A 31-year-old primigravida at 7 weeks gestation is brought to the emergency department by her husband due to vaginal bleeding and lower abdominal pain. The bleeding began 4 hours earlier, and the patient has saturated 3 perineal pads in that time. Her abdominal cramping has become progressively more severe and unresponsive to acetaminophen. She has no fevers, chills, or abnormal vaginal discharge. The patient was treated at age 18 for Chlamydia trachomatis cervicitis. Her surgical history includes a loop electrode excision procedure for high-grade cervical intraepithelial neoplasia, but she has had normal Pap tests since. The patient takes a prenatal vitamin daily and does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.7 F), blood pressure is 100/76 mm Hg, pulse is 112/min, and respirations are 14/min. Pelvic examination reveals blood clots in the vaginal vault and active bleeding from a dilated cervix. A bimanual examination demonstrates a 6-week-size tender uterus. Ultrasound reveals a gestational sac in the lower segment of the uterus, a simple cyst in the right ovary, and free fluid in the posterior cul-de-sac. Which of the following is the most likely diagnosis of this patient?

Question

A 31-year-old primigravida at 7 weeks gestation is brought to the emergency department by her husband due to vaginal bleeding and lower abdominal pain.  The bleeding began 4 hours earlier, and the patient has saturated 3 perineal pads in that time.  Her abdominal cramping has become progressively more severe and unresponsive to acetaminophen.  She has no fevers, chills, or abnormal vaginal discharge.  The patient was treated at age 18 for Chlamydia trachomatis cervicitis.  Her surgical history includes a loop electrode excision procedure for high-grade cervical intraepithelial neoplasia, but she has had normal Pap tests since.  The patient takes a prenatal vitamin daily and does not use tobacco, alcohol, or illicit drugs.  Temperature is 37 C (98.7 F), blood pressure is 100/76 mm Hg, pulse is 112/min, and respirations are 14/min.  Pelvic examination reveals blood clots in the vaginal vault and active bleeding from a dilated cervix.  A bimanual examination demonstrates a 6-week-size tender uterus.  Ultrasound reveals a gestational sac in the lower segment of the uterus, a simple cyst in the right ovary, and free fluid in the posterior cul-de-sac.  Which of the following is the most likely diagnosis of this patient?

Quizplus · Accepted Answer

11ec25c8_d1e1_41bf_bc81_bdb5d1af8ded_MD0003_00 A spontaneous abortion, defined as an unprovoked pregnancy loss at <20 weeks gestation, is a common cause of first trimester bleeding. Spontaneous abortions are most commonly the result of fetal chromosomal abnormalities but are also associated with congenital anomalies (eg, teratogen exposure) and müllerian anomalies (eg, uterine septum). Spontaneous abortions are categorized based on cervical dilation and the location of the products of conception in relation to the cervix. This patient has pain, vaginal bleeding, a dilated cervix, and products of conception in the lower uterine segment, a presentation consistent with an inevitable abortion. Her other ultrasound findings of a simple ovarian cyst (eg, corpus luteum) and free fluid in the posterior cul-de-sac are the results of the physiologic processes of pregnancy. Treatment options include expectant, medical (eg, prostaglandin administration), or surgical (eg, suction curettage) management, and the choice of option is dependent on patient preference and hemodynamic stability. (Choice A) Acute cervicitis can present as first trimester bleeding; however, pelvic examination reveals a closed, friable cervix with mucopurulent discharge. Acute cervicitis (Choice B) Cervical insufficiency refers to painless cervical dilation during the second trimester that results in loss of pregnancy. The presence of lower abdominal pain (from uterine contractions) excludes cervical insufficiency. (Choice C) An ectopic pregnancy typically presents with unilateral pain and light vaginal bleeding. Ultrasound findings consist of a complex adnexal mass rather than a simple cyst. ectopic pregnancy (Choice D) A molar pregnancy is characterized by first trimester vaginal bleeding associated with expulsion of vesicles and uterine size greater than dates. Ultrasonography reveals a "snowstorm" appearance with no fetal heart rate or identifiable structures. β-hCG levels are markedly elevated. (Choice F) Patients with missed abortions are typically asymptomatic or have loss of pregnancy symptoms (eg, nausea). Pelvic examination shows a closed cervix, and ultrasound demonstrates a fetus with no heartbeat. (Choice G) A threatened abortion presents with bleeding, a closed cervix, and an ultrasound revealing an intrauterine gestation with a normal fetal heartbeat. Educational objective: An inevitable abortion presents with vaginal bleeding, lower abdominal pain, and a dilated cervix without expulsion of the products of conception. Ultrasound typically reveals a nonviable gestation in the lower uterine segment. References: Diagnosing miscarriage. (http://www.ncbi.nlm.nih.gov/pubmed/19502113) Assessment and management of bleeding in the first trimester of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/19879521)

A 31-Year-Old Primigravida at 7 Weeks Gestation Is Brought to the Emergency