Incomplete abortion, treat as indicated

1
Figure 1. Evaluation of First Trimester Bleeding
Bleeding in desired pregnancy, lt 12 weeks
gestation
Physical exam
Peritoneal signs or hemodynamic instability
Non-obstetric cause of bleeding identified
Products of conception (POCs) visible on exam
Patient stable, no POCs or other cause of
bleeding
Incomplete abortion, treat as indicated
Diagnose and treat as indicated
Transvaginal ultrasound (TVUS) and ß-hCG level
Transfer to ED
Viable intrauterine pregnancy (IUP)
Ectopic or signs suggestive of ectopic pregnancy
Nonviable IUP
No IUP, no ectopic seen
IUP, viability uncertain
Embryonic demise, anembryonic gestation, or
retained POCs discuss treatment options
No
Threatened abortion repeat TVUS if further
bleeding
Presume ectopic refer for high-level TVUS and/or
treatment
Repeat TVUS in one week and/or follow serial
ß-hCGs
IUP seen on prior TVUS?
See Figure 2
Yes
Completed abortion expectant management
Reproductive Health Access Project/October 2013
www.reproductiveaccess.org
2
Figure 2. Evaluation of first trimester bleeding
with no intrauterine pregnancy on ultrasound
Continued from Figure 1
No intrauterine (IUP) or ectopic pregnancy seen
on transvaginal ultrasound (TVUS)
Completed abortion expectant management
Yes
IUP seen on prior TVUS?
No
ß-hCG lt 1500 2000
ß-hCG gt 1500 2000
Ectopic precautions, Repeat ß-hCG in 48 hours
Single ß-hCG gt 1500 2000 and bleeding history
consistent with having passed POCs
Single ß-hCG gt 1500 2000 and bleeding history
not consistent with having passed POCs
Serial ß-hCGs rising and gt 1500 2000
Repeat ß-hCG gt 1500 2000
Repeat ß-hCG lt 1500 2000
Repeat TVUS See TVUS in Figure 1
Ectopic precautions, repeat ß-hCG in 48 hrs
Repeat ß-hCG fell lt 50 or rose lt 53
Repeat ß-hCG rose gt 53
Repeat ß-hCG fell gt 50
Repeat ß-hCG fell gt 50
Repeat ß-hCG fell lt50 or rose
Obtain high-level TVUS serial bhCGs to
differentiate between ectopic, early IUP, and
retained POCs treat as indicated
Suggests completed abortion ectopic precautions,
follow ß-hCG weekly to zero
Suggests viable pregnancy but does not exclude
ectopic follow ß-hCG until gt 1500
2000, then TVUS for definitive diagnosis
Suggests early pregnancy failure or ectopic
serial ß-hCGs /- high-level TVUS until
definitive diagnosis or ß-hCG zero
The ß-hCG level at which an intrauterine
pregnancy should be seen on transvaginal
ultrasound is referred to as the discriminatory
zone and varies between 1500 2000 mIU depending
on the machine and the sonographer. ß-hCG
needs to be followed to zero only if ectopic
pregnancy has not been reliably excluded. If a
definitive diagnosis of completed miscarriage has
been made there is no need to follow further
ß-hCG levels. In a viable intrauterine
pregnancy there is a 99 chance that the ß-hCG
will rise by at least 53 in 48 hours. In
ectopic pregnancy, there is a 21 chance that the
ß-hCG will rise by 53 in 48 hours.
Reproductive Health Access Project/October 2013
www.reproductiveaccess.org