Family Medicine 12 A16-year-old female with vaginal bleeding and UCG

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Family Medicine 12: 16-year-old female with vaginal bleeding and UCG
Author: John B. Waits, MD; Case Editor: Vasil Nika, MD

INTRODUCTION
CARE DISCUSSION
You are working at an outpatient family medicine clinic with Dr. Hill. She has asked you to interview and examine Savannah, a 16-year-old who has come in for a routine sports physical before the softball season begins. Her mother, Leslie, accompanies her.

Dr. Hill informs you, “This is one of the special aspects I love about family medicine: I have cared for Savannah and her entire family since I helped Leslie deliver Savannah 16 years ago!”

She continues, “Today, in addition to performing a pre-participation physical examination, I would like to use this opportunity to perform prevention screening and counseling. Perhaps the most important ‘screening’ issue is the medical interview and developing a safe and trusting doctor-patient relationship. Since this can sometimes be challenging with adolescents, I have found it helpful to organize my interview around the adolescent interviewing mnemonic, HEEADSSS.”

Logistically, you both decide that it would be best to begin the medical interview with Savannah’s mother present and then delve into details and sensitive information after inviting her mother to wait in the waiting room.

TEACHING POINT
HEEADSSS Adolescent Interview
Pre-participation exams are a great opportunity for prevention and counseling, as otherwise healthy adolescents may not come in for this routinely.

HEEADSSS covers the following issues:

Home

Education / Employment

Eating

Activities

Drugs

Sexuality

Suicide / Depression

Safety / Violence

Remember that in caring for adolescents, patients should be encouraged to involve parents in their health care decisions. Nevertheless, teens have a right to be interviewed and examined without a parent or guardian in the room.

SCREENING AND THE USPSTF
TESTING
Dr. Hill reminds you, “Along with the psychosocial medical interview, we will want to consider prevention screening. First, you need to decide whether a screening test is worth ordering. The U.S. Preventive Services Task Force (USPSTF) has taken the qualities of a good screening test into account when they make recommendations of what screening tests we should do. Let’s take chlamydia for example and look online together and see what they have to say about chlamydia screening in a 16-year-old, such as Savannah.”

TEACHING POINT
Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations
Epidemiology

Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2018, 1,758,668 chlamydia cases were reported to the CDC. This is the highest number of infections of any disease ever reported to the CDC prior to the COVID pandemic. It corresponds to an incidence rate of 539.9 cases per 100,000 people. From 2014 to 2018, the rate in females and males increased by 11.4 and 37.8 percent respectively. The female infection rate remains almost double of that among males, likely due to the fact that females are more likely to be screened than males.

Course of disease

Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality.

Screening recommendations

The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a positive test is more likely to be a false positive than a true positive, even with the most accurate tests available.

TEACHING POINT
Qualities of a Good Screening Test
The condition should be an important health problem and the condition screened for must have a high prevalence in the population.

There should be a latent stage of the disease.

There should be effective treatment for the condition being screened.

Facilities for diagnosis and treatment should be available.

There should be a test or examination for the condition.

The test should be acceptable to the population and the total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. The potential benefits of early detection and treatment of a condition need to be weighed against many factors, including adverse side effects of the screening test, time and effort required (of both the patient and the health care system) to take the test, financial cost of the test, potential psychological and physical harm of false-positive results (such as labeling and overtreatment), and adverse effects of the treatment.

The natural history of the disease should be adequately understood.

There should be an agreed policy on whom to treat.

Case-finding should be a continuous process, not just a “once and for all” project.

An effective screening test should have very good sensitivity (identify most or all potential cases) and specificity (label incorrectly as few as possible as potential cases). Even a test with a sensitivity of 95% will lead to many false positives when the prevalence of the condition is very low.

Question
According to USPSTF, of the groups listed below, who should be screened for chlamydia?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. All non-pregnant women
B. All pregnant women
C. All sexually active men
D. All sexually active women 25 years or older who are at high risk
E. All sexually active women under 25 years
Answer Comment
The correct answers are D, E.

TEACHING POINT
United States Preventive Services Task Force Recommendations for Chlamydia Screening
The USPSTF recommends screening for chlamydia infection in the following:

Grade Recommendation

Rationale:

All sexually active women age 24 and younger

Sexually active women age 25 and older who are at increased risk

Grade B recommendation

There is direct evidence that screening reduces complications of chlamydial infection in women who are at increased risk, with a moderate magnitude of benefit. Such complications include pelvic inflammatory disease, infertility, and premature delivery (among pregnant women).

The USPSTF advises against screening women age 25 and older if not at increased risk, regardless of pregnancy status.

Only the above categories are found to have a high enough pretest probability to recommend screening. Women (pregnant or non-pregnant) in general are not recommended for chlamydial screening as the overall benefit of screening would be small, given the low prevalence of infection among women not at increased risk.

Risk factors for chlamydial infection include a history of chlamydial or other sexually transmitted infection, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the same as for nonpregnant women.

The USPSTF states that there is “Insufficient” evidence for or against screening men.

The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high risk behaviors overall.

The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high-risk behaviors overall.

The AAP recommends considering annual screening for chlamydia in sexually active males in settings with high prevalence rates, such as jail or juvenile correction facilities, national job training programs, STD clinics, high school clinics, and adolescent clinics (for patients who have a history of multiple partners), as well as routine annual screening for men who have sex with men.

There are several good sources for preventive screening recommendations. The Guidelines for Adolescent Preventive Services (GAPS) was developed by the AMA in 1993. Other recommendations include those from the American Academy of Pediatrics’ Bright Futures and the U.S. Preventive Services Task Force.

References
CDC. Centers for Disease Control and Prevention. Screening Recommendations and Considerations Referenced in the 2015 STD Treatment Guidelines and Original Sources. Accessed March 17, 2022.

Committee on Adolescence; Society for Adolescent Health and Medicine. Screening for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics. 2014;134(1):e302-e311.

US Preventive Services Task Force. Final Recommendation Statement: Chlamydia and Gonorrhea: Screening. September 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening. Accessed February 28, 2022.

Wilson JMG, Jungner G. (1968) Principles and practice of screening for disease (large pdf). WHO Chronicle Geneva: World Health Organization. 22(11):473. Public Health Papers, #34. https://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34.pdf?sequence=17 Accessed March 17, 2022.

MEETING THE PATIENT
HISTORY

You greet Savannah and her mother.
After discussing preventive screening, you and Dr. Hill review the sports pre-participation questionnaire that Savannah filled out in the waiting room.

Then, Dr. Hill tells you, “I think you are ready to go meet Savannah and her mother.”

You enter the room and see Savannah, a tall, athletic, 16-year-old, sitting with her mother.

You introduce yourself and explain, “Dr. Hill and I have been reviewing your sports pre-participation questionnaire together.

Would it be okay if I begin talking with you today, before Dr. Hill comes in?”
“Also, after the three of us spend some time talking together, I am going to take some time to talk with Savannah alone. Is this okay?”
After reviewing and confirming the questionnaire as well as completing a brief medical history, you find that Savannah has no health problems that would limit participation in softball this year. To help put Savannah at ease, you talk with her a bit and discuss her hopes of being selected for the pitching rotation and batting higher in the order.

HEEADSSS ASSESSMENT
HISTORY

You continue to interview Savannah without her mother present.
You then turn to Leslie and ask, “Would you mind if I speak with Savannah alone for a few minutes?” Leslie excuses herself from the room. With the HEEADSSS mnemonic in mind, you continue your conversation with Savannah. You explain to Savannah that everything discussed here is confidential.

“Tell me about your periods, how old were you when you started?”
“How long do they usually last?”
“That’s great! Are they regular?”
“So, besides softball, tell me about school?”
“Oh, really? What got you interested in nursing?”
“What do you and your friends do for fun?”
“Do any of your friends use drugs or alcohol?”
During continued conversation, Savannah mentions several of her friends have begun to smoke cigarettes, but she does not like the taste of them. Similarly, neither she nor her female friends have experimented with dietary supplements or steroids, although she does know some on the baseball team that have tried them. She maintains a healthy diet and feels satisfied with her current weight and shape.

“Are you currently in a relationship with anyone?”
“Are you having sex?”
Savannah goes on to describe two other male sexual partners in the past and says that she uses condoms “most of the time” but reports no other methods of contraception. She admits that the possibility of pregnancy worries her. She has had no sexually transmitted infections that she knows of.

“In this relationship or others, have you ever been pressured to do something sexually that you didn’t want to do?”
You then ask Savannah if she has any further questions and excuse yourself while she changes clothes for the physical exam.

On your way out the door, you remember that the preventive exam is an important opportunity to update immunizations. You tell Savannah, “By the way, Dr. Hill may recommend some shots today.” She responds with a groan, but she nods her head in assent.

collapseDEEP DIVELegal Issues and Confidentiality
REVIEWING IMMUNIZATIONS
THERAPEUTICS
In the hallway, while waiting to present Savannah’s interview to Dr. Hill, you review her immunization record.

Vaccine

Dose 1

date

Dose 2

date

Dose 3

date

Dose 4

date

Dose 5

date

Dose 6

date

Total doses

DTP, DTAP, DT, TD, TDAP

11/07/2003

01/15/2004

03/05/2004

12/21/2004

10/04/2007

5

IPV

11/07/2003

01/15/2004

03/05/2004

10/04/2007

4

Hib (Under age 5)

11/07/2003

01/15/2004

03/05/2004

09/09/2004

4

Measles, Mumps, Rubella (MMR)

09/09/2004

10/04/2007

2

Varicella

10/04/2007

1

Hep A

09/04/2015

04/01/2016

2

Hep B

09/05/2003

11/07/2003

03/05/2004

3

HPV

09/04/2015

03/05/2016

2

MCV or MPSV

PCV 13

11/07/2003

01/15/2004

03/05/2004

12/21/2004

4

Rotavirus

01/15/2004

03/05/2004

2

You also take a moment to look over the CDC’s recommended immunization schedule for persons aged 7 through 18 years in the U.S. on your computer.

For more information on immunizations, visit: https://www.cdc.gov/vaccines/index.html

Question
Which immunizations would be appropriate to administer to her at this time? When reviewing the immunization record, assume that it is fall 2019 and Savannah is 16 years old.

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Hepatitis A
B. Hepatitis B
C. Human Papillomavirus (HPV)
D. Inactivated Polio Virus (IPV)
E. Measles, Mumps, and Rubella (MMR)
F. Meningococcal (MCV)
G. Tetanus, Diphtheria, Pertussis (Tdap)
H. Varicella
Answer Comment
The correct answers are F, G, H.

Appropriate Vaccination Administration

Meningococcal (MCV) (F) — A recommended vaccine for Savannah since she did not have this vaccine at her 11-year-old visit.

Tetanus, Diphtheria, Pertussis (Tdap) (G) — It is time for Savannah’s Td booster. The Tdap would be recommended to provide additional coverage for Pertussis.

Varicella (H) — A second dose is recommended

Savannah had her Hep A, Hep B series, HPV, as well as her MMR and IPV series (Answer options A, B, C, D, and E).

Because Savannah is engaging in unprotected sex without contraception, some might consider testing for rubella immunity as a part of this “functional” pre-conception visit. It is important to remember that if this live, attenuated vaccine (MMR or rubella vaccine) is administered, the patient should be encouraged to wait 28 days before conceiving to provide adequate protection from embryonic and/or fetal complications.

There is nothing in the history (such as cochlear implants or asplenia) to suggest Savannah is in a high-risk group requiring the pneumococcal vaccine (PPSV).

Influenza would be recommended for Savannah. However, it is not the season to administer the influenza vaccine (typically October through March).

REPRODUCTIVE HEALTH SCREENING
HISTORY

You and Dr. Hill continue your history with Savannah.
You find Dr. Hill and present the interview and relevant findings, including your recommendations for Tdap, MCV, and varicella. You and Dr. Hill also conclude that as a sexually active woman under 25, she should be screened for chlamydia.

Dr. Hill praises you, “The adolescent interview can be challenging. You obviously developed a rapport with Savannah and conducted a thorough adolescent interview. How about if we go in together now and do the physical exam?”

After greeting Savannah, Dr. Hill walks you through a routine preparticipation sports physical exam. After she has finished the exam, Dr. Hill says, “Your examination shows that you are healthy. I have a few follow-up questions before your mom comes back in.”

“I understand that you are involved in a relationship. Have you ever felt any pressure to do something sexually, on a date or otherwise, that you didn’t want to do?”
“I would like to recommend a few more things to you. Even though you haven’t had a sexually transmitted infection before, it is recommended that we test you for chlamydia.”
“Last question: have you considered using any form of birth control?”
After discussing various options of birth control, Savannah indicates that she wants to start Depo-Provera because it will be easier than “remembering to take pills every day,” but wants the chance to go home and discuss things with her mother first. She plans to schedule her follow-up visit with you in a week and will let you know her final decision then.

You refer her to familydoctor.org for more information on contraceptive options.

You let Savannah know that she needs three vaccines today and that the varicella vaccine is a live, attenuated vaccine and ideally would feature a one-month period before she conceived, so the birth control discussion really is important and relevant. You also mention that if her plans change and she decides to not start depo, the chances of her becoming pregnant are higher, and in that case, she may want to consider taking a daily prenatal vitamin.

After bringing Savannah’s mother, Leslie, back for an update on the sports physical and the immunizations, the visit is concluded. Savannah plans to call for a follow-up visit after talking with her mother.

TEACHING POINT
Adolescent Health Counseling and Screening: Preventing Sexually Transmitted Infection and Unintended Pregnancy
Counsel all sexually active adolescents regarding contraception.

Options include: oral contraceptives, medroxyprogesterone (Depo-Provera) injections, long-acting reversible contraceptives such as implantable options and IUDs, as well as the vaginal ring (NuvaRing) and patches

Remind patients these options do not protect against sexually transmitted infections

Discuss condoms and abstinence

Discuss emergency contraception

Recommend folic acid supplementation to prevent neural tube defects in the event of pregnancy

Question
Although Savannah is not planning on getting pregnant, you have informed her about folic acid supplements because any sexually active woman should be aware of preconception counseling in case she unintentionally becomes pregnant. What other issues would you want to address with women who are trying to get pregnant?

Select all that apply:

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Assessing and advising against alcohol and tobacco use
B. Assessing current weight and nutritional status
C. Family history of cystic fibrosis
D. Reviewing current medications
E. Risk factors for HIV
F. Screening for safety and domestic violence
Answer Comment
The correct answers are A, B, C, D, E, F.

TEACHING POINT
Preconception Counseling
It can be challenging to find the opportunity to discuss reproductive life planning. Whether it is a walk-in/urgent care visit, sports pre-participation examination, or adolescent well-child exam, it can be helpful to bring this topic up to allow for adequate counseling around pregnancy prevention or preconception planning, as appropriate.

Preconception Health Care Checklist:

Genetic

Folic acid supplement:

The USPSTF recommends that all women “planning or capable of pregnancy” take a daily supplement containing 400 to 800 mcg of folic acid.

The dose is increased for the following high-risk scenarios:

A. 1 mg in patients with diabetes or epilepsy

B. 4 mg in patients who have had a child with a previous neural tube defect

Carrier screening (ethnic background):

Sickle cell anemia

Thalassemia

Tay-Sachs disease

Carrier screening (family history):

Cystic fibrosis

Nonsyndromic hearing loss (connexin-26)

Screen for infectious diseases, treat, immunize, counsel

HIV

Syphilis

Hepatitis B immunization

Preconception immunizations (rubella, varicella)

Toxoplasmosis—avoid cat litter, garden soil, raw meat

Cytomegalovirus, parvovirus B19 (fifth disease)—frequent hand washing, universal precautions for child care and health care

Environmental toxins

Occupational exposures: material safety data sheets from employer

Household chemicals: avoid paint thinners and strippers, other solvents, pesticides

Smoking cessation: bupropion (Zyban), nicotine patches (Nicoderm)

Screen for alcoholism and use of illegal drugs

Medical assessment

Diabetes: optimize control, folic acid 1 mg per day, off ACE-inhibitors

Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists, thiazide diuretics

Epilepsy: optimize control; folic acid 1 mg per day

DVT: switch from warfarin (Coumadin) to heparin

Depression/anxiety: avoid benzodiazepines

Lifestyle

Recommend regular moderate exercise

Avoid hyperthermia (hot tubs, overheating)

Caution against obesity and being underweight

Screen for domestic violence

Assess risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium or iron deficiency)

Avoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per day) with daily upper intake limit of 3,000 mcg (10,000 IU))

Avoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable upper intake is 4000 IU)

Caffeine (limit to the equivalent of two cups of coffee or six glasses of soda per day)

Note: The sugar intake in six glasses of soda is not recommended.

collapseDEEP DIVEFolic Acid Supplementation
References
Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination, N Engl J Med. 2007; 356(26):e26. Accessed March 17, 2022.

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.

NIH. National Institute of Health: Office of Dietary Supplements:

Fact Sheet on Vitamin D

Fact Sheet on Vitamin A

US Preventive Services Task Force. Final Recommendation Statement: Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication. January 2017. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication. Accessed March 17, 2022.

U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150(9):626-31.

Wilkes J. AAFP Releases Position Paper on Preconception care. Am Fam Physician. 2016;94(6):508-10.

RETURN VISIT TWO WEEKS LATER
HISTORY

Savannah returns and talks with you about pregnancy.
Two weeks later, Savannah returns to discuss her first Depo-Provera injection and chlamydia screening. When you go to see her, you notice Savannah is alone. You greet her and catch up a bit, and then you turn your attention to more details about her menstrual history.

“When was your last normal menstrual period?”
“Is that unusual for you, to miss a period?”
Question
Besides amenorrhea, which of the following are signs and symptoms of pregnancy?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Breast tenderness
B. Cervix and vaginal walls have an increasingly purplish-blue hue
C. Enlargement of the uterus
D. Fatigue
E. Fetal heart tones
F. Fetal movement
G. Nausea
H. Softening of the cervix and uterus
I. Urinary frequency
J. Vomiting
Answer Comment
The correct answers are A, B, C, D, E, F, G, H, I, J.

TEACHING POINT
Signs and Symptoms of Pregnancy
Amenorrhea with fatigue, nausea, and/or vomiting as well as breast changes, including tenderness, are the classic presentations of pregnancy.

Urinary frequency can also occur. Although urinary frequency can be a normal symptom of pregnancy, the possibility of a UTI should also be considered.

Softening of the cervix is known as Goodell’s sign, while softening of the uterus is known as Hegar’s sign.

The bluish-purple hue in the cervix and vaginal walls is known as Chadwick’s sign and is caused by hyperemia.

Enlargement of the uterus can be detected by an experienced examiner as early as 8 weeks on bimanual exam. Around 12 weeks, the uterine fundus can be palpated above the symphysis pubis. Between 20 to 36 weeks of gestation, the uterine enlargement, measured in centimeters, approximates gestational age and will become a routinely elicited physical exam finding.

Fetal heart tones are typically elicited by hand-held Doppler between 10-12 weeks gestation.

Fetal movement or “quickening” is detected by the mother around 18-20 weeks of gestation.

Unfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report having missed menses. Conversely, not every adolescent who misses a menses is pregnant because anovulatory cycles are normal in the early postmenarcheal years. Bleeding can occur in early pregnancy around the time of the missed menses as a result of an invasion of the trophoblast into the decidua (implantation bleed). Some adolescents mistake this bleeding for menses, leading to a delay in diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that teens who have not yet menstruated but are sexually active, may be at risk for pregnancy because ovulation can occasionally occur before the first menstrual period.

References
Polaneczky M, O’Connor K. Pregnancy in the adolescent patient. Screening, diagnosis, and initial management. Pediatr Clin North Am. 1999;46(4):649-x.

ORDERING UCG
TESTING
After you update Dr. Hill on the interval history, you return to the exam room together.

Dr. Hill Greets Savannah:

“I heard about some of your concerns. How are you feeling?”
“It’s quite understandable and normal that you feel nervous under the circumstances. While pregnancy is one of the possibilities for a delayed period, there are other possibilities too. I have a few more questions for you, and then we can discuss next steps. Would that be okay with you?”
“Have you had any nausea or breast tenderness?”
“Does your partner know that you missed your period?”
“Do you feel safe in your relationship?”
“Alright, I just wanted to be sure. You can always feel safe to share anything with me. Let’s take this a step at a time. First, why don’t we check a urine pregnancy test. We will also test your urine sample for chlamydia like we planned on doing. Then, we’ll have some information that we can sit down and review together.

Do you want your mother here for any part of this?”
You and Dr. Hill wait in the hall while Savannah collects a urine sample for the urinary human chorionic gonadotropin (UCG) testing and a urine PCR for chlamydia, and then returns to the exam room.

References
Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination, N Engl J Med. 2007; 356(26):e26. Accessed March 17, 2022.

DELIVERING THE RESULTS
MANAGEMENT

Savannah is informed about her positive pregnancy test.
When the nurse hands you the results of the test, you accompany Dr. Hill back into the examination room.

Dr. Hill begins: “Savannah, your urine pregnancy test is positive. You are pregnant.” She pauses.

“I know that’s a lot to take in. How are you feeling about that news?”

Savannah says,

“I can’t say I’m surprised because I was feeling afraid that was the case. But I feel really shaken.”

Savannah asks,

“How far along am I?”
“What should I do?”
“What is the procedure if I want to end the pregnancy?”
“What is the fetus like right now? Is an abortion still legal at this point?”
TEACHING POINT
Reproductive Choice Counseling
Continue the pregnancy…

Terminate the pregnancy…

‎‎‎‎‎‎‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎○ Medically

‎‎‎‎‎‎‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎‏‏‎ ‎○ Surgically

Abortion restrictions in the U.S. vary state to state, as shown here:

https://www.guttmacher.org/state-policy/explore/overview-abortion-laws

TEACHING POINT
Calculating Estimated Gestational Age
Calculating the estimated gestational age (EGA) based on the last normal menstrual period (LNMP). Calculating the EGA in this manner is not only convenient but ubiquitous in clinical practice. Keep in mind, however, that the actual embryonic age (e.g., the age of the fetus since the date of conception) will typically be approximately two weeks less than the clinically calculated EGA based upon the LNMP.

The other calculation used in clinical practice—which patients care a great deal about—is the estimated due date.

Calculating the estimated due date (EDD—sometimes referred to as the estimated date of confinement or EDC) from the last menstrual period is a relatively simple process that can be done with an obstetric “wheel”, with an electronic calculator (e.g., http://www.mdcalc.com/pregnancy-due-dates-calculator ) or using Naegele’s Rule.

Naegele’s Rule is commonly described as starting with the first day of the last normal menstrual period, then:

Add 1 year

Subtract 3 months

Add 1 week

For example, if a patient’s LNMP was 7/10/2020, then:

7/10/2021 (+1 yr)

4/10/2021 (-3 mo)

4/17/2021 (+1 wk)

Thus, the EDD is 4/17/2021.

There are a variety of error corrections to Naegele’s Rule and other ways to calculate the EDD in the first trimester that will be discussed later.

collapseDEEP DIVEProviding Information Regarding Reproductive Planning
References
© 2022 Guttmacher Institute. Abortion rules by state. Accessed March 17, 2022.

AAFP. American Academy of Family Physicians. AAFP Policy on Reproductive Decisions. Accessed February 28, 2022.

DISCUSSING INITIAL LAB TESTS
TESTING
Dr. Hill says, “I can appreciate that you are in a difficult situation. Nevertheless, I think it is wise for you not to jump into making any decisions right this moment. I recommend that you take time to consider all of your options. It is a good idea for you to go home and talk to your parents and your boyfriend about this. Do you feel comfortable doing that?”

Savannah responds, “Yes, they will be upset, but I can talk to them.”

Dr. Hill continues, “Please feel free to call me if you have any questions. Even though I know that you are overwhelmed, you aren’t the first young woman to be in a similar situation. I can point you toward some people that can help and also to some good resources if you would like more information. I would like you to come back in one week. You can bring your parents or your boyfriend if you like, and we will discuss your options further, then when you have had a chance to think about things. All right?”

Savannah, although initially shaken, now appears reassured. She nods her head in agreement.

Dr. Hill concludes, “In the meantime, it is recommended to do a few blood tests today, just to make sure you don’t have any sexually transmitted infections like HIV, or other types of diseases that could affect pregnancy. Additionally, should you decide to continue your pregnancy, I would recommend taking a prenatal vitamin. Do you have any questions for me?”

Savannah replies, “No, that’s fine. Oh, and Dr. Hill. One more thing. The handout for the chickenpox vaccine said that I should not take the vaccine if I was planning on getting pregnant within the next month. I wasn’t planning on this. But what could happen to the baby? Why would they warn us about this?”

Dr. Hill replies, “That’s a good question, Savannah. Although a case of a birth defect in a fetus caused by the mother receiving the varicella vaccine has never been documented, getting the actual chickenpox illness naturally while pregnant has been attributed to some birth defects. So we are just really cautious. You don’t need to do anything. It is routine for us to report this to the health department. But I wouldn’t give this any more thought than this, okay?”

Savannah, “Ok, thank you.”

Dr. Hill fills out a lab slip and hands it to Savannah. After you have directed her to the lab, she heads out.

Question
When Savannah has left, Dr. Hill asks you, “What lab tests would be ordered as part of the initial pregnancy workup plan?”

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Complete blood count
B. Hepatitis B surface antigen
C. HIV
D. RPR
E. Rubella antibodies
F. Serum pregnancy test
G. Type & screen
H. Ultrasound
Answer Comment
The correct answers are A, B, C, D, E, G.

TEACHING POINT
Initial Pregnancy Laboratory Studies
CBC is important to detect various nutritional and congenital anemias and to detect platelet disorders.

Hepatitis B surface antigen tests for hepatitis B, which is a major risk to the newborn. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)

HIV status should be checked as the risk of perinatal transmission can be reduced from 15%-40% without treatment to less than 2% with antiretroviral therapy and avoidance of breastfeeding and labor.

RPR tests for syphilis, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus. Congenital infection is associated with several adverse outcomes, including: perinatal death, premature delivery, low birth weight, congenital anomalies, and active congenital syphilis in the neonate.

Rubella immunity should be tested by assessing the presence of IgG antibodies. If the patient isn’t immune, they should receive a postpartum immunization. The Rubella and the MMR vaccine is a live-virus vaccine and should not be used during pregnancy. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)

Blood type to detect rhesus antibody presence. RH(D)-negative women should receive anti (D)-immune globulin to prevent hemolytic disease of the newborn.

It is probably not necessary to test serum hCG as well as urine hCG to confirm pregnancy, in the setting of a positive urine hCG.

However, as early pregnancy urine hCG concentrations are lower than serum hCG concentrations, it is possible to have a positive serum hCG result, even with a negative urine hCG result.

Additionally, one must specify a qualitative (positive vs. negative) vs. a quantitative serum hCG. Quantitative serum hCG levels rise at a predictable rate, so serial testing of serum hCG levels can be useful to determine viability or to diagnose an ectopic pregnancy, although one measurement alone is not sufficient to accurately estimate gestational age.

An ultrasound would not be the best test to order at an early stage of pregnancy. For example, at five weeks’ estimated gestation, an embryo would typically not be seen. Furthermore, the results would be difficult to interpret without a serum quantitative beta-human chorionic gonadotropin test (quantitative pregnancy test).

collapseDEEP DIVEAccording to the CDC’s varicella vaccine Q&A:
References
CDC. Centers for Disease Control and Prevention. Chickenpox Vaccination: What Everyone Should Know. Accessed March 17, 2022.

Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.

RETURN VISIT: VAGINAL BLEEDING
MANAGEMENT

You review Savannah’s lab work.
About one week later, the nurse, Mary, tells you, “Savannah called earlier complaining of vaginal bleeding. She said that she was not hurting, but she sounded worried. After talking with her I didn’t get the impression that her bleeding warranted going to the emergency room. I told her to go ahead and come here first. When Dr. Hill comes out of that room, tell her I’m going to go ahead and have Savannah in a gown. Oh, her mother is with her today too.”

As you are waiting on Dr. Hill, the nurse brings you Savannah’s labs from last week.

Labs

CBC (WBC 8.4 x 103/mm3, Hgb 12.7 g/dl, Hct 37.4%, Plt 270)

Rubella immune

Hepatitis B surface antigen negative

Blood type: O negative, Rh antibody negative

RPR non-reactive

HIV negative

Gonorrhea/chlamydia PCR negative

A few moments later, Dr. Hill joins you and comments: “Obviously, I am concerned about this bleeding, but before we delve off into searching for the differential diagnosis and pathophysiological source, let’s remember some fundamentals. Two of the most urgent pieces of information about first-trimester bleeding are contained in the vital signs.”

Vital signs:

Temperature is 37.2 °C (99 °F)

Pulse is 85 beats/minute

Blood pressure is 98/66 mmHg

Question
How would you interpret Savannah’s vital signs and prenatal labs?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Rhesus immune globulin (RhoGam) is indicated.
B. The low-grade fever suggests infection.
C. The normal blood pressure suggests it is unlikely that she is bleeding now.
D. The pulse is within normal limits, suggesting hemodynamic stability.
Answer Comment
The correct answers are A, D.

The correct answers are that RhoGam is indicated (A); and that her normal pulse suggests hemodynamic stability (D).

Dr. Hill continues: “Savannah’s pulse and blood pressure indicate that she is hemodynamically stable. If she was hemodynamically unstable, it would change how urgently you need to begin to make your assessment and, in some cases, intervene. Similarly, the concern of significant pelvic abdominal pain associated with vaginal bleeding would increase the urgency and necessity of assessment. Additionally, her vital signs indicate that she is afebrile. This does not conclusively rule out infection, but it does make significant infection and/or sepsis less likely.

“Finally, although this is not the most urgent issue, Savannah’s blood type is important. She is Rh-negative and she should be administered a 50 mcg dose of Rho(D) Immune Globulin (e.g., RhoGAM), regardless of the eventual diagnosis. RhoGAM is indicated for bleeding episodes during pregnancy, regardless of the gestational age.”

TEACHING POINT
Hemodynamic Instability
Typically, a significant bleed will first cause the pulse to rise and then the blood pressure to drop. Despite the fact that blood pressure is normal, bleeding can continue for a while before the blood pressure reflects this. This finding really changes how urgently you need to begin to make your assessment and, in some cases, intervene.

TEACHING POINT
Rhesus immune globulin (RhoGam)
Rho(D) Immune Globulin is a critical part of modern obstetrics. Prior to the clinical use of this medication, Rh-negative mothers with Rh-positive first gestations were at high risk of having subsequent gestations and developing hemolytic anemia, hydrops, and/or fetal death. With every pregnancy, there is some passage of fetal red blood cells into the maternal circulation. This occurs at either miscarriage or delivery and can even occur in small but significant quantities across the otherwise placental barrier.

When a mother with an intact immune system detects enough of the fetal Rho-D antigen, she forms antibodies to this antigen. This immune response is usually not robust enough to impact the first gestation, but subsequent gestations are at significant risk of an immune response. When this occurs, the maternal antibodies attack the fetus’ red blood cells, causing hemolytic anemia, which can lead to fetal hydrops and even fetal death.

Rho(D) Immune Globulin administered at appropriate times interrupts the maternal immunologic process. You can visualize this process by imagining the RhoGAM attaching to all of the fetal Rho-D antigenic load, making it immunologically “invisible” to the maternal immune system.

Note: If the 50 mcg dose appropriate for the first trimester is unavailable, the 300 mcg dose used at 28 weeks and post-partum may be administered without consequence.

References
Gabbe S, Niebyl J, Simpson J. Red Cell Alloimmunization. In: Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia: Churchill Livingstone Elsevier; 2007.

Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management. Am Fam Physician. 2019;99(3):166-74.

New York Times. NYTimes Health Section: (Slideshow) Rh Incompatibility. Accessed March 17, 2022.

HISTORY AND PHYSICAL EXAM
PHYSICAL EXAM

Dr. Hill talks to Savannah about vaginal bleeding.
You and Dr. Hill greet Savannah and her mother, Leslie. Dr. Hill begins:

“How have you been, Savannah?”
“How many pads have you had to change?”
Leslie interjects, “Doctor, we are worried that this is a miscarriage. How will we know and is there anything that we can do?”

“I understand that is a concern. You should know that some sort of bleeding is relatively common during the first trimester. Incidentally, bleeding does not necessarily mean that you are having a miscarriage.”

Dr. Hill continues, “However, before I can give you a more educated answer about what may be the source of your bleeding, I need to ask you a few more questions, perform a brief examination, and perhaps obtain some diagnostic lab work and imaging.”

“Have you had any pain or cramping with this episode of bleeding?”
“Have you fainted or been dizzy?”
“Okay, Savannah, I am going to need to do a pelvic exam in order to gather all the information we need to assess what is happening. I am going to insert a small plastic instrument called a speculum into your vagina to begin the pelvic examination. This instrument will allow me to see your cervix. Then, I will use my gloved hand and examine your vagina, cervix, uterus, and ovaries directly. If you are hurting or uncomfortable at any point, please let me know. Are you ready?”

Savannah nods her head.

After washing her hands and applying gloves, Dr. Hill then approaches the patient as she described above and proceeds to a focused and appropriate physical exam.

Physical Exam

General: well-developed and athletic, but anxious adolescent

CV: regular rate and rhythm, 2/6 soft decrescendo murmur in early systole

Abdomen: normal bowel sounds on auscultation, non-tender during auscultation, and to both percussion and palpation; the uterine fundus was not palpable on the abdominal exam due to the gestation age

Genital exam: external genital exam reveals a normal appearing labia without visible lesions. The speculum exam revealed minimal amount of fresh blood in the posterior fornix. The vaginal sidewall was found to be pink and moist, without obvious signs of trauma. The cervix revealed mild ectropion, no obvious masses or lesions, and appeared to be undilated. Both a wet prep and cultures for gonorrhea and chlamydia were obtained. On bimanual exam, the cervix was closed, the uterus was felt to be less than eight weeks size, and nontender. There were no adnexal masses palpable. Additionally, there was no unusual cervical motion tenderness nor adnexal tenderness.

As Dr. Hill re-drapes Savannah and helps her sit up, she informs her: “Savannah, I did see a little bit of blood, but nothing else I saw was conclusive… and that is not at all unusual. I would like to let you get dressed and do some diagnostic testing at this time. I think that we can get an ultrasound and some lab work done. If you have time to come back to the waiting room and sit for a little while, I think the results will be back this morning. That way we can review everything today.”

TEACHING POINT
First Trimester Vaginal Bleeding
One in four pregnant patients experiences vaginal bleeding during the first trimester.

When women have significant bleeding in the first trimester, there is a 25%-50% chance of miscarriage.

TEACHING POINT
Ectropion
Ectropion: When the central part of the cervix appears red from the mucous-producing endocervical epithelium protruding through the cervical os, onto the face of the cervix. It has no clinical significance and is common in women who are taking oral contraceptive pills.

Question
In addition to the pelvic ultrasound, which of the following laboratory tests would be reasonable to obtain at this juncture?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Complete blood count (CBC)
B. PCR for gonorrhea and chlamydia
C. Progesterone
D. Quantitative beta-human chorionic gonadotropin (quant. beta-hCG)
E. Type and screen (Rhesus typing)
F. Wet mount preparation
Answer Comment
The correct answers are A, B, C, D, F.

TEACHING POINT
Recommended Laboratory Studies to Investigate First Trimester Vaginal Bleeding
CBC: The main utility of the CBC is for the hemoglobin/hematocrit. The white blood cell (WBC) count is limited in its usefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have a mild leukocytosis. Nevertheless, if significantly elevated, or associated with a bandemia, this test would need to be factored into the consideration of a septic abortion.

Wet mount preparation for trichomonas, as well as PCR testing for gonorrhea and chlamydia: All sexually transmitted infections can cause vaginal bleeding. These tests should be obtained in this clinical context, despite a previously normal recent result.

Progesterone: Laboratory testing for progesterone is most useful in extreme situations. If the result is > 25, it is highly associated with a sustainable intrauterine pregnancy. If the result is < 5, it is highly associated with an evolving miscarriage or ectopic pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic pregnancy. Algorithms for the diagnosis of ectopic pregnancy emphasizing progesterone measurements have been associated with a higher use of surgical management and often miss ectopic pregnancy since 85% of ectopic pregnancies will have a normal progesterone level. Nevertheless, the test remains valuable because of its positive and negative predictive value at the extremes of the reference range. In many labs, it is a common and quick test, which makes it frequently ordered. Quantitative beta-human chorionic gonadotropin (quant. beta-hCG): This test has enormous significance, and when combined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can be challenging to interpret, especially without the ultrasound results. Human chorionic gonadotropin is secreted by the trophoblastic cells very early in embryonic life (day 7, post-ovulation). Additionally, testing for the beta-subunit is exquisitely sensitive (down to 5 mIU/mL) and specific (the placenta is the only normal tissue that excretes beta-hCG). By the expected date of menses, the beta-hCG is usually > or = 100 mIU/mL.

Furthermore, in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first six to seven weeks of gestation. The discriminatory value is the serum beta-hCG level above which a gestational sac should be seen on ultrasound when an intrauterine pregnancy is present and is generally recognized to be > 3500 mIU/mL. In both ectopic gestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during early gestation. Molar pregnancy and multiple gestations are both associated with higher hCG levels.

Not recommended:

Type and screen: Knowing the Rhesus status is critical, as all Rh negative women who are pregnant need to be given RhoGam during any episode of bleeding. However, this does not need to be repeated after initial type and screen, especially in a setting that does not appear that this is a major bleed. If the bleeding is of great volume, a type and screen would be warranted both for potential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the maternal circulation and with dosing RhoGam.

collapseDEEP DIVEHuman Chorionic Gonadotropin (β-hCG)
References
Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018;131(2):e65-e77.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination, N Engl J Med. 2007; 356(26):e26. Accessed March 17, 2022.

Fossum GT, Davajan V, Kletzky OA. Early detection of pregnancy with transvaginal ultrasound. Fertil Steril. 1988;49(5):788-91.

Polaneczky M, O’Connor K. Pregnancy in the adolescent patient. Screening, diagnosis, and initial management. Pediatr Clin North Am. 1999;46(4):649-x.

Speroff L, et al. Ectopic Pregnancy. In Clinical Gynecologic Endocrinology and Infertility. Ed. 5. Baltimore, MD: Williams & Wilkins; 1994.

DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
Later that morning, Savannah’s laboratory and imaging come back with the following results:

Labs

CBC: WBC = 9.3 x103/μL (9.3 x109/L), Hgb = 12.1 g/dL (121 g/L), Hct = 36.3% (0.36), Platelets = 176000/mm3( 176 x109/L)

Wet prep: no trichomonas, no yeast, no clue cells

GC/chlamydia: pending

Quantitative beta-hCG = 1492 mIU/mL

Progesterone = 14.5 nmol/L

Transabdominal and transvaginal ultrasound report:

No intrauterine pregnancy is noted

Left ovarian cyst 3cm

Cannot rule out ectopic pregnancy

See the associated reference ranges in conventional and SI units.

Question
Dr. Hill asks, “What do you think are the three most likely causes of Savannah’s vaginal bleeding?”

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Cervical abnormalities (e.g., excessive friability, malignancy, polyps, trauma)
B. Ectopic pregnancy
C. Idiopathic bleeding in a viable pregnancy
D. Molar pregnancy (gestational trophoblastic disease)
E. Spontaneous abortion (miscarriage)
F. Vaginal trauma
Answer Comment
The correct answers are B, C, E.

TEACHING POINT
Differential of First Trimester Vaginal Bleeding
Most Likely Diagnoses

There are many important causes of bleeding in early pregnancy, but the three most common are spontaneous abortion, ectopic pregnancy, and idiopathic bleeding in a viable pregnancy.

Finding

Significance

Physical Exam Findings

A cervical os dilated with obvious bleeding lends support to the diagnosis of a spontaneous abortion.

A distended, acute abdomen may turn one’s attention to the immediate possibility of a ruptured ectopic pregnancy.

However, an unremarkable pelvic exam does not rule out either a spontaneous abortion, ectopic pregnancy, or a normal pregnancy.

Quantitative beta-hCG

Neither transabdominal nor transvaginal ultrasound can reliably detect an intrauterine pregnancy at a beta-hCG level less than 1500 mIU/mL. A quantitative beta-hCG slightly less than 1500 mIU/ml does not argue for or against a spontaneous abortion, an ectopic pregnancy, or a normal pregnancy.

However, the quantitative beta-hCG should approximately double every 48 hours in a normal pregnancy, so the velocity of the increase or decrease is a more useful diagnostic modality than the point value in a stable patient. If the patient is stable, 1-2 serial hCG measurement(s) can prove diagnostically useful and often conclusive when combined with a repeat ultrasound.

Ultrasound

An ovarian cyst is not necessarily abnormal, and a report stating “cannot rule out ectopic pregnancy” is a classic reminder by the radiologist that they simply cannot rule out ectopic pregnancy.

One should be neither cavalier that such an ultrasound finding is a benign finding nor overly aggressive in “treating” for a suspected ectopic pregnancy in a stable patient. Better to make the diagnosis more certain. It would be a mistake to assume a confirmed ectopic pregnancy and to begin either medical or surgical treatment for ectopic pregnancy. This may, after all, prove in 48 hours to be the corpus luteum cyst supporting a normal intrauterine pregnancy.

Intrauterine contents (e.g., gestational sac, fetal pole, etc.) are not expected to be seen until the quantitative beta-hCG reaches > 1500 IU/L, so a serial reading (in the stable patient) is needed. In a stable patient without active bleeding, serial readings every 48-72 hours would be appropriate.

At each lab reassessment, a clinical assessment should be done as well. At any time, a spontaneous abortion can cause hemodynamic instability or a ruptured ectopic can prove life-threatening.

If the patient was or has become unstable, a dilation and curettage (for an unstable spontaneous abortion) or a diagnostic laparoscopy or laparotomy (for a suspected ruptured ectopic) would be the most appropriate course of action.

Less Likely Diagnoses

Gestational trophoblastic disease (GTD), or molar pregnancy, is a heterogeneous constellation of conditions whereby the placenta acts like a tumor. GTDs are usually benign, but can sometimes be malignant. Typically, they have a characteristic appearance on ultrasound and are associated with markedly increased (>100,000 mIU/mL) quantitative hCG levels.

Vaginal trauma and cervical pathology are unlikely if nothing abnormal is seen on physical exam. However, these can’t be ruled out conclusively until gonorrhea and chlamydia results are obtained.

References
Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243-50.

Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72(9):1707-14.

EXPLAINING THE RESULTS
MANAGEMENT

Dr. Hill discusses the diagnostic findings of the ultrasound.
It is almost noon when the nurse accompanies Savannah and Leslie back into the exam room. Dr. Hill invites you to join her as she enters the room.

Savannah asks:

“Dr. Hill, when I had my ultrasound, they said they couldn’t see a fetus. What does that mean?”
Leslie asks:

“So we really don’t know much more than we did before we started this day, do we?”
Dr. Hill asks:

“Leslie, would you mind if I talk with Savannah alone for just a minute, like we usually do at her routine visits? Do you have any final questions?”
After Savannah’s mom has gone to the check-out window, Dr. Hill asks:

“How are you doing emotionally, Savannah?”
“Are you able to talk with your mother and father?”
“What about the father of the baby?”
“Is there anything I can answer for you or do for you now?”
“Well, I’ll see you in two days, okay?
FOLLOW-UP TESTING
TESTING

Transvaginal ultrasound

Transvaginal ultrasound (zoom)

Transvaginal ultrasound showing 6w3d embryo next to a yolk sac

Transvaginal ultrasound M-mode that shows precise motion along a linear path, allowing measurement of the fetal heart rate
Two days later, Savannah returns to the clinic with her mother. Her serial quantitative beta-hCG was drawn earlier today and the results are back from the lab.

Labs

Quantitative beta-hCG = 2900 mIU/mL

Vital signs:

Temperature is 36.9 °C (98.4 °F)

Pulse is 87 beats/minute

Blood pressure is 107/72 mmHg

During the interview, Savannah tells you and Dr. Hill that her bleeding stopped and the pain and cramping subsided two days ago, shortly after she left the office.

Dr. Hill confirms that while bleeding and pain subsiding is always a comforting sign, they are not sufficient to reassure us that everything is fine yet. She also explains to Savannah that her increasing hormone level (quant hCG), while not conclusive, makes an intrauterine pregnancy more likely and an ectopic slightly less likely. She recommends repeating the lab work in two to three days.

Savannah asks,

“Why aren’t you going to do an ultrasound today, Dr. Hill?”
Savannah persists, “Could we get an answer if you did another vaginal ultrasound? I’m not sure I can survive much more uncertainty.”

Dr. Hill performs a transvaginal ultrasound. (See the images above.)

Question
Should Savannah’s estimated gestational age (and estimated due date) change based on today’s ultrasound findings?

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Yes
B. No
Answer Comment
The correct answer is B.

Savannah has regular menstrual periods and her estimated gestational age (EGA) from the estimated date of delivery, based on the last normal menstrual period (LNMP) using Naegele’s rule, is 6 weeks and 2 days.

TEACHING POINT
Estimating Gestational Age Based on Last Known Menstrual Period and Ultrasound
Recall that Naegele’s rule for estimating date of delivery (EDD) is to subtract three months and add seven days to the first day of the last menstrual period. Calculating today’s estimated gestational age is typically done on a pregnancy calculator, but can be counted from the EDD on any calendar.

Ultrasounds have their own extensive nomograms that estimate gestational age from measured fetal size.

Trimester

Measure

Accuracy and precision

Interpretation

First trimester

crown-rump length

+/- 1 week

If the EGA & EDD from the ultrasound measurements are within one week of the EGA/EDD estimated from the LNMP, today’s gestational age and the due date (EGA & EDD) should not change to reflect the ultrasound calculations, as in this case.

If, however, the ultrasound measurements suggest an EGA & EDD that is greater than seven days from the EGA & EDD calculated from the LNMP (or, in some cases, if the LNMP is historically inaccurate), then the estimated gestational age today, as well as the estimated due date, should be changed to reflect the ultrasound measurements and estimates.

Second trimester

biparietal diameter

head circumference

abdominal circumference

femur length

+/- 2 weeks

Same

Third trimester

+/- 3 weeks

Fetal size cannot be used accurately to assess EGA or EDD and should not change a due date.

This is because of the response of the fetus to internal and external insults. During the 1st and 2nd trimesters, many problems that develop result in pregnancy loss and/or teratogenesis. However, during the third trimester, many fetal and maternal challenges manifest themselves in fetal growth. Two examples would be macrosomia due to gestational diabetes or intrauterine growth restriction as a part of the pre-eclampsia syndrome. Additionally, fetal size discrepancies can be either familial or idiopathic.

Since the ultrasound estimate of gestational age and due date is based on measurements of fetal size compared to a computerized nomogram, these third-trimester measurements should not be used for dating the EGA or EDD.

DISCUSSING THE ULTRASOUND
MANAGEMENT
After seeing the ultrasound, Savannah seems visibly relieved.

Dr. Hill asks her:

“Savannah, would you like me to show you and explain to you what I am seeing?”
“The fetus is now visible and you are seeing the embryologic heart beating.”
“How do you feel?”
“I think that you are a remarkable young woman, Savannah. You are brave, strong, intelligent, and you have a loving family, who are going to help you through this, whatever course of action you decide to pursue.”

As Dr. Hill helps Savannah cover herself and reposition, you print a photograph from the machine for Savannah. Dr. Hill explains that she would like to see Savannah in two to four weeks in follow-up for a routine prenatal visit. She reassures her and her mother about the ultrasound findings but reminds them that if the bleeding returns, or there is significant pain, dizziness, lightheadedness, or fainting, that they should call her office or after-hours answering service. They will page her immediately. Finally, she reminds her to continue taking her prenatal vitamin daily.

EMERGENCY DEPARTMENT VISIT
MANAGEMENT

Savannah is informed that her fetus is no longer viable.
Ten days later, you are covering the emergency room with Dr. Hill. The nurse approaches you to inform Dr. Hill that Savannah is here:

Nursing Note: Patient presenting with vaginal bleeding. Her mother says that she is two months pregnant. Her vital signs are BP 105/75 mmHg, pulse of 90 beats/minute, and a temperature of 36.9 °C (98.4 °F).”

Dr. Hill thanks the nurse and asks you to accompany her. As you enter the room, Savannah recognizes you and begins to cry. She tells you she has been bleeding on and off for about an hour, with some clots, and a fair amount of pain, but when you ask she tells you she hasn’t had any dizziness or light-headedness.

Dr. Hill says, “Savannah, we need to examine your abdomen and cervix like we did a few weeks ago in the office. Like before, it will involve the speculum to allow us to see, then it will involve a hand in your vagina and another on your abdomen. Is it all right with you if the student performs the exam?”

Savannah responds, “That’s fine. I don’t have any questions yet.”

Dr. Hill assists you in performing a pelvic exam. You find:

Pelvic Exam: Some pooled blood in the vaginal vault. On both the speculum and digital exam, the os appears to be opened to about 1-2 cm. Her abdominal exam reveals normal bowel sounds on auscultation, no tenderness on palpation, and is soft.

Dr. Hill then states to Savannah and Leslie, “I’m going to ask the ultrasound technician to perform another ultrasound, that will allow me to assess the fetus’ heart rate. We should be able to obtain the ultrasound images through your lower abdomen this time.”

Several minutes later, you and Dr. Hill are called to the ultrasound room.

Abdominal Ultrasound: No detectable fetal heart rate. The fetus’ crown-rump length measures 0.65 cm, or approximately 6w4d gestation, similar to the last ultrasound.

“Savannah,” Dr. Hill begins, “your fetus does not have a heartbeat. That means that the fetus has died. I’m sorry.”

Leslie gently but tearfully indicates that they would like a few moments alone.

Dr. Hill excuses you and herself from the room so you may discuss the findings, promising to return in a moment.

Question
In the hallway, Dr. Hill asks you,

“What do you think are the key findings?”
Dr. Hill replies, “That’s right. So, based on these key findings, what do you think is our diagnosis?”

Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

A. Complete abortion
B. Incomplete abortion
C. Inevitable abortion
D. Missed abortion
E. Septic abortion
F. Threatened abortion
Answer Comment
The correct answer is C.

TEACHING POINT
Spontaneous Abortion
Spontaneous abortion is the loss of a pregnancy without outside intervention before 20 weeks’ gestation. Spontaneous abortions can be subdivided into:

Threatened abortion: bleeding before 20 weeks gestation.

Threatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is, in some ways, a “catch-all” descriptive diagnosis.

Inevitable abortion: dilated cervical os.

Incomplete abortion: some but not all of the intrauterine contents (or products of conception) have been expelled.

Missed abortion: fetal demise without cervical dilatation and/or uterine activity (often found incidentally on ultrasound without a presentation of bleeding).

Septic abortion: with intrauterine infection (abdominal tenderness and fever usually present).

Complete abortion: the products of conception have been completely expelled from the uterus.

Savannah’s situation is most compatible with an inevitable abortion (C). Her vaginal bleeding is associated with a dilated cervix, distinguishing this situation from a threatened abortion or missed abortion where there is usually no uterine activity. Yet, no products of conception have been expelled, distinguishing Savannah’s condition from both complete and incomplete abortions. Finally, there are no findings to suggest a septic abortion.

References
Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243-50.

MANAGEMENT OPTIONS
MANAGEMENT
Question
What are the management options for an inevitable abortion?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Expectant management
B. Medical therapy
C. Surgical management
Answer Comment
The correct answers are A, B, C.

TEACHING POINT
Management of Inevitable Abortion
In the setting of an inevitable (or similarly, an incomplete) spontaneous abortion, the traditional choices for management are expectant management or surgical management.

Expectant management means watchful waiting with precautions regarding unusual amounts of bleeding or pain, or fever, and is effective in over 75% of cases in this setting. The disadvantage with this course of action is that it can take up to a month for the products of conception to be completely expelled. This timeframe might not normally be a problem, but a spontaneous abortion is usually complicated by sadness, grief, and even guilt. Expectant management can delay emotional closure. Nevertheless, this is a viable course of action.

Surgical options include dilation and curettage (D&C), with or without vacuum aspiration, or manual or electric vacuum aspiration. These choices depend on a variety of factors, including primarily local resources and the surgeon’s preference and experience. The main indication for suction D&C is unusually heavy bleeding and patient preference. The main contraindication is active pelvic infection.

Medical management, can be done with several regimens, but, oral mifepristone 200 mg, followed 24 hours later by misoprostol 800 mcg vaginally, is the most effective for medical management of early pregnancy loss and should be recommended over misoprostol alone when available. Success with this method is generally around 97%, and the time to completion is generally three to four days (but may take up to two weeks), as opposed to two to six weeks with expectant management.

Finally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given previously, it should now be administered.

When you and Dr. Hill present these options to Savannah, she chooses medical management. Dr. Hill places the vaginal misoprostol per the above protocol, the precautions, and side-effects to expect, and asks to see her back again in a week for follow-up.

collapseDEEP DIVEOne Technique for Performing a D&C
ED FOLLOW-UP VISIT
MANAGEMENT

Savannah returns for her follow-up visit with her boyfriend.
About a week later, you are in the office with Dr. Hill, when Savannah is scheduled for a follow-up from her emergency room visit.

Savannah has brought her boyfriend, the father of the baby, to this visit. Upon questioning, she reports that about two days later, she had several hours of pain and bleeding, but it was not worse than her normal menstrual period.

Her vital signs are normal and her hemoglobin is 11.7 g/dL (117 g/L).

Her boyfriend asks:

“Did we do anything wrong? I mean, should we not have had sex? Would the baby have been okay if she hadn’t been playing softball?”
Savannah says: “I’m sad that my baby miscarried, but some part of me also feels relieved, and I feel guilty about that. Is that wrong? You know, I really want to finish school first, but I want children in the future.

Will I have another miscarriage?”
Savannah says, “I will think about that. Thank you both for all of your help, though.”

Dr. Hill reminds Savannah, “You were considering Depo-Provera for birth control. Would you like us to get you started on that today?”

Savannah says, “Yes, it would be a good idea to start it today.”

Dr. Hill encourages Savannah to return with any questions she may come up with, or if she finds herself having trouble dealing with the grief. You wish Savannah luck, and she and Jim head out the door to the nurse for the Depo-Provera.

See the associated reference ranges in conventional and SI units.

TEACHING POINT
Spontaneous Abortion: Incidence, Causes, and Recurrence
Incidence

Miscarriages are very common: about one-third of all pregnancies end in miscarriage.

Causes

Individuals who have a spontaneous abortion and their partners frequently struggle with guilt about their role in the loss. Physicians should address the issue of guilt with their patients and allay any concerns that they may have “caused” the spontaneous abortion. There is no proof that stress or physical/sexual activity causes miscarriage. About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities.

Recurrence

Most people (87 percent) who have miscarriages have subsequent normal pregnancies and births.

References
Cleveland Clinic. Health Library. Disease & Conditions. Miscarriage. https://my.clevelandclinic.org/health/diseases/9688-miscarriage. Accessed March 17, 2022.

Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243-50.

Reproductive Health Access Project. Resources. First Trimester Bleeding Algorithm. https://www.reproductiveaccess.org/resource/first-trimester-bleeding-algorithm/. November 1, 2017. Accessed, March 10, 2022.

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RELEASE NOTES
RELEASE NOTES
LEARNING OBJECTIVES
LEARNING OBJECTIVES
The student should be able to:

Describe the essential features of a preconception consultation, including how to incorporate this content into any visit.

Develop a health promotion plan regarding sexually transmitted infections for a patient of any age or gender.

Demonstrate a respectful history taking technique specifically aimed at adolescent patients.

Recognize pregnancy and differentiate intrauterine and ectopic conditions.

Recognize miscarriage and differentiate intrauterine and ectopic location of pregnancy.

Appreciate wide range of responses that patients and their families exhibit upon discovering a pregnancy, and discuss options for an unplanned pregnancy.

Discuss a cost-effective approach to initial prenatal labs.

Counsel a pregnant patient for healthy behavior, folic acid supplementation, and immunizations.

Outline usual normal progression of symptoms and physical exam findings during pregnancy.

Demonstrate the management of a miscarriage, including the medical and social follow-up.

Demonstrate performance of a focused history and physical examination in newly diagnosed pregnancy.

Describe the principles of screening and the characteristics of a good screening test.

Discuss who should be screened for chlamydia depending on gender, age and risk.

Propose a cost-effective diagnostic work-up for a patient presenting with pregnancy including possible complications.

Summarize the key features of a patient presenting with first trimester vaginal bleeding, capturing the information essential for differentiating between the common and “don’t miss” etiologies.

Find and apply diagnostic criteria and surveillance strategies for normal and abnormal pregnancies.

QUESTION 1
SAQ
Question
A 33-year-old G0P0 patient presents to your clinic for her first prenatal visit. She is otherwise healthy, and normal weight. Her home pregnancy test was positive, she has been experiencing mild nausea for two weeks. Her last normal menstrual period was six weeks ago.

What test should her initial prenatal visit include?

A. Abdominal ultrasound
B. Complete blood count
C. Complete metabolic panel
D. Glucose challenge test
E. Quad screen
QUESTION 2
SAQ
Question
A 32-year-old patient presents at your office for a preconception health visit. She is a G2P2, both deliveries were vaginal. Her first child was born with a neural tube defect.

According to the USPSTF, what dosage of folate should this patient take daily before she gets pregnant?

A. 1 mg
B. 4 mg
C. 8 mg
D. 400 mcg
E. 800 mcg
QUESTION 3
SAQ
Question
A 24-year-old G1P0 patient at 14 weeks presents with vaginal bleeding and abdominal cramping. On examination, her vital signs are: blood pressure 120/75 mmHg, pulse 74/minute, temperature 36.9 °C (98.4 °F), respiratory rate 18/minute, and oxygen saturation 99% on room air. On pelvic examination, there is a small amount of blood in the vagina, the cervical os is open, and there is no cervical or adnexal tenderness noted. On pelvic ultrasound, an intrauterine gestational sac with a yolk sac is seen.

What is her diagnosis?

A. Complete abortion
B. Inevitable abortion
C. Missed abortion
D. Septic abortion
E. Threatened abortion
QUESTION 4
SAQ
Question
A 25-year-old patient presents with vaginal bleeding and cramping. Her last normal menstrual period was six weeks ago. The patient’s vital signs are stable. On speculum exam of the vagina, there is no bleeding from the cervix. A quantitative beta-human chorionic gonadotropin (beta-hCG) level is 1832 mIU/ml. The patient is sent home and told to return to the office in 48 hours. Her beta-hCG on the return visit is 3700 mIU/ml.

What is the appropriate next step in the management of this patient?

A. Dilation and curettage for non-viable pregnancy
B. Methotrexate for ectopic pregnancy
C. Progesterone level to confirm pregnancy
D. Surgery for ectopic pregnancy
E. Ultrasound to confirm intrauterine pregnancy
QUESTION 5
SAQ
Question
A 27-year-old G0P0 patient presents to your office with abdominal pain, fever, and vaginal discharge. The discharge has an abnormal odor. She reports a new, male, sexual partner. On pelvic exam, there is cervical motion tenderness and adnexal pain during the bimanual exam. The strings from her IUD placed two years ago are seen coming from the os. A cervical culture is positive for Chlamydia trachomatis.

What risk factor for chlamydia infection is present in this patient?

A. Age
B. New sexual partner
C. Nulliparity
D. IUD
E. Sexual orientation
Thank you for completing Family Medicine 12: 16-year-old female with vaginal bleeding and UCG.

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