Patient Name; Age



Author: Kathryn Steele, MD; Shellie Asher, MD Reviewer: Grace Sousa, MD

Case Title: First Trimester Bleeding

Target Audience: First- and second-year residents may be appropriate for upper-level medical students.

Primary Learning Objectives:

1. Possibility of pregnancy must be assessed in all cases of vaginal bleeding in females of child-bearing capacity.

2. Bleeding in pregnancy requires evaluation of Rh status and Rhogam administration if indicated.

3. Importance of arranging for appropriate follow-up for pregnant patients who are hemodynamically stable with non-visualized pregnancy and B-Hcg below the discriminatory zone.

Secondary Learning Objectives: Appropriate counseling to the patient regarding implications of not visualizing the pregnancy during early trimester – early normal pregnancy vs. abortion vs. ectopic

1. Appropriate discharge instructions including informing the patient to return for worsening bleeding or pain.

Critical actions checklist:

1. Pregnancy test

2. Obtain and correctly interpret pelvic ultrasound

3. Check Rh factor and administration of Rhogam

4. Follow-up with repeat Beta Hcg in 48 hours at OB/GYN clinic

Environment

1. Room Set Up – ED

2. If this is to be oral-board review, no further environmental cues would be necessary. If to be used in sim lab, requires mannequin with appropriate moulage, standardized patient and/or actors to play patient and “significant other”..

For Examiner Only

Author: Kathryn Steele, MD Reviewer: Grace Sousa, MD

Case Title: First Trimester Bleeding

CASE SUMMARY

CORE CONTENT AREA Obstetrics: First Trimester Bleeding

SYNOPSIS OF HISTORY/ Scenario Background

CC/Brief History: 23 year old female comes in to the ED with significant other at 4pm in the afternoon for evaluation of vaginal bleeding. She has had bleeding for 3 days, heavier than her typical menstruation, crampy abdominal pain not relieved with ibuprofen.

Examinee must evaluate for ectopic pregnancy, administer Rhogam, and provide appropriate follow up. Patient remains hemodynamically stable throughout the visit.

SYNOPSIS OF PHYSICAL

Vital signs - Temp 98.8, R 20, HR 90, BP 110/86, O2 Sat: 99% on RA

General – awake, alert, NAD

HEENT – normal, no pallor

Chest – normal heart sounds with regular rhythm; lungs clear and equal with good aeration

Abdomen – soft, nonperitoneal, tenderness to deep palpation in the left lower quadrant and suprapubic area, positive bowel sounds, no mass palpated

Pelvic – small amount of blood from the cervical os, cervix closed, no focal adnexal tenderness

For Examiner Only

CRITICAL ACTIONS

Scenario branch points/ PLAY OF CASE GUIDELINES

1. Critical Action

Pregnancy test.

Cueing Guideline: The nurse told the patient to collect a urine sample. Would you like any tests run on it?

2. Critical Action

Obtain and correctly interpret pelvic ultrasound

Cueing Guideline: Would any imaging be indicated in this patient?

3. Critical Action

Rh factor and administration of Rhogam

Cueing Guideline: Since the patient is pregnant and bleeding, are there any other blood tests you would order?

4. Critical Action

Follow-up with repeat Beta Hcg in 48 hours at OB/GYN clinic.

Cueing Guideline: What should the patient do now that her emergency department evaluation is complete?

SCORING GUIDELINES

1. Ideally urine pregnancy should be done first to facilitate timely management in ED, but acceptable to include in bloodwork.

2. Critical not only that ultrasound is obtained but also that examinee understands that failure to visualize ectopic does not exclude the diagnosis, and demonstrates such with further management and patient counseling.

3. Must administer Rhogam, bonus points for educating the patient about Rhogam, that it is a blood product, etc.

4. More aggressive management such as OB/GYN consultation in the emergency department would also be acceptable. Appropriate outpatient follow-up is the minimum for standard of care.

For Examiner Only

HISTORY

Onset of Symptoms: 23 year old female comes in to the ED with significant other at 4pm for evaluation of vaginal bleeding. She has had bleeding for 3 days, heavier than her typical menstruation, abdominal pain not relieved with ibuprofen.

Background Info: If examinee asks, patient is using approximately 1 pad every 2 hours, passing some clots. Pain is located more in the left lower quadrant. Patient has had not GI or urinary symptoms. She has had no symptoms of blood loss such has fatigue, syncope/presyncope, SOB, Chest pain. She does not know when her last menstrual period was and is irregular at baseline.

Chief Complaint: Vaginal Bleeding

Past Medical Hx: Patient initially denies any medical history

G2P0 with two elective terminations

History of recurrent GC/Chlamydia infections.

Past Surgical Hx: None.

Habits: Smoking: Patient denies.

ETOH: Socially

Drugs: Patient denies.

Family Medical Hx: None

Social Hx: Marital Status: Single

Children: None

Education: Some college.

Employment: Student/retail

Sexually active, uses condoms intermittently.

Feels safe in her current relationships and at home.

ROS: Otherwise negative.

Medications: None

Allergies: None

For Examiner Only

PHYSICAL EXAM

Patient Name: Henrietta Willoughby Age & Sex: 23 yo female

General Appearance: Well appearing female, awake, alert, NAD

Vital Signs: Temp 98.8, R 20, HR 90, BP 110/86, O2 Sat: 99% on RA

Head: atraumatic, normocephalic

Eyes: PEERL

Neck: supple, full range of motion

Skin: warm, dry, no rash or lesions

Lungs: clear to auscultation bilaterally

Heart: regular rate and rhythm, no murmurs, rubs or gallops

Back: nontender, no CVA tenderness

Abdomen: soft, nonperitoneal, tender to deep palpation in the left lower quadrant and suprapubic area, positive bowel sounds, no mass palpated

Extremities: no clubbing, cyanosis, or edema

Rectal: deferred

Pelvic: small amount of blood from the cervical os, cervix closed, no focal adnexal tenderness

Neurological: GCS 15, moving all extremities, interacting appropriately

Mental Status: calm, cooperative, oriented

For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form

#2 CBC

#3 BMP

#4 U/A

#5 Urine Pregnancy

#6 Rh factor

#7 Quantitative B-Hcg level

#8 Pelvic Ultrasound

#9 Debriefing materials

For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2 Stimulus #5

Complete Blood Count (CBC) Urine Pregnancy Test

WBC 8.0/m Positive

Hgb 13 g/dL

Hct 38% Stimulus #6

Platelets 200/mm3 Type and Screen

Differential A negative

Segs 60% Negative antibody screen

Bands 0%

Lymphs 29% Stimulus #7

Monos 8% Quantitative B-Hcg

Eos 3% 893

Stimulus #3

Basic Metabolic Profile (BMP)

Na+ 130 mEq/L

K+ 4.2 mEq/L

CO2 22 mEq/L

Cl- 110 mEq/L

Glucose 98 mg/dL

BUN 18 mg/dL

Creatinine 0.7 mg/dL

Stimulus #4

Urinalysis (U/A)

Color yellow

Sp gravity 1.010

Glucose neg

Protein neg

Ketone neg

Leuk. Est. neg

Nitrite neg

WBC 0-1

RBC 0-1

Diagnostic Imaging

Stimulus #8

Transvaginal Pelvic Ultrasound:

No intrauterine pregnancy identified (typically visualized at B-Hcg of >1400 in this institution)

No free fluid visualized. No ectopic pregnancy identified.

Learner Stimulus #1

ABEM General Hospital

Emergency Admitting Form

Name: Henrietta Willoughby

Age: 23 years

Sex: Female

Method of Transportation: Private car

Person giving information: Patient

Presenting complaint: Vaginal Bleeding

Background: 23 year old female comes in to the ED with significant other at 4 pm for evaluation of vaginal bleeding. She has had bleeding for 3 days, heavier than her typical menstruation, abdominal pain not relieved with ibuprofen.

Triage or Initial Vital Signs

BP: 110/867

P: 90

R: 20

T : 98.8

Learner Stimulus #2

Complete Blood Count (CBC)

WBC 8.0/m

Hgb 13 g/dL

Hct 38%

Platelets 200/mm3

Differential

Segs 60%

Bands 0%

Lymphs 29%

Monos 8%

Eos 3%

Learner Stimulus #3

Basic Metabolic Profile (BMP)

Na+ 130 mEq/L

K+ 4.2 mEq/L

CO2 22 mEq/L

Cl- 110 mEq/L

Glucose 98 mg/dL

BUN 18 mg/dL

Creatinine 0.7 mg/dL

Learner Stimulus #4

Urinalysis (U/A)

Color yellow

Sp gravity 1.010

Glucose neg

Protein neg

Ketone neg

Leuk. Est. neg

Nitrite neg

WBC 0-1

RBC 0-1

Learner Stimulus #5

Urine Pregnancy Test

Positive

Learner Stimulus #6

Type and Screen

A negative

Negative antibody screen

Learner Stimulus #7

Quantitative B-Hcg

893

Learner Stimulus #8

Pelvic Ultrasound:

[pic]

Transabdominal image

[pic]

Transvaginal image

Learner Stimulus #9

Pelvic Ultrasound Results:

No intrauterine pregnancy identified (typically visualized at B-Hcg of >1400 at this institution)

No free fluid visualized. No ectopic pregnancy identified.

Feedback/ Assessment Form

Obstetrics: First Trimester Bleeding

Candidate ________________________ Examiner _________________________

Critical Actions:

← Critical Action #1 – Pregnancy Test

← Critical Action #2 – Pelvic Ultrasound and Correct Interpretation

← Critical Action #3 – Rh factor and Rhogam administration

← Critical Action #4 – Appropriate 48 hr follow-up.

Dangerous Actions: (Performance of one dangerous action results in failure of the case)

← Administering any drug without first asking about allergies.

← Discharge without evaluating for pregnancy.

Overall Score:

← Pass

← Fail

For Examiner

Date: Examiner: Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the following:

NI = Needs Improvement

ME = Meets Expectations

AE = Above Expectations

NA= Not Assessed

|Actions |NI |ME |AE |NA |Category |

|Obtain Pregnancy Test | | | | |PC, MK |

|Obtain Pelvic Ultrasound | | | | |PC, MK |

|Appropriately interpret ultrasound results. | | | | |PC, MK, PBL |

|Obtain Rh factor | | | | |PC, MK |

|Administer Rhogam due to negative Rh factor | | | | |PC, MK |

|Counsel patient regarding Rhogam, the fact that it is a | | | | |PC, MK, ICS |

|blood product, etc. | | | | | |

|Set up follow up with OB/GYN clinic for repeat B-Hcg or | | | | |PC, MK, SBP, ICS, P |

|offer return to the emergency department if unable to be | | | | | |

|seen in clinic. (More aggressive OB consultation also | | | | | |

|acceptable) | | | | | |

|Provide appropriate discharge instructions including return | | | | |PC, MK, SBP, ICS |

|for worsening bleeding or worsening pain. | | | | | |

|Counsel patient regarding possible diagnoses: early normal | | | | |PC, MK, ICS |

|pregnancy, ectopic, missed abortion | | | | | |

|Demonstrate / utilize effective communication techniques | | | | |MK, ICS |

|such as specifying order details | | | | | |

Category: One or more of the ACGME Core Competencies as defined in the SDOT

PC= Patient Care

Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical Knowledge

Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & Improvement

Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

ICS= Interpersonal Communication Skills

Results in effective information exchange and teaming with patients, their families, and other health professionals

P= Professionalism

Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based Practice

Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Debriefing Materials:

Approach to vaginal bleeding in the Emergency Department.

History

Gyn: How much has the patient been bleeding (pads or tampons/hour is a typical measure, and whether they were saturated) and for how long? Did the bleeding start at the patient’s usual menarchal cycle, early or late? Has the patient missed a menstrual cycle? When was the last episode of normal menses for this patient? Does the patient think she is pregnant? Has she been pregnant before and if so, what were the outcomes of those pregnancies? Has she engaged in sexual intercourse? If so, what form of contraception was used, if any? Has the patient been treated for infertility or is she undergoing and assisted reproduction therapies (i.e. Clomid, IVF, etc.)? Has she ever had any pelvic infections/STDs?

Other: Any chronic illnesses? Medications, including over-the-counter or herbals? Associated symptoms such as fever/chills, lightheadedness, syncope, abdominal pain (including location, quality, severity, exacerbating/alleviating factors), vaginal discharge, urinary symptoms? Any other bleeding (GI, mucous membranes, bruising)? Recent significant weight change or social stressors?

Physical

Vital signs

HEENT – pallor of the conjunctivae or mucous membranes, mucosal hemorrhage or petechiae

Abdomen – tenderness, peritoneal signs, mass, palpable uterine fundus

Pelvic – volume and source of bleeding, trauma, vaginal discharge, products of conception in the os or vaginal canal, uterine size and tenderness, adnexal mass and tenderness, cervical motion tenderness

Tests

Pregnancy test! Urine qualitative, then serum quantitative, if the patient does not already have an ultrasound-proven intrauterine pregnancy.

Ultrasound: Transvaginal ultrasound can detect an intrauterine pregnancy if the beta-HCG is above the discriminatory zone, usually 1500 IU/liter (roughly 35 days after the last normal menstrual cycle), and can be used to look for free fluid in the pelvis. Ultrasound can sometimes also detect ectopic pregnancy.

Hemoglobin/hematocrit, to assess volume of blood loss.

Studies to assess for coagulopathy, as indicated.

Differential Diagnosis

- Ruptured ectopic pregnancy

- Spontaneous abortion

- Breakthrough bleeding in intrauterine pregnancy

- Placental abruption (in later pregnancy)

- Placenta previa

- Postpartum hemorrhage

- Menorrhagia

- Genital trauma

- Vaginal foreign bodies

- Medication-related

- Coagulopathies

- Endocrine dysfunction

- Gynecologic malignancy

- Uterine leiomyoma (fibroid)

- Uterine polyps

- Dysfunctional uterine bleeding

- GI bleeding mistaken for uterine bleeding

ED Evaluation

Is the patient hemodynamically stable? If not ( resuscitate and emergent gyn evaluation.

Is the patient pregnant? If so, what trimester? Evaluate for ectopic pregnancy. Patients with ectopic pregnancy should be considered to be at imminent risk of hemorrhagic shock, even if they present with stable hemodynamics. Surgical or medical management of ectopic pregnancy should be coordinated with Gyn.

Patients with a clear IUP or nondiagnostic ultrasound and beta-HCG below the discriminatory zone can be managed with outpatient Gyn follow-up within the next 48 hours (assess reliability of the patient to follow up, and ability to return for worsening symptoms).

Urgent obstetrical consultation should be obtained for patients with third-trimester bleeding.

Rh-immune globulin should be administered to patients who are Rh-negative with bleeding in the setting of pregnancy.

If the patient is not pregnant, what life-threatening causes of vaginal bleeding could be present?

Keywords for future searching functions

• Obstetrics

• Ectopic Pregnancy

• Vaginal Bleeding

• Abdominal Pain

References:

Dart, Robert. Approach to vaginal bleeding in the emergency department. Downloaded from on March 22, 2011.

Hosek, William T. "OB/GYN Pelvic Ultrasound in Early Pregnancy." . Web. 20 Sept. 2010. .

- Used for images under pelvic ultrasound and reference value for typical discriminatory zone of 1000-2000.

Has this work been previously published? No

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