Ectopic pregnancy — the can't-miss diagnosis
— Gestational trophoblastic disease (GTD) — complete or partial mole
— Non-pregnancy causes: cervicitis, polyp, ectropion, postcoital trauma, vaginitis, malignancy
— Outpatient evaluation decisions: who gets same-day ultrasound vs serial β-hCG vs ED referral
— Rh status determination and anti-D immunoglobulin timing
— Recognizing hemodynamic instability requiring transfer
— Counseling expectations around early pregnancy loss (1 in 4 pregnancies)
— Unilateral pelvic pain + amenorrhea + spotting → ectopic until proven otherwise
— Heavy bleeding with passage of tissue + cramping → inevitable or incomplete loss
— Hyperemesis + uterus large for dates + theca-lutein cysts → molar pregnancy
— Fever + foul discharge + bleeding after instrumentation → septic abortion
— Confirm pregnancy (urine or quantitative β-hCG)
— Assess hemodynamics (HR, BP, orthostatics)
— Determine gestational age by LMP
— Determine Rh status
— Plan transvaginal ultrasound (TVUS) once β-hCG > discriminatory zone
Board pearl: Any reproductive-age woman with abdominal pain, syncope, or shoulder-tip pain gets a urine β-hCG before any other workup — this single reflex test prevents the classic missed ectopic vignette on Step 3.
— Onset: sudden (ectopic rupture, cervical lesion) vs gradual (threatened abortion)
— Quantity: number of pads/hour, passage of clots, passage of tissue
— Color: bright red (active) vs brown spotting (older blood, often benign)
— Pain: unilateral sharp (ectopic), midline cramping (loss), painless (implantation, polyp, ectropion)
— Triggers: postcoital (cervical pathology), spontaneous, post-procedure
— Confirmed IUP on prior ultrasound: dramatically reduces ectopic risk (but heterotopic possible with ART)
— Prior ectopic: 10–15% recurrence risk
— Tubal surgery, PID, IUD in place, smoking, IVF: all raise ectopic risk
— Prior molar pregnancy: 1–2% recurrence
— Recurrent pregnancy loss (≥2): consider antiphospholipid, karyotype, uterine anomaly
— LMP, cycle regularity, contraception use at conception
— Any prior ultrasound dating — earliest scan is most accurate
— Shoulder pain, presyncope, rectal pressure → ruptured ectopic with hemoperitoneum
— Severe nausea/vomiting, early preeclampsia, hyperthyroidism → molar pregnancy
— Fever, chills, foul discharge → septic abortion
— Loss of pregnancy symptoms (breast tenderness, nausea) → missed abortion
— Intimate partner violence — pregnancy is a peak-risk window; screen privately
— Substance use, especially cocaine/methamphetamine (abruption-like presentation)
— Access to transportation if outpatient expectant management planned
Step 3 management: In an outpatient clinic vignette, a hemodynamically stable patient with a small amount of bleeding and known IUP on prior scan can be managed with reassurance, pelvic rest counseling, and return precautions — not every spotter needs the ED.
— Tachycardia (HR >100) may be the only early sign of ruptured ectopic; young women compensate well
— Orthostatic vitals if any concern for volume loss
— Hypotension is a late finding — don't wait for it
— Fever >38°C raises septic abortion concern
— Pallor, diaphoresis, anxious affect → consider hemorrhage
— Peritoneal posture (lying still, knees flexed) → hemoperitoneum or peritonitis
— Localized adnexal tenderness → ectopic
— Diffuse peritoneal signs, rebound, guarding → ruptured ectopic or septic abortion
— Fundal height palpable >12 weeks → uterine size for dates; large-for-dates suggests mole or multiples
— Source of bleeding: uterine (from cervical os) vs cervical/vaginal lesion
— Cervical os: closed (threatened, missed, complete, or ectopic) vs open (inevitable or incomplete)
— Products of conception visible in os or vault → inevitable/incomplete abortion
— Cervical motion tenderness, purulent discharge → infection
— Inspect for polyps, ectropion, lacerations, malignancy
— Uterine size vs dates; boggy/large = mole
— Adnexal mass or fullness → ectopic, corpus luteum cyst, theca-lutein cysts
— Cervical motion tenderness non-specific but supportive of ectopic or PID
— Avoid bimanual exam if placenta previa suspected — but in first trimester previa is not yet the concern
— Don't remove visible tissue forcefully if dilated cervix unless stable and prepared
CCS pearl: On a CCS-style case of suspected ruptured ectopic, the order set is "two large-bore IVs, type and crossmatch 2 units PRBCs, CBC, β-hCG, transvaginal ultrasound, OB/GYN consult STAT" — all moved in parallel, not in sequence.
— Establishes pregnancy and a reference for trending
— Discriminatory zone: β-hCG ~1500–2000 mIU/mL — above this, an IUP should be visible on transvaginal ultrasound (TVUS); absence suggests ectopic, very early IUP, or completed loss
— Doubling time: normal early IUP rises ≥35% in 48 hours; suboptimal rise or plateau → abnormal pregnancy (ectopic or failed IUP)
— Falling β-hCG: consistent with completed or resolving pregnancy (ectopic or loss)
— Markedly elevated β-hCG (>100,000 with large uterus) → suspect molar pregnancy
— Baseline hemoglobin/hematocrit
— Leukocytosis suggests septic abortion
— Every first-trimester bleeder needs Rh status
— Rh(D)-negative unsensitized → anti-D immunoglobulin (RhoGAM) 50 mcg (mini-dose) if <12 weeks, 300 mcg standard dose if ≥12 weeks, within 72 hours
— Gestational sac visible at β-hCG ~1500–2000, ~5 weeks
— Yolk sac at ~5.5 weeks
— Fetal pole with cardiac activity at ~6–6.5 weeks
— Findings of failed pregnancy (per SRU criteria): CRL ≥7 mm with no heartbeat, or mean sac diameter ≥25 mm with no embryo
— Empty uterus + adnexal mass + free fluid → ectopic until proven otherwise
— Snowstorm or cluster-of-grapes pattern → complete mole
Board pearl: A single β-hCG value cannot diagnose ectopic — it's the trend + ultrasound correlation that does. Avoid the trap of "β-hCG below discriminatory zone, therefore not ectopic" — early ectopics commonly present with low β-hCG.
— Repeat in 48 hours
— ≥35% rise: likely IUP, repeat TVUS when β-hCG crosses discriminatory zone
— <35% rise or plateau: abnormal — ectopic vs failed IUP
— >50% decline: likely resolving failed pregnancy; follow to zero
— Continue weekly until β-hCG undetectable to exclude persistent ectopic
— 7–10 days after initial indeterminate scan in stable patients
— Look for definitive IUP (yolk sac within gestational sac) vs ectopic findings
— In abnormally rising β-hCG with no IUP visualized: D&C can distinguish failed IUP (chorionic villi present) from ectopic (villi absent → treat as ectopic)
— Useful when methotrexate vs expectant decision hinges on diagnosis
— Reserved for unstable patients or when imaging is equivocal and clinical suspicion is high
— Simultaneously diagnostic and therapeutic for ectopic
— Sent on products of conception after ≥2 losses (recurrent pregnancy loss workup) — not routine after first loss
— Antiphospholipid antibodies: lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein I (x2, 12 weeks apart)
— TSH, prolactin, HbA1c
— Parental karyotype for balanced translocations
— Uterine cavity assessment: sonohysterography, hysteroscopy, or MRI for septate uterus, fibroids, Asherman syndrome
— Histopathology of evacuated tissue is definitive
— Baseline chest X-ray and metastatic workup if persistent GTN suspected
Key distinction: Threatened abortion = bleeding with closed os and viable IUP; inevitable abortion = bleeding with open os; missed abortion = nonviable IUP with closed os and no expulsion; complete abortion = all POC passed with closed os and empty uterus on TVUS.
— Unstable (hypotension, peritonitis, hemoperitoneum) → resuscitate, OR/laparoscopy for presumed ruptured ectopic
— Stable + IUP confirmed with cardiac activity → reassurance, pelvic rest, return precautions, repeat TVUS if symptoms worsen
— Stable + indeterminate scan + β-hCG below discriminatory zone → serial β-hCG q48h + repeat TVUS
— Stable + ectopic confirmed → methotrexate vs surgery decision
— Stable + failed IUP confirmed → expectant, medical (misoprostol), or surgical (suction D&C)
— No proven benefit to bed rest, progesterone (except possibly in recurrent loss), or hCG
— Counsel: 50% of bleeding with viable IUP continue to term
— Re-evaluate for worsening pain or heavy bleeding
— Expectant management: up to 4 weeks for natural passage; ~80% success in incomplete loss, lower in missed abortion
— Medical: misoprostol 800 mcg vaginally, may repeat in 24–48h; add mifepristone 200 mg PO 24h before misoprostol to improve success
— Surgical: suction curettage / manual vacuum aspiration — preferred for hemorrhage, infection, instability, or patient preference
— Hemodynamically stable
— Unruptured, mass <3.5 cm, no fetal cardiac activity
— β-hCG <5000 mIU/mL (best success)
— Reliable follow-up, no contraindications (renal/hepatic dysfunction, immunodeficiency, active PUD, breastfeeding)
Step 3 management: Always document Rh status, anti-D administration, contraceptive plan, and follow-up appointment in every first-trimester bleeding encounter — these are commonly tested quality measures and missed in vignettes about "what was the most appropriate next step at discharge."
— Single-dose protocol: 50 mg/m² IM on day 1
— β-hCG on days 1, 4, 7 — expect ≥15% decline between days 4 and 7
— If <15% decline, give second dose; if no response after second, surgery
— Weekly β-hCG until undetectable (may take weeks)
— Counseling: avoid folate, NSAIDs, alcohol, intercourse, sun exposure; use reliable contraception for 3 months before next attempt (teratogen)
— Ruptured ectopic, hemodynamic instability, heterotopic with viable IUP
— Immunodeficiency, moderate-severe anemia, leukopenia, thrombocytopenia
— Hepatic or renal dysfunction, active pulmonary disease, active PUD, breastfeeding
— 800 mcg vaginally, repeat dose in 24–48h if no response
— Add mifepristone 200 mg PO 24h before misoprostol (improves completion from ~70% to ~85%)
— Counsel: cramping, heavy bleeding for several hours, pass tissue, then taper
— Provide analgesia (ibuprofen 600–800 mg) and antiemetic
— Follow-up at 1–2 weeks with TVUS or β-hCG to confirm completion
— 50 mcg IM if <12 weeks gestation (mini-dose); some institutions use 300 mcg universally
— 300 mcg IM if ≥12 weeks
— Within 72 hours of bleeding event in Rh(D)-negative unsensitized patients
— Indications: any first-trimester bleeding, ectopic, threatened/spontaneous/induced abortion, molar pregnancy
— Broad-spectrum IV: ampicillin + gentamicin + clindamycin (or metronidazole)
— Urgent uterine evacuation
Board pearl: The classic methotrexate trap on Step 3 is the patient who develops abdominal pain on day 3–7 post-dose — this is often separation pain (sloughing trophoblast) but you must rule out rupture with TVUS and serial β-hCG before reassuring.
— First-line surgical option for early pregnancy loss <13 weeks
— Indications: heavy bleeding, infection, hemodynamic compromise, failed medical management, patient preference, molar pregnancy
— Office MVA acceptable up to ~10–12 weeks
— Pre-procedure: misoprostol 400 mcg buccal or vaginal 2–3h before for cervical preparation
— Complications: perforation (<1%), retained tissue, infection, intrauterine adhesions (Asherman), hemorrhage
— For losses >13 weeks
— Laparoscopy is standard approach; laparotomy reserved for instability or extensive adhesions
— Salpingostomy (tube-sparing) — for women desiring future fertility with healthy contralateral tube; risk of persistent trophoblast → check weekly β-hCG
— Salpingectomy (tube removal) — preferred for: ruptured tube, uncontrolled bleeding, large mass, recurrent ipsilateral ectopic, completed childbearing
— Equivalent subsequent fertility rates in healthy contralateral tube
— Suction D&C with simultaneous oxytocin infusion (after cervix dilated to avoid embolization)
— Send tissue to pathology to confirm complete vs partial mole
— Post-evacuation surveillance: weekly β-hCG until undetectable x 3, then monthly x 6 months
— Reliable contraception (not IUD) during surveillance — pregnancy would confound β-hCG monitoring
— Persistent or rising β-hCG → gestational trophoblastic neoplasia → methotrexate or actinomycin-D, referral to gyn-onc
CCS pearl: For a ruptured ectopic CCS case, the move sequence is: IV access x2, NS bolus, type/crossmatch, CBC, β-hCG, OB consult, transport to OR — and anti-D Ig within 72 hours even if patient is hemodynamically critical.
— Spontaneous abortion risk rises sharply: ~20% at age 35, ~40% at age 40, ~80% at age 45
— Driven by aneuploidy (most commonly trisomies, monosomy X)
— Ectopic risk also higher in AMA
— Counseling should set realistic expectations, but management of acute bleeding is unchanged
— Offer genetic counseling and aneuploidy screening (cell-free DNA from 10 weeks) in continuing pregnancies
— After loss in AMA, do not delay workup — fertility window is narrow
— Methotrexate is renally cleared — contraindicated if CrCl <50 mL/min or significant CKD
— Use surgical management for ectopic in these patients
— Adjust analgesia: avoid NSAIDs if eGFR <30; acetaminophen safer
— Methotrexate hepatotoxic — contraindicated if AST/ALT >2× upper limit normal or chronic liver disease
— Check baseline LFTs before methotrexate; recheck if symptoms
— Avoid acetaminophen high-dose in severe liver disease
— Pre-existing anemia, thrombocytopenia, or leukopenia → methotrexate contraindicated
— Anticoagulated patients (mechanical valve, prior VTE): bleeding may be more severe; hold therapeutic anticoagulation cautiously, consider bridging strategy with OB and hematology
— Inherited bleeding disorders (vWD, factor deficiencies): coordinate with hematology, consider tranexamic acid, DDAVP for vWD
— Septic abortion risk higher
— Methotrexate contraindicated
— Lower threshold for surgical management and broad-spectrum antibiotics
Board pearl: Before prescribing methotrexate for ectopic, always order CBC, CMP (creatinine, AST/ALT), and Rh — missing any of these is a common Step 3 distractor in "what should have been done before treatment?" questions.
— May present late due to denial, fear, or unrecognized pregnancy
— Always screen privately for intimate partner violence and coercion
— Confidentiality: in most US states, minors can consent to pregnancy-related care without parental notification — know your state
— Higher rates of cervical infection (gonorrhea, chlamydia) — co-test
— Counseling should be developmentally appropriate; offer mental health support
— Heterotopic pregnancy risk rises from ~1:30,000 (natural) to ~1:100 with IVF
— Documented IUP does not exclude concurrent ectopic
— TVUS must scan adnexa carefully even when IUP is seen
— Multiple gestations more common — early loss of one twin ("vanishing twin") can cause bleeding
— Workup: antiphospholipid antibody panel, TSH, prolactin, HbA1c, parental karyotype, uterine cavity imaging (sonohysterogram, hysteroscopy, or MRI)
— Treat identified causes: aspirin + LMWH for antiphospholipid syndrome; hysteroscopic septum resection; thyroid optimization
— ~50% of recurrent loss workups identify no cause — empathetic counseling, ~60–70% subsequent live birth rate
— Rare ectopic implantation in cesarean scar
— High risk of catastrophic hemorrhage and uterine rupture if not recognized
— TVUS shows gestational sac in lower anterior uterus at scar
— Refer to MFM; treatment may involve methotrexate, suction with balloon tamponade, or hysterectomy
— Anti-D Ig no longer beneficial once sensitized; refer to MFM for future pregnancy monitoring (MCA Doppler)
Step 3 management: In an IVF patient with first-trimester bleeding and a confirmed IUP, do not stop scanning at the uterus — explicitly evaluate both adnexa for heterotopic pregnancy before discharge.
— Most often from ruptured ectopic; less commonly from molar pregnancy or heavy spontaneous loss
— Resuscitation: 2 large-bore IVs, crystalloid bolus, transfuse PRBCs early if class III/IV shock
— Massive transfusion protocol if ongoing hemorrhage
— Retained POC + ascending infection → endometritis → sepsis
— Classic vignette: recent unsafe abortion or incomplete miscarriage with fever, foul discharge, abdominal pain
— Pathogens: polymicrobial (E. coli, Bacteroides, Group A Strep, Clostridium perfringens)
— Clostridial sepsis = catastrophic; hemolysis, renal failure, DIC, shock
— Treat with broad-spectrum antibiotics + urgent uterine evacuation
— Triggered by missed abortion retained for weeks, septic abortion, or amniotic fluid embolism (later)
— Check fibrinogen, PT/PTT, platelets, D-dimer
— Treat underlying cause, transfuse FFP/cryoprecipitate/platelets as needed
— Persistent bleeding, infection, prolonged β-hCG positivity
— Treat with repeat misoprostol or surgical evacuation
— Intrauterine adhesions after aggressive curettage, especially infected uterus
— Presents with amenorrhea, infertility, recurrent loss
— Diagnosis: hysteroscopy; treatment: adhesiolysis
— Develops in ~15% of complete moles, ~1–5% of partial moles
— Manifested by plateauing or rising β-hCG after evacuation
— May metastasize (lung, liver, brain) — referral to gynecologic oncology, chemotherapy
— Pregnancy loss is associated with depression, anxiety, PTSD
— Screen at follow-up; offer counseling and support resources
Key distinction: Threatened abortion → can still progress normally; missed abortion → fetus already nonviable but retained; the former needs reassurance and observation, the latter needs a management plan (expectant, medical, or surgical).
— Hemodynamic instability: HR >120, SBP <90, orthostasis with symptoms
— Severe abdominal pain with peritoneal signs
— Heavy bleeding (saturating >1 pad/hour)
— Suspected ruptured ectopic
— Suspected septic abortion with fever and toxicity
— Ectopic pregnancy diagnosis (any stability)
— Pregnancy of unknown location requiring serial β-hCG management
— Molar pregnancy
— Inevitable or incomplete abortion needing intervention
— Cervical scar pregnancy or other rare ectopics
— Recurrent pregnancy loss workup
— Septic abortion (IV antibiotics, evacuation, possible ICU)
— Hemodynamic instability or transfusion needs
— Inability to tolerate oral intake (severe hyperemesis with molar pregnancy)
— Social: unsafe home, IPV, lack of follow-up
— Vital signs stable
— Bleeding light to moderate
— Pain controlled with oral analgesia
— Clear follow-up plan within 48–72 hours
— Patient understands return precautions (heavy bleeding, severe pain, fever, syncope)
— Reliable transport
— Anti-D Ig administered if Rh(D)-negative
— Septic shock, DIC, massive transfusion requirements
— Multiorgan failure (Clostridial sepsis)
— After recurrent loss with identified etiology
— Prior molar pregnancy
— Prior cesarean scar ectopic
— Antiphospholipid syndrome
CCS pearl: On CCS, "obtain OB/GYN consult" should be ordered in parallel with stabilization for any ectopic or septic abortion — consults take simulated hours to materialize, so order early and continue management actions while waiting.
— Bleeding + closed os + viable IUP on TVUS
— ~50% progress to viable pregnancy
— Management: reassurance, pelvic rest, follow-up
— Bleeding + open os + IUP (viable or not)
— Loss is imminent; offer expectant, medical, or surgical
— Bleeding + open os + partial passage of POC; retained tissue on TVUS
— Often heavy bleeding; usually needs misoprostol or suction curettage
— Bleeding has slowed/stopped, closed os, empty uterus on TVUS
— β-hCG declining; no intervention needed
— Confirm with serial β-hCG to zero if ectopic not yet excluded
— No bleeding or minimal spotting, closed os, nonviable IUP on TVUS (CRL ≥7mm without cardiac activity, or empty sac MSD ≥25mm)
— May be detected at routine scan
— Three management options (expectant, misoprostol±mifepristone, suction D&C)
— Any of the above + infection (fever, foul discharge, uterine tenderness)
— Emergency — antibiotics + evacuation
— Most common in fallopian tube (ampulla)
— Risk factors: prior ectopic, tubal surgery, PID, IUD, IVF, smoking
— Triad: amenorrhea + abdominal pain + vaginal bleeding (only ~50% have all three)
— Rare locations: ovarian, abdominal, cervical, cesarean scar
— Coexisting IUP + ectopic; ~1:100 with IVF
— Don't miss the ectopic just because IUP is confirmed
— Complete mole: 46,XX, all paternal; no fetus; markedly elevated β-hCG; "snowstorm" TVUS
— Partial mole: 69,XXY (triploid); abnormal fetus; lower β-hCG
— Risks: hyperthyroidism, early preeclampsia, hyperemesis, theca-lutein cysts
Board pearl: A patient with "empty uterus, β-hCG above discriminatory zone, no adnexal mass" still has ectopic until proven otherwise — the absence of a visible adnexal mass does not rule it out.
— Cervical polyp: painless postcoital or contact bleeding; visible on speculum; biopsy/remove if symptomatic
— Cervical ectropion: physiologic in pregnancy; columnar epithelium everted onto ectocervix, friable; reassure
— Cervicitis: GC, chlamydia, trichomonas, HSV; mucopurulent discharge, contact bleeding; treat empirically while awaiting NAAT
— Cervical cancer: rare in young women but can present in pregnancy; abnormal-appearing lesion needs biopsy regardless of pregnancy
— Vaginitis (BV, candida, trichomonas): irritation, sometimes spotting
— Vaginal trauma: consensual or non-consensual intercourse, foreign body
— Always consider sexual assault; document and offer SANE if applicable
— Fibroids: usually heavy bleeding pre-pregnancy; can grow and degenerate during pregnancy (pain more than bleeding)
— Endometrial pathology rarely the cause in this age group
— UTI with hematuria
— Hemorrhoids, anal fissure
— Confirm source on speculum exam
— Von Willebrand disease (most common inherited bleeding disorder; often unmasked by menstruation/pregnancy)
— Platelet disorders, anticoagulant use
— Workup if bleeding seems disproportionate or personal/family history suggestive
— Anovulatory bleeding misattributed to pregnancy in patient with positive home test from prior pregnancy
— Always confirm current pregnancy with quantitative β-hCG
— Anticoagulants, antiplatelets
— Recent ovulation induction agents
Key distinction: In a pregnant patient with bleeding, the speculum exam tells you whether the blood is coming from the cervical os (uterine) or from a cervical/vaginal lesion — this single finding redirects the entire workup.
— Diagnosis communicated and documented (threatened, complete loss, ectopic post-treatment, etc.)
— Rh status assessed; anti-D Ig given if indicated (and documented in record)
— Pain control: scheduled acetaminophen ± NSAIDs (after pregnancy ended)
— Pelvic rest counseling: no intercourse, tampons, or douching until bleeding resolved (~2 weeks)
— Return precautions: heavy bleeding (>1 pad/hr x 2h), fever >38°C, severe abdominal pain, syncope, foul discharge
— Emotional support resources and bereavement counseling
— Follow-up appointment scheduled (1–2 weeks)
— β-hCG to zero if ectopic or molar (serial)
— Contraception discussion — ovulation can resume within 2 weeks; can conceive before next period
— No medical reason to delay conception after a single uncomplicated early loss; emotional readiness guides timing
— Folic acid 400–800 mcg daily ongoing
— Optimize chronic conditions: diabetes (HbA1c <6.5%), hypertension, thyroid (TSH <2.5)
— Smoking, alcohol, illicit drug cessation
— Weekly β-hCG to zero
— Contraception for 3 months (methotrexate teratogenic; allows folate stores recovery)
— Counsel: ~10–15% recurrence risk; early TVUS in next pregnancy at 6 weeks
— β-hCG weekly to undetectable x3, then monthly x 6 months
— Reliable contraception (not IUD initially) during surveillance period
— Early scan in next pregnancy
— Treat identified etiology
— Preconception counseling with MFM if indicated
Step 3 management: The single most common Step 3 discharge oversight is forgetting anti-D immunoglobulin in Rh-negative patients — even for ectopic, even for a few drops of bleeding, even <12 weeks. Document type, dose, and time.
— Threatened abortion: 1–2 weeks for repeat TVUS or as-needed
— Expectant management of loss: 1–2 weeks with TVUS or β-hCG to confirm completion
— Medical management with misoprostol: 1–2 weeks, repeat dose if incomplete
— Surgical management: 2 weeks for wound check, contraception, emotional check-in
— Methotrexate for ectopic: β-hCG day 4, day 7, then weekly
— Molar pregnancy: weekly β-hCG until negative x3, then monthly x6
— Bleeding amount and duration
— Pain trend
— Return of menstruation (typically 4–6 weeks post-loss)
— Mood, sleep, function — screen for depression at every visit
— Pregnancy loss is not caused by exercise, intercourse, lifting, mild stress, or "skipping prenatal vitamins"
— Most early losses are due to chromosomal abnormalities in the embryo
— Subsequent live birth rates are high (~85% after one loss)
— Validate grief; loss at any gestational age can trigger profound grief
— Refer to therapist with perinatal grief experience
— Pregnancy loss support groups
— Screen for PHQ-9 and GAD-7 at follow-up
— Discuss contraception preferences at every visit (LARCs immediately available after evacuation in stable patient)
— Folic acid continuation
— Preconception optimization for next attempt
— Partners also grieve; include in counseling when appropriate
— Address relationship strain proactively
Board pearl: Patients with first-trimester loss are at elevated risk of depression, anxiety, and PTSD for at least a year; "no medical issues to follow up" is not a complete plan — always book a mental-health–inclusive return visit.
— Document understanding of risks, benefits, alternatives (expectant, medical, surgical)
— In missed/incomplete abortion, clarify that evacuation is medically indicated, not elective
— In some US jurisdictions, post-Dobbs (2022), state laws may restrict management of nonviable pregnancies — know local law and institutional protocols; do not delay care that the patient's clinical condition requires
— Ectopic pregnancy treatment is not restricted by abortion laws in any US state — but documentation should clearly establish the diagnosis
— Providers may decline to perform procedures they find ethically objectionable, but must refer the patient to another provider without delay or judgment
— Cannot refuse care for ectopic, septic abortion, or other life-threatening emergencies
— Adolescents can consent to pregnancy-related care in most states without parental notification
— Spouses/partners do not have right to information without patient consent
— Family members in the room: ask patient privately first
— Pregnancy is a peak window for IPV; screen privately
— Provide resources; mandatory reporting laws vary by state for adult IPV (typically not mandatory unless weapon involved)
— Sexual assault: offer (do not mandate) SANE exam and law enforcement reporting in adults
— Minor sexual abuse: report per state law
— Suspected coerced abortion or trafficking: report per institutional protocol
— Common Step 3 trap: discharging Rh-negative patient without anti-D Ig
— Hand-off from ED to outpatient OB must include β-hCG trend plan and explicit follow-up date
— Document return precautions and that the patient verbalized understanding
— Clearly distinguish "elective termination" from "evacuation of nonviable pregnancy" in chart given current legal climate
— Use medical terminology accurately
Key distinction: Treatment of ectopic pregnancy and septic abortion is universally protected medical care — no state law prohibits it. Delay in treatment due to legal hesitation is a patient-safety event.
— Doubles every 48–72h in normal IUP through ~8 weeks
— Peaks ~10 weeks (~100,000 mIU/mL), then declines
— Discriminatory zone: 1500–2000 mIU/mL for TVUS visualization of gestational sac
— Gestational sac: 5 weeks (β-hCG ~1500)
— Yolk sac: 5.5 weeks
— Fetal pole: 6 weeks
— Cardiac activity: 6–6.5 weeks
— CRL ≥7 mm without cardiac activity
— MSD ≥25 mm without embryo
— No embryo with heartbeat ≥2 weeks after scan showed sac without yolk sac
— No embryo with heartbeat ≥11 days after scan showed sac with yolk sac
— Prior ectopic, PID, tubal surgery, IUD in situ at conception, IVF, smoking, age >35
— Complete: 46,XX paternal-only, no fetus, β-hCG very high, "snowstorm"
— Partial: 69,XXY triploid, abnormal fetus, lower β-hCG
— Both: hyperemesis, theca-lutein cysts, early preeclampsia, hyperthyroidism
— 50 mcg <12 weeks; 300 mcg ≥12 weeks
— Within 72 hours of bleeding event
— Stable, mass <3.5 cm, β-hCG <5000, no cardiac activity, no contraindications, reliable follow-up
— APLS, TSH, prolactin, HbA1c, karyotype, uterine imaging
— Folate, NSAIDs, alcohol, sun
Board pearl: Hyperemesis + uterus larger than dates + hyperthyroidism symptoms + pre-20-week preeclampsia = molar pregnancy until proven otherwise — confirm with TVUS "snowstorm" and a very high quantitative β-hCG.
— 28F, LMP 7 weeks ago, sudden RLQ pain, light vaginal spotting, BP 90/60, HR 118, positive urine pregnancy, TVUS shows empty uterus with right adnexal mass and free fluid
— Answer: Immediate OR for laparoscopic salpingectomy after IV access, type/crossmatch
— 32F, 10 weeks by LMP, routine OB visit, no bleeding, no pain, TVUS shows CRL 9 mm without cardiac activity
— Answer: Counsel three options; if medical chosen → mifepristone 200 mg then misoprostol 800 mcg vaginally 24h later
— 24F, 12 weeks by LMP, severe vomiting, BP 150/95, uterine fundus at umbilicus, β-hCG 250,000, TVUS shows "snowstorm" pattern
— Answer: Suction D&C with weekly β-hCG surveillance until undetectable
— 26F Rh(D)-negative, 8 weeks, small bleed, viable IUP confirmed
— Answer: Anti-D immunoglobulin 50 mcg within 72 hours
— Day 7 post-MTX β-hCG declined <15% from day 4
— Answer: Second dose methotrexate (not surgery yet, if still stable and meets criteria)
— 34F, two consecutive losses at 8 and 10 weeks
— Answer: APLS antibodies, TSH, prolactin, HbA1c, parental karyotype, sonohysterogram
— Fever 39°C, foul discharge, tender uterus after attempted home abortion
— Answer: Broad-spectrum IV antibiotics + urgent suction D&C
— IVF patient with IUP on scan and persistent unilateral pain
— Answer: Re-scan adnexa carefully; do not assume single IUP
— β-hCG 800, no IUP, no adnexal findings, asymptomatic
— Answer: Repeat β-hCG in 48h; trend determines next step
CCS pearl: On CCS, the most penalized error in first-trimester bleeding cases is failing to order Rh type early — order it on first encounter alongside CBC and quantitative β-hCG, every time.
First-trimester bleeding requires a parallel, not sequential, workup: confirm pregnancy with quantitative β-hCG, assess hemodynamic stability, obtain Rh status, perform transvaginal ultrasound, and rule out ectopic and molar pregnancy before attributing bleeding to threatened or completed loss — with anti-D immunoglobulin given to every Rh-negative patient within 72 hours regardless of gestational age or bleeding volume.
— Discriminatory zone ~1500–2000 mIU/mL — above this, expect IUP on TVUS; absent IUP = ectopic until proven otherwise
— Normal IUP doubles β-hCG every 48–72h; <35% rise is abnormal
— Confirmed IUP on TVUS = ectopic essentially excluded (except heterotopic in ART)
— Hemodynamic instability + positive pregnancy test = ruptured ectopic until proven otherwise
— Fever + foul discharge after attempted abortion = septic abortion → antibiotics + evacuation
— Markedly elevated β-hCG + large-for-dates uterus + hyperemesis = molar pregnancy
— Unstable → resuscitate + OR
— Stable + viable IUP + bleeding = threatened abortion → reassurance, pelvic rest, follow-up
— Stable + nonviable IUP = expectant vs misoprostol±mifepristone vs suction D&C
— Stable + ectopic meeting criteria = methotrexate; otherwise laparoscopic salpingectomy/salpingostomy
Board pearl: Master the trio "β-hCG trend + TVUS findings + Rh status + anti-D administration" and you will answer 90% of Step 3 first-trimester bleeding stems correctly.