Pelvic pain and vaginal bleeding early in pregnancy

Barbara Piccirillo, MS, RPA-C; Truman J. Milling, Jr, MD

October 01, 2005

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CASE

The patient is a 36-year-old Hispanic woman who presented to the emergency department (ED) with a complaint of first-trimester vaginal bleeding associated with pelvic pain. She described the pain as cramping and nonradiating. The symptoms had started when she woke up that morning and had necessitated the use of one sanitary pad. The patient admitted to urinary frequency but denied dysuria, vaginal discharge, fever, chills, vomiting, or low back or flank pain.

History The patient's last menstrual period started 7 weeks previously. Her first prenatal visit was 1 week before at the OB/GYN clinic. She had had three earlier pregnancies; two resulted in normal vaginal deliveries and one in a first-trimester spontaneous abortion. The patient denied a history of sexually transmitted disease, coagulation disorders, or previous surgery. She reported no allergies, medication use, or use of tobacco, alcohol, or illicit drugs. She had a history of hypothyroidism and admitted to noncompliance in taking levothyroxine for approximately 4 months. The family history was unremarkable.

Physical examination The patient was in no acute discomfort and was afebrile. Her BP was 120/76 mm Hg; respiratory rate, 20 breaths per minute; pulse, 88 beats per minute (bpm), with negative orthostatic changes. Her breasts were engorged and tender. Results of the pulmonary, cardiac, abdominal, and musculoskeletal examinations were normal. The speculum examination was positive for scant blood in the vaginal vault with a closed cervical os. The uterus was antiverted and antiflexed, with a smooth flat fundus. The left adnexa were tender.

Testing A urine test result for human chorionic gonadotropin (hCG) was positive. The quantitative beta-hCG level was 113,000 mIU/mL. Urinalysis results were normal with the exception of moderate blood. Results of the CBC also were normal. The thyrotropin level was 14.9 mIU/mL, consistent with hypothyroidism. The patient's blood type was A positive. The antibody screen was negative. Bedside ultrasonography (US) was performed in the ED (see Figure 1).