Early Pregnancy Loss in Emergency Medicine Differential Diagnoses

Updated: Nov 05, 2018
  • Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Diagnostic Considerations

Important considerations

Perform pregnancy testing for every woman of childbearing age who presents with lower abdominal pain, vaginal bleeding, or both. History alone is not sufficient to exclude pregnancy. Pregnancy is possible even if the patient gives a history of a recent normal menstrual period, lactation, or contraceptive use.

Rule out ectopic pregnancy. An ectopic pregnancy must be excluded in every pregnant woman with abdominal pain, vaginal bleeding, or both during the first or second trimester. Endometrial shedding, which clinically simulates miscarriage, may occur with an ectopic pregnancy. This misdiagnosis is the greatest potential pitfall. An empty uterus on sonogram may represent an ectopic pregnancy.

Prevent hemolytic disease of the newborn. Ascertain the blood type of every pregnant patient with vaginal bleeding. If the patient is Rh-negative, administer RhoGAM to prevent hemolytic disease of the newborn (see Medication).

Assess the intensity of hemorrhage. External bleeding may not accurately reflect total hemorrhage. The patient, especially in the supine position, may collect large amounts of blood in the vagina with minimal external bleeding. Similarly, a large quantity of retained blood may be present in the uterine cavity and, in the case of ectopic pregnancy, in the peritoneal cavity. Therefore, never rely on the external examination to assess the rate of hemorrhage in patients with vaginal bleeding. Always perform a pelvic examination to look for blood collection in the vagina, disproportionately tender uterus, and signs of peritoneal irritation.

Identify retained products of conception. Ultrasonography for the diagnosis of retained products can yield false-positive rates, with one report of an overall false-positive rate of 34%. Retained products may be more commonly found when an evacuation is performed after 15 weeks' gestation.

Special considerations

Offer grief counseling to all patients after a miscarriage.

Referral to a specialist for determination of the cause of recurrent miscarriage may be indicated. [13]

Differential Diagnoses