Early Pregnancy Loss in Emergency Medicine Clinical Presentation

Updated: Jan 03, 2017
  • Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Presentation

History

Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding, abdominal pain, or both. Note the following:

  • Vaginal bleeding may vary from slight spotting to a severe life-threatening hemorrhage. The patient's history should include the number of pads or tampons used. Hasan et al found that heavy bleeding in the first trimester, particularly when associated with abdominal pain, is associated with higher risk of miscarriage. [12]
  • Presence of blood clots or tissue may be an important sign indicating progression of spontaneous miscarriage.
  • Abdominal pain is usually located in the suprapubic area or in one or both lower quadrants.
  • Pain may radiate to the lower back, buttocks, genitalia, and perineum.

The patient's history should also include the following:

  • Date of last menstrual period (LMP)
  • Estimated length of gestation
  • Sonogram results, if previously performed
  • Bleeding disorders
  • Previous miscarriage or elective abortions

Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or abortion.

Consider any woman of childbearing age with vaginal bleeding pregnant until proven otherwise.

Next:

Physical

Pelvic examination should focus on determining the source of bleeding, such as the following:

  • Blood from cervical os
  • Intensity of bleeding
  • Presence of clots or tissue fragments
  • Cervical motion tenderness (presence increases suspicion for ectopic pregnancy)
  • Status of internal cervical os: open indicates inevitable or possibly incomplete miscarriage; closed indicates threatened miscarriage.
  • Uterine size and tenderness, as well as adnexal tenderness or masses

Signs of threatened miscarriage include the following:

  • Vital signs should be within reference ranges unless infection is present or hemorrhage has caused hypovolemia.
  • The abdomen usually is soft and nontender.
  • Pelvic examination reveals a closed internal cervical os. The bimanual examination is unremarkable.

Signs of incomplete miscarriage include the following:

  • The cervix may appear dilated and effaced, or it may be closed.
  • Bimanual examination may reveal an enlarged and soft uterus.
  • On pelvic examination, products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina. Bleeding and cramping usually persist.

Signs of complete miscarriage: On pelvic examination, the cervix should be closed, and the uterus should be contracted.

Signs of missed miscarriage include the following:

  • Vital signs usually are within reference ranges. Abdominal examination may or may not reveal a palpable uterus. If palpable, the uterus usually is small for the presumed gestational age.
  • Fetal heart tones are inaudible or unseen on sonogram.
  • The cervical os is closed upon pelvic examination. The uterus may feel soft and enlarged.
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