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Incomplete abortion, treat as indicated

Evaluation of First Trimester Bleeding. Bleeding in desired pregnancy, < 12 weeks gestation . Physical exam. Peritoneal signs or hemodynamic instability. Non-obstetric cause of bleeding identified. Products of conception (POC’s) visible on exam.

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Incomplete abortion, treat as indicated

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  1. Evaluation of First Trimester Bleeding Bleeding in desired pregnancy, < 12 weeks gestation Physical exam Peritoneal signs or hemodynamic instability Non-obstetric cause of bleeding identified Products of conception (POC’s) visible on exam Patient stable, no POC’s or other cause of bleeding Diagnose and treat as indicated Incomplete abortion, treat as indicated Transvaginal ultrasound (TVUS) Transfer to ED Ectopic or signs suggestive of ectopic pregnancy Viable intrauterine pregnancy (IUP) Nonviable IUP IUP, viability uncertain No IUP, no ectopic seen Embryonic demise, anembryonic gestation, or retained POC’s; discuss treatment options Completed abortion; expectant management Presume ectopic; refer for high-level TVUS and/or treatment Threatened abortion; repeat TVUS if further bleeding Repeat TVUS in one week and/or follow serial β-hCG’s IUP seen on prior TVUS? Yes No Check β-hCG Β-hCG > 2000 β-hCG < 2000 Ectopic precautions, Repeat β-hCG in 48 hours Serial β -hCG’s rising and > 2000 Singleβ -hCG > 2000 and bleeding history not consistent with having passed POC’s Singleβ -hCG > 2000 and bleeding history consistent with having passed POC’s Repeat β-hCG < 2000 Repeat β-hCG > 2000 Ectopic precautions, repeat β-hCG in 48 hrs Repeat β-hCG fell > 50% Repeat β-hCG fell < 50%, plateaued or rose < 66% Repeat β-hCG rose > 66% Repeat β-hCG fell <50% or rose Repeat β-hCG fell > 50% Obtain high-level TVUS to differentiate between ectopic, early IUP, and retained POC’s; treat as indicated Suggests completed abortion; ectopic precautions, follow β-hCG weekly to zero* Suggests viable pregnancy but not diagnostic; follow β-hCG until > 2000 then TVUS for definitive diagnosis Suggests early pregnancy failure or ectopic; offer uterine aspiration orhigh-level TVUS & serial β-hCG’s until definitive diagnosis or β-hCG zero* *β-hCG should be followed to zero only in cases when pregnancy location cannot be confirmed and the possibility of a spontaneously resolving ectopic pregnancy has not been excluded; β -hCG does not need to be followed to zero following miscarriage of a known intrauterine pregnancy.

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