Soap Note Assignment

Patient information to complete the Soap Note. See attachment 

Fam

ily

Med

icine 12: 16-year-old female with vaginal bleeding and UCG

User: Beatriz Duque

Email: bettyd2382@stu.southuniversity.edu Date: August 28, 2020 8:38PM

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.

Discuss chlamydia screening.

Demonstrate the use of the HEEADSS adolescent-interviewing technique.

Recognize pregnancy: intrauterine, ectopic, and miscarriage.

Discuss options during an unplanned pregnancy.

Select initial prenatal labs.

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

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

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

Knowledge

Chlamydia:

Epidemiology

, Course of Disease, and Screening

Recommendation

s

Epidemiology

Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2007, more than 1.1 million chlamydia cases were reported to the CDC. It is thought that another million cases of chlamydia remain unreported.

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.

Qualities of a Good Screening Test

1.  The condition should be an important health problem and the condition screened for must have a high prevalence in the population.

2.  There should be a latent stage of the disease.

3.  There should also be effective treatment for the condition being screened.

4.  Facilities for diagnosis and treatment should be available.

5.  There should be a test or examination for the condition.

6.  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.

7.  The natural history of the disease should be adequately understood.

8.  There should be an agreed policy on whom to treat.

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

10.  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.

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.

1.  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.

2.  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.

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)

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

Preconception Counseling

It can be challenging to find the opportunity to discuss reproductive life planning. Whether it is walk-in / urgent care visits, sports pre-participation examinations, or adolescent well-child exams, 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 (400 mcg routine):

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 bore 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.

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 in a pregnant woman 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 a 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 a menses, leading to a delay in diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that young women 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.

Reproductive Choice Counseling

Continue the pregnancy…

…and raise the child.

…and create an adoption plan.

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

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 7/10/2009, then:

7/10/2010 (+1 yr)

4/10/2010 (-3 mo)

4/17/2010 (+1 wk)

Thus, the EDD is 4/17/2010.

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.

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.

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.

First

Trimester

Vaginal Bleeding

One in four pregnant patients experience vaginal bleeding during the first trimester.

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

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.

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 with an obstetrical “wheel” or a handheld computer, 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

Interpretation

precision

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

1.  biparietal diameter

2.  head circumference

3.  abdominal circumference

4.  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 preeclampsia 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 thirdtrimester measurements should not be used for dating the EGA or EDD.

Spontaneous Abortion

:

Incidence

,

Causes

, and

Recurrence

Incidence

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

Causes

Women who have a spontaneous abortion and their partners frequently struggle with guilt about their role in the loss.

Physician

s 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 women (87 percent) who have miscarriages have subsequent normal pregnancies and births.

Clinical Skills

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, every effort should be made to encourage the patient 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.

Management

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 and patient refusal.

Medical management, despite being off-label, is a useful third option that is becoming more common. The most common protocol involves the vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this method is generally around 95%, 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.

Studies

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).

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. However, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 15001800. To detect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 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-than-normal 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.

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 dilitation 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.

Clinical Reasoning

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 betahCG 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.

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

Ultrasound

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

Abortion rules by state

.

American Academy of Family Physicians.

AAFP Policy on Reproductive Decisions: 1989-2006

. Accessed April 28, 2017.

Brudage SC. Preconception Health Care. Am Fam Physician. 2002 Jun 15;65(12):2507-2515. Dec. 6, 2019.

Centers for Disease Control and Prevention.

2015 Sexually Transmitted Disease Treatment Guidelines: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources.

Accessed June 16, 2020.

Centers for Disease Control and Prevention.

Chickenpox Vaccination: What Everyone Should Know

. Accessed April 17, 2017.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Tep. 2006;55(RR-11):7.

Cleveland Clinic. Miscarriage.

http://my.clevelandclinic.org/disorders/Miscarriage/hic_Miscarriage.aspx

. Accessed April 28, 2017.

Committee on Adolescence and Society for Adolescent Health and Medicine. Screening for Nonviral Sexually Transmitted Infections in Adolescents and Young Adults. Pediatrics. July 2014, 134 (1) e302-e311.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination,

N

Engl

J Med

. 2007; 356(26):e26. Accessed Dec. 6, 2019.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination. N Engl J Med. 2007;356(26):e26 (Web only). Accessed Dec. 6, 2019.

Fact Sheet on Vitamin A

Fact Sheet on Vitamin D

Fossum GT, et al. Early detection of pregnancy with transvaginal ultrasound. Fertil Steril. 1998;49:788.

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

Griebel C, Halvorsen J, Golemon, T, Day A. Management of Spontaneous Abortion. Am Fam Physician. 2005 Oct 1;72(7):1243-50.

http://www.aafp.org/afp/2005/1001/p1243.html

. Accessed April 28, 2017.

Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician

. 2005;72:1243-50.

Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-50. http://www.aafp.org/afp/2005/1001/p1243.html. Accessed April 28, 2017.

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

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

http://www.aafp.org/afp/2005/1101/p1707.html

. Accessed June 2, 2017.

Meyers, DS, Halvorson, H, Luckhaupt, S. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task Force.

Ann

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2007;147:135.

National Institute of Health Office of Dietary Supplements

New York Times. (Slideshow) Rh Incompatibility. NYTimes Health Section:

http://ow.ly/JqnW

. Accessed April 28, 2017.

Polaneczky M, O’Connor K. Pregnancy in the adolescent patient: Screening, diagnosis, and initial management. Pediatr Clin North Am. August, 1999;46(4):649-70, x.PMID:10494250.

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

U.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement.

Ann Int

ern Med 2009;150:626-31.

USPSTF. Folic Acid for the Prevention of Neural Tube Defects: U.S. Preventive Services Task Force Recommendation Statement.

Ann Int Med

, 2009; 150:626-631. Accessed March 6, 2017.

USPSTF.

Folic Acid to Prevent Neural Tube Defects

.

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 ? sequence=17 Accessed June 16, 2020.

SOAPNOTE

Name:	Date:	Time:
	Age:	Sex:
SUBJECTIVE
CC: Reason given by the patient for seeking medical care “in quotes”
HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, marijuana. Safety status
ROS
General Weight change, fatigue, fever, chills, night sweats, energy level	Cardiovascular Chest pain, palpitations, PND, orthopnea, edema
Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles	Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
Eyes Corrective lenses, blurring, visual changes of any kind	Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears Ear pain, hearing loss, ringing in ears, discharge	Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain	Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
Breast SBE, lumps, bumps or changes	Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance	Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE

Weight BMI	Temp	BP
Height	Pulse	Resp
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests Urinalysis – pending Urine culture – pending Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses o 1- o 2- o 3- Diagnosis o
Plan/Therapeutics
o Plan: · Further testing · Medication · Education · Non-medication treatments
Evaluation of patient encounter

Family Medicine 12: 16-year-old female with vaginal
bleeding and UCG
User: Beatriz Duque
Email: bettyd2382@stu.southuniversity.edu
Date: August 28, 2020 8:38PM

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.
Discuss chlamydia screening.
Demonstrate the use of the HEEADSS adolescent-interviewing technique.
Recognize pregnancy: intrauterine, ectopic, and miscarriage.
Discuss options during an unplanned pregnancy.
Select initial prenatal labs.
Counsel a pregnant patient for healthy behavior, folic acid supplementation, and immunizations.
Outline normal progression of symptoms and physical exam findings during pregnancy.
Demonstrate the management of a miscarriage, including the medical and social follow-up.

Knowledge

Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations

Epidemiology

Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2007, more than 1.1
million chlamydia cases were reported to the CDC. It is thought that another million cases of chlamydia remain unreported.
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.

Qualities of a Good Screening Test

1. The condition should be an important health problem and the condition screened for must have a high prevalence in the
population.

2. There should be a latent stage of the disease.
3. There should also be effective treatment for the condition being screened.
4. Facilities for diagnosis and treatment should be available.
5. There should be a test or examination for the condition.
6. 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.

7. The natural history of the disease should be adequately understood.
8. There should be an agreed policy on whom to treat.
9. Case-finding should be a continuous process, not just a “once and for all” project.

10. 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.

United States Preventive Services Task Force Recommendations for Chlamydia Screening

The USPSTF

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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.

1. 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.

2. 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.

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)
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

Preconception Counseling

It can be challenging to find the opportunity to discuss reproductive life planning. Whether it is walk-in / urgent care visits, sports
pre-participation examinations, or adolescent well-child exams, 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 (400 mcg routine):
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 bore 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

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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.

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 in
a pregnant woman 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 a 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 a
menses, leading to a delay in diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that
young women 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.

Reproductive Choice Counseling

Continue the pregnancy…
…and raise the child.
…and create an adoption plan.

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

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

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 7/10/2009, then:
7/10/2010 (+1 yr)
4/10/2010 (-3 mo)
4/17/2010 (+1 wk)

Thus, the EDD is 4/17/2010.
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.

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.

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.

First Trimester Vaginal Bleeding

One in four pregnant patients experience vaginal bleeding during the first trimester.
When women have significant bleeding in the first trimester, there is a 25%-50% chance of miscarriage.

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.

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 with an obstetrical “wheel” or a
handheld computer, 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 Interpretation

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http://www.mdcalc.com/pregnancy-due-dates-calculator

precision

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

1. biparietal
diameter

2. head
circumference

3. abdominal
circumference

4. 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.

Spontaneous Abortion: Incidence, Causes, and Recurrence

Incidence

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

Women 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 women (87 percent) who have miscarriages have subsequent normal pregnancies and births.

Clinical Skills

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, every effort should be made to encourage the patient 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.

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Management

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 and patient refusal.
Medical management, despite being off-label, is a useful third option that is becoming more common. The most common
protocol involves the vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this
method is generally around 95%, 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.

Studies

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).

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

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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. However, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 1500-
1800. To detect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 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-than-normal 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.

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 dilitation 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.

Clinical Reasoning

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.

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

© 2020 Aquifer 7/9

Ultrasound 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

Abortion rules by state.

American Academy of Family Physicians. AAFP Policy on Reproductive Decisions: 1989-2006. Accessed April 28, 2017.

Brudage SC. Preconception Health Care. Am Fam Physician. 2002 Jun 15;65(12):2507-2515. Dec. 6, 2019.

Centers for Disease Control and Prevention. 2015 Sexually Transmitted Disease Treatment Guidelines: Screening Recommendations
and Considerations Referenced in Treatment Guidelines and Original Sources. Accessed June 16, 2020.

Centers for Disease Control and Prevention. Chickenpox Vaccination: What Everyone Should Know. Accessed April 17, 2017.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Tep.
2006;55(RR-11):7.

Cleveland Clinic. Miscarriage. http://my.clevelandclinic.org/disorders/Miscarriage/hic_Miscarriage.aspx. Accessed April 28, 2017.

Committee on Adolescence and Society for Adolescent Health and Medicine. Screening for Nonviral Sexually Transmitted Infections in
Adolescents and Young Adults. Pediatrics. July 2014, 134 (1) e302-e311.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination, N Engl J Med. 2007; 356(26):e26. Accessed Dec. 6, 2019.

Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination. N Engl J Med. 2007;356(26):e26 (Web only). Accessed
Dec. 6, 2019.

Fact Sheet on Vitamin A

Fact Sheet on Vitamin D

Fossum GT, et al. Early detection of pregnancy with transvaginal ultrasound. Fertil Steril. 1998;49:788.

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

Griebel C, Halvorsen J, Golemon, T, Day A. Management of Spontaneous Abortion. Am Fam Physician. 2005 Oct 1;72(7):1243-50.
http://www.aafp.org/afp/2005/1001/p1243.html. Accessed April 28, 2017.

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

Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-50.
http://www.aafp.org/afp/2005/1001/p1243.html. Accessed April 28, 2017.

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

Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72:1707-14.
http://www.aafp.org/afp/2005/1101/p1707.html. Accessed June 2, 2017.

Meyers, DS, Halvorson, H, Luckhaupt, S. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task
Force. Ann Intern Med. 2007;147:135.

National Institute of Health Office of Dietary Supplements

New York Times. (Slideshow) Rh Incompatibility. NYTimes Health Section: http://ow.ly/JqnW. Accessed April 28, 2017.

Polaneczky M, O’Connor K. Pregnancy in the adolescent patient: Screening, diagnosis, and initial management. Pediatr Clin North Am.
August, 1999;46(4):649-70, x.PMID:10494250.

© 2020 Aquifer 8/9

https://www.guttmacher.org/geography/united-states

https://www.aafp.org/about/policies/all/reproductive-decisions.html

http://www.aafp.org/afp/2002/0615/p2507.html

https://www.cdc.gov/std/tg2015/screening-recommendations.htm

https://www.cdc.gov/vaccines/vpd/varicella/public/index.html

http://my.clevelandclinic.org/disorders/Miscarriage/hic_Miscarriage.aspx

https://www.nejm.org/doi/full/10.1056/NEJMvcm061320

https://www.nejm.org/doi/full/10.1056/NEJMvcm061320

http://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

http://www.aafp.org/afp/2005/1001/p1243.html

http://www.aafp.org/afp/2005/1001/p1243.html

http://www.aafp.org/afp/2005/1001/p1243.html

http://www.aafp.org/afp/2005/1101/p1707.html

https://www.ncbi.nlm.nih.gov/pubmed/17576995

http://ow.ly/JqnW

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

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recommendation statement. Ann Intern Med 2009;150:626-31.

USPSTF. Folic Acid for the Prevention of Neural Tube Defects: U.S. Preventive Services Task Force Recommendation Statement. Ann
Int Med, 2009; 150:626-631. Accessed March 6, 2017.

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sequence=17 Accessed June 16, 2020.

© 2020 Aquifer 9/9

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https://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34 ?sequence=17

• Family Medicine 12: 16-year-old female with vaginal bleeding and UCG

Learning Objectives
Knowledge
Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations
Qualities of a Good Screening Test
United States Preventive Services Task Force Recommendations for Chlamydia Screening
Adolescent Health Counseling and Screening: Preventing Sexually Transmitted Infection and Unintended Pregnancy
Preconception Counseling
Signs and Symptoms of Pregnancy
Reproductive Choice Counseling
Calculating Estimated Gestational Age
Hemodynamic Instability
Rhesus immune globulin (RhoGam)
First Trimester Vaginal Bleeding
Ectropion
Estimating Gestational Age Based on Last Known Menstrual Period and Ultrasound
Spontaneous Abortion: Incidence, Causes, and Recurrence
Clinical Skills
HEEADSSS Adolescent Interview
Management
Management of Inevitable Abortion
Studies
Initial Pregnancy Laboratory Studies
Recommended Laboratory Studies to Investigate First Trimester Vaginal Bleeding
Spontaneous Abortion
Clinical Reasoning
Differential of First Trimester Vaginal Bleeding
References