…but not everything in its place.
Today’s Med Student (thanks to Sarah Marchand!) Case of the Week is a 30’s y.o. multiparous patient (with one prior miscarriage) presenting with first trimester vaginal bleeding. Bread and butter emergency medicine, right?
So far her pregnancy has been uneventful though her first appointment with Ob hasn’t yet occurred. She has started her pre-natal vitamins. She has no pain but is having vaginal bleeding which started the morning of presentation. There are no clots. There is no light-headedness.
So. About 40% of all women will have some bleeding in the first trimester of pregnancy, about 60% go on and have a normal pregnancy (with the bleeding usually from implantation of the placenta growing into the uterus) though for 40% it’s the first sign of a miscarriage. Hence the ~20% rate of spontaneous miscarriage, numbers I usually give patients. I let them know miscarriage occurs not because of anything they have or haven’t done, but because nature’s way isn’t perfect.
Obviously we’re concerned about ectopic pregnancy in any first trimester patient with vaginal bleeding. Of interest she has no pain. The classic triad for ectopic pregnancy is Abdominal Pain (present in ~95%), Missed Period (present in ~85%), and Vaginal Bleeding (present in ~75%). (1) Note that if you multiply 95% x 85% x 75% you get about 60% – nearly half of all women will be missing one of the classic symptoms of ectopic!
Physical exam was fairly unremarkable. She presented with blood pressure 110/46, heart rate 85. Abdominal exam was reported as non-tender. Pelvic exam was reported as showing no adnexal mass or tenderness with a closed cervix and scant blood in the vault.
I always re-iterate with students the importance of a wide differential. The first question is whether blood is even vaginal. Urinary or GI sources can sometimes masquerade as vaginal bleeding. In this case it appears the blood is vaginal.
Basic labs including CBC, beta-HCG, and blood type are sent off and an ultrasound is ordered.
Don’t forget the blood type! Don’t forget the blood type on your oral board exam! Your pregnant patient there will always need rhogam just like a few of your real patients each year.
In this case the patient has a normal CBC, is Rh(+), and has a beta-HCG of about 6700.
Classic teaching is that you should be able to see the pregnancy trans-abdominally if the beta is above 5000 and trans-vaginally if about 1500. We should expect to find the pregnancy on the ultrasound therefore. And find it they did:
Oh my. We can see the (empty) uterus, along with a pregnancy in the … cervix.
Fewer than 1% of ectopics implant into the cervix. The most common symptom of cervical ectopic is indeed painless vaginal bleeding (2). Similar to the bleeding of a placenta previa patient, these patients are at risk for significant hemorrhage; digital exam once the diagosis is known should generally be avoided. Treatment of this problem is complex, ultimately ob-gyn elected for methotrexate (with leucovorin to decrease side effects) which was successful.
The biggest take-home from this case for me is the reminder that ectopics can be in the cervix, make sure if you’re doing a bedside ultrasound that you understand the location of pregnancies that you find!
- Beckmann, CB et al. Obstetrics and Gynecology, 3rd ed. “Ectopic Pregnancy,” pp 183, 185. 1998.
- Heer, JS et al. “Cervical Ectopic Pregnancy,” West J Emerg Med. 2012 Feb; 13(1): 125–126.