A 22-year-old woman comes to the emergency department due to 4 hours of severe lower abdominal cramping and heavy vaginal bleeding with passage of large clots. The patient's pain subsided after the passage of a round, pale mass while she was at home. Her bleeding currently is as heavy as a normal period and she reports some mild lower abdominal discomfort. She has no fevers, chills, or abnormal vaginal discharge. Her last menstrual period was 7 weeks ago. The patient has a history of intermittent cocaine abuse and smokes a pack of cigarettes daily. Temperature is 37 C (98.7 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 16/min. Abdominal examination shows mild tenderness over bilateral lower quadrants but no palpable masses or rigidity. Pelvic examination shows a closed cervix and a small amount of blood pooled in the vaginal vault. Urine β-hCG is positive. Transvaginal ultrasound reveals a normal uterus with an empty endometrial cavity, no adnexal masses, and scant free fluid in the posterior cul-de-sac. Which of the following is the most likely diagnosis?

Question

A 22-year-old woman comes to the emergency department due to 4 hours of severe lower abdominal cramping and heavy vaginal bleeding with passage of large clots.  The patient's pain subsided after the passage of a round, pale mass while she was at home.  Her bleeding currently is as heavy as a normal period and she reports some mild lower abdominal discomfort.  She has no fevers, chills, or abnormal vaginal discharge.  Her last menstrual period was 7 weeks ago.  The patient has a history of intermittent cocaine abuse and smokes a pack of cigarettes daily.  Temperature is 37 C (98.7 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 16/min.  Abdominal examination shows mild tenderness over bilateral lower quadrants but no palpable masses or rigidity.  Pelvic examination shows a closed cervix and a small amount of blood pooled in the vaginal vault.  Urine β-hCG is positive.  Transvaginal ultrasound reveals a normal uterus with an empty endometrial cavity, no adnexal masses, and scant free fluid in the posterior cul-de-sac.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_da0b_b5c8_bc81_8914eefc98c8_MD0003_00 A complete abortion, a type of spontaneous abortion, typically presents as lower abdominal pain and heavy vaginal bleeding with the passage of clots at <20 weeks gestation. These symptoms worsen until the products of conception, often described as a solid or sack-like bloody, white mass, are expelled and the symptoms lessen and resolve. Pelvic examination findings include a normal-size uterus with a closed cervix. Ultrasonography reveals an empty uterus and normal adnexa. A positive β-hCG is common in patients who present with a complete abortion as it can take up to 6 weeks for β-hCG levels to become undetectable. Risk factors for spontaneous abortion include tobacco, alcohol, and cocaine use. (Choice A) Abruptio placentae, the premature separation of the placenta from the uterus, is a cause of painful vaginal bleeding at >20 weeks gestation. Abruptio placentae > (Choice C) Although an ectopic pregnancy can present with pain and vaginal bleeding, the pain is typically unilateral and the bleeding is typically light. Ultrasound findings include an empty uterus and an adnexal mass. ectopic pregnancy (Choice D) A hydatidiform mole presents with pain, bleeding, and the passage of vesicles. Ultrasound reveals a heterogeneous uterine cystic mass with a "snowstorm" appearance. β-hCG levels are markedly elevated. (Choice E) An inevitable abortion presents with vaginal bleeding, lower abdominal pain, and a dilated cervix. Ultrasonography reveals a nonviable gestation in the lower uterus. (Choice F) Although some pain and/or bleeding can occur even with a normal pregnancy, ultrasound of such a pregnancy would reveal a normal fetal heartbeat. (Choices G and H) A threatened abortion also presents with pain, bleeding, and a closed cervix at <20 weeks gestation, but ultrasound would reveal a normal intrauterine gestation with a normal fetal heartbeat. Threatened abortions often have an associated subchorionic hematoma, an abnormal collection of blood between the placenta and uterus. Educational objective: A complete abortion refers to the passage of the products of conception through the cervix at <20 weeks gestation. The cervix then closes, and the associated pain and bleeding subside. Ultrasonography reveals an empty uterus. References: Diagnosing miscarriage. (http://www.ncbi.nlm.nih.gov/pubmed/19502113) Ultrasound criteria for diagnosis of early pregnancy failure and ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/18825605)

A 22-Year-Old Woman Comes to the Emergency Department Due to 4