CASE
Mrs. M, a 34-year-old pregnant female with an estimated gestational age of 7 weeks, presented to the emergency department (ED) with a 1-hour history of vaginal bleeding and intermittent suprapubic cramping. The patient had passed a few small blood clots but had used only one pad since the bleeding started. She denied any lightheadedness, chest pain, shortness of breath, nausea, vomiting, fever, or dysuria.
History Mrs. M had given birth twice by cesarean section (c-section), once in 1996 with vertical skin incision and unknown hysterotomy and once in 2004 with Pfannenstiel skin and low transverse hysterotomy. She had also had one therapeutic abortion. Menses cycles were regular with normal Pap smear results. She denied using any contraception. No history of pelvic inflammatory disease or sexually transmitted disease was present.
Examination The patient was alert, oriented, and tearful but in no acute distress. Lungs were clear to auscultation, and rate and rhythm were regular. The abdomen was soft with minimal tenderness in the suprapubic region without rebound or guarding. A speculum examination demonstrated minimal bright red blood oozing from a closed cervical os; no cervical motion or adnexal tenderness was present.
She had a normal h
ematocrit level of 38%, an international normalized ratio of 1, and a serum beta-human chorionic gonadotropin (hCG) level of 28,162 mIU/mL. The patient was rhesus (Rh) factor negative and was given Rh-immune globulin. A pelvic ultrasound was performed (Figure 1).
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