Case 3
Bleeding during the first trimester requires prompt attention as this can be a sign of early pregnancy loss. Causes of vaginal bleeding during the first trimester include miscarriage, ectopic pregnancy, gestational trophoblastic disease, anembryonic pregnancy, incomplete abortion, molar pregnancy, threatened abortion, spontaneous abortion, and subchorionic hemorrhage. History and physical assessment must be gathered as well as a review of menstrual history and any ultrasonography to aid in determining the gestational date and to determine whether the pregnancy location is known. In this case, G.P gestational term is determined. The patient should be asked for how long has she been bleeding, the amount, and if it is equal to or heavier than her menstrual cycle. The patient should also be asked if there are any products of conception seen in the blood and ask about pelvic pain such as cramping and peritoneal pain and if she has had sexual intercourse, and unprotected sex and some sexually transmitted diseases such as N.gonorreah can cause miscarriages. A speculum examination should also be done in this case to help identify and rule out nonobstetric causes of the bleeding such as cervical polyps, vaginitis, and cervicitis, and infections, if an infection is suspected further testings should be done such as vaginal swabs, NAAT, KOH, wet mount. The speculum examination will also help identify if there are visible products of conception. The patient should also be assessed for signs and symptoms of hypovolemia such as tachycardia, hypotension, pale and clammy skin. These are indicative signs and symptoms of low hemoglobin and hematocrit and hemodynamic instability secondary to vaginal bleeding. A complete blood count should be done for this patient to r/o anemia, sepsis if the causation of bleeding is an incomplete abortion which means that the products of conception are still in and causing infection, and if need a blood transfusion depending on the levels of her H&H. If the patient’s blood type was unknown, type and screen testing should be done. A CMP should also be done to see if there is acute kidney injury (pre-renal) secondary to the vaginal bleeding and if she has sepsis. Rh factor is already determined, if Rh status was unknown, an Rh testing should be done. The patient should be given Rho (D) immune goblin (Rhogam) within 72 hours. It can also be administered within the 72 hours or early pregnancy loss, especially later in the first trimester and ectopic pregnancy, abdominal trauma, and or those who underwent uterine aspiration (AAFP, 2019). Progesterone levels should also be assessed via laboratory testing. The measurement of progesterone is useful in distinguishing between early viable and nonviable pregnancy (AAFP, 2019). Ultrasonography/transvaginal ultrasound should also be done as this aids in determining where the developing fetus is and how it is growing and can determine if there is an ectopic pregnancy. Fetal heart tones should also be done this can be done via a doppler, this will also help determine if the fetus is viable or not. Human Chorionic Gonadotropin (hCG) testing should also be done, to determine if the bleeding is caused by twin or multiple pregnancies, molar pregnancy which both causes the levels of hCG to be increased, and low levels of hCG is usually caused by ectopic pregnancy, abnormal growth, and miscarriages (HealthLine, 2021). Medication treatment such as Cytotec can help manage pregnancy loss, it can replace the need for dilation and curettage (MedicalNewsToday, 2021). Other management and interventions include uterine aspiration as surgical management for vaginal bleeding during the first trimester. This is done if there is a diagnosis of pregnancy loss (AAFP, 2021).
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