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Case 12
16-year-old female with vaginal bleeding and UCG Savannah Bauer
Author: John Waits, M.D., University of Alabama School of Medicine
Learning Objectives:
1. Describe the essential features of a preconception consultation, including
how to incorporate this content into any visit.
2. Discuss chlamydia screening.
3. Demonstrate the use of the HEEADSS adolescent interviewing technique.
4. Diagnose pregnancy: intrauterine, ectopic, and miscarriage.
5. Discuss options during an unplanned pregnancy.
6. Order initial prenatal labs.
7. Counsel pregnant patient for healthy behavior, folic acid supplementation,
and immunizations.
8. Predict normal progression of symptoms and physical exam findings during
pregnancy.
9. Demonstrate the workup of first trimester vaginal bleeding.
10. Demonstrate the management of a miscarriage, including the medical and
social follow-up.

Summary of Clinical Scenario

Savannah is a healthy 16-year-old girl who presents with her mother for a routine
pre-participation sports exam. The visit includes development of a trusting
doctor-patient relationship to facilitate adolescent health promotion and disease
treatment. Immunizations are updated and an adolescent interview is conducted,
which reveals that Savannah is engaging in unprotected sex. Birth control and
preconception counseling are provided, and Savannah is scheduled to return for
Depo-Provera, a pelvic exam, and a chlamydia test.
When Savannah returns to the clinic two weeks later, she reports 5 weeks since
her last menstrual period, morning sickness, breast tenderness, and tiredness.
Urine pregnancy test is positive. She is given unintended pregnancy options

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counseling.
A week later, Savannah returns due to vaginal bleeding. Her pulse and blood
pressure are normal and pelvic exam is unremarkable. Quantitative beta-hCG is
1492 mIU/mL. Ultrasound does not reveal intrauterine pregnancy, but a left
ovarian cyst is noted. After reviewing the differential diagnosis, it is determined
none of the top three diagnoses (spontaneous abortion, ectopic pregnancy, or
idiopathic bleeding in a normal pregnancy) can be currently ruled out.
However, two days later, her serial beta-hCG has doubled, the bleeding has
subsided, and transvaginal ultrasound reveals an appropriately developing fetus
with a heartbeat. Ten days later, at 7 weeks and 4 days gestation, Savannah
presents to the emergency department with vaginal bleeding, some clots, and a
fair amount of pain. Pelvic exam reveals the cervical os opened 1-2 cm with
pooled blood in the vaginal vault. On ultrasound, the fetus no longer has a heart
beat, and the inevitable abortion is appropriately managed.

Key Teaching Points

Knowledge
Chlamydia
Epidemiology
Most common sexually transmitted bacterial infection in the United States.
In 2007, more than 1.1 million chlamydia cases were reported to the Center
for Disease Control (CDC).
Another million cases of chlamydia remain unreported.
Risk factors
Age - Women and men aged 24 and younger are at greatest risk.
History of chlamydial or other sexually transmitted infection.
New or multiple sexual partners.
Inconsistent condom use.
Exchanging sex for money or drugs.
African American and Hispanic women and men have higher prevalence
rates than the general population in many communities.
Course of disease & complications
Chlamydia is often insidious and asymptomatic.
Women may develop:
Urethritis
Cervicitis
Pelvic inflammatory disease (PID)
Infertility

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Ectopic pregnancy
Chronic pelvic pain
Pregnant women may develop adverse pregnancy outcomes:
Miscarriage
Premature rupture of membranes
Preterm labor
Low birth weight
Infant mortality
Screening test
Nucleic acid amplification tests (NAATs) have high specificity and sensitivity
and can be used with urine and vaginal swabs.
US Preventive Services Task Force chlamydia screening recommendations
Strongly Recommends screening; (A)
All sexually active non-pregnant young women aged 24 and younger
(chlamydia and gonorrhea)
Non-pregnant women age 25 and older at increased risk (chlamydia,
gonorrhea, hepatitis B, HIV, and syphilis)
High pretest probability with risk factors, including age <25.
Screening can reduce the incidence of PID.
Recommends; (B)
All pregnant women aged 24 and younger (chlamydia, gonorrhea,
hepatitis B, HIV, and syphilis)
Pregnant women age 25 and older at increased risk (chlamydia,
gonorrhea, hepatitis B, HIV, and syphilis)
Pregnant women have a relatively high prevalence of infection.
Fair evidence of improved pregnancy and birth outcomes for pregnant
women who are treated for chlamydial infection.
Advises against screening women age 25 and older if not at
increased risk, regardless of pregnancy status.
Overall benefit of screening would be small given the low prevalence of
infection among women not at increased risk.
Positive test is more likely to be a false positive than a true positive, even
with the most accurate tests available, in a low prevalence population.
Insufficient evidence for or against screening men.
Characteristics of a good screening test
An effective test is:
Sensitive Able to identify most or all potential cases.
Specific - Labels incorrectly as few as possible potential cases.
The condition screened for must have:
High prevalence in the population
Even a test with a sensitivity of 95% will lead to many false
positives when the prevalence of the condition is very low.
Latent stage of the disease when patients are asymptomatic.

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Effective treatment
The potential benefits of early detection and treatment of a condition need
to be weighed against many factors including:
Adverse side effects of the screening test.
Time and effort required (of both the patient and the healthcare
system) to take the test.
Financial cost of the test.
Potential psychological and physical harm of false positive results
(such as labeling and overtreatment).
Adverse effects of the treatment.
A full list of criteria for a good screening test as originally listed by the
World Health Organization (WHO) in 1968:
The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
The test should be acceptable to the population.
The natural history of the disease should be adequately
understood.
There should be an agreed policy on who to treat.
The total cost of finding a case should be economically balanced
in relation to medical expenditure as a whole.
Case-finding should be a continuous process, not just a "once
and for all" project.
Preventive screening resources
1.
2.
3.
4.
5.

The Guidelines for Adolescent Preventive Services (GAPS)

American Academy of Pediatrics
Bright Futures
U.S. Preventive Services Task Force
CDC
Immunization Guidelines
Medical Eligibility Criteria for Contraception

Immunizations
Utilize every opportunity to update vaccinations.
See the Center for Disease Control (CDC) for a vaccination schedule.
If a live, attenuated vaccine (MMR, Rubella, or Varicella vaccine) is
administered, the patient must wait 3 months before conceiving to provide
adequate protection from embryonic and/or fetal complications.
If a patient is engaging in unprotected sex without contraception, some
might consider testing for Rubella immunity as a part of this "functional"
pre-conception visit.
Pneumococcal vaccine (PPSV) required if high risk (such as cochlear
implants or aspenia).

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Administer the influenza seasonal vaccine

Birth control
Oral contraceptives
Medroxyprogesterone (Depo-Provera) injections
Transdermal
Vaginal ring (NuvaRing)
Condoms (offer some protection against sexually transmitted infections.)
Abstinence
Preconception counseling
Find the opportunity to do preconception counseling in situations where the
woman does not take the initiative to schedule a preconception visit.
Preconception Health Care Checklist
Genetic
Folic acid supplement:
The USPSTF recommends that all women planning or capable of
pregnancy take a daily supplement containing 400 800 mcg of folic
acid.
The dose is increased for the following high-risk scenarios:
1 mg in patients with diabetes or epilepsy
4 mg in patients who bore a child with a previous neural tube defect
Carrier screening (ethnic background):
sickle cell anemia
thalassemia
Tay-Sachs disease
Carrier screening (family history):
cystic fibrosis
nonsyndromic hearing loss (connexin-26)
Screen for infectious diseases, treat, immunize, counsel
HIV
Syphilis
Hepatitis B immunization
Preconception immunizations (rubella, varicella)
Toxoplasmosis-avoid cat litter, garden soil, raw meat
Cytomegalovirus, parvovirus B19 (fifth disease)-frequent hand washing,
universal precautions for child care and health care
Environmental toxins
Occupational exposures: Material Safety Data Sheets from employer
Household chemicals: avoid paint thinners and strippers, other solvents,
pesticides

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Smoking cessation: bupropion (Zyban), nicotine patches (Nicoderm)

Screen for alcoholism and use of illegal drugs
Medical assessment
Diabetes: optimize control, folic acid, 1 mg per day, off ACE-inhibitors
Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists,
thiazide diuretics
Epilepsy: optimize control; folic acid, 1 mg per day
DVT: switch from warfarin (Coumadin) to heparin
Depression/anxiety: avoid benzodiazepines

Lifestyle
Recommend regular moderate exercise
Avoid hyperthermia (hot tubs, overheating)
Caution against obesity and being underweight
Screen for domestic violence
Assess risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium
or iron deficiency)
Avoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per
day) with daily upper intake limit of 3,000 mcg [10,000 IU])
Avoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable
upper intake is 4000 IU)
Caffeine (limit to the equivalent of two cups of coffee or six glasses of soda
per day)
Note: the sugar intake in six glasses of soda is not recommended.
Pregnancy
Symptoms
Amenorrhea
Only 68% of pregnant adolescents report having missed a menses.
Anovulatory cycles are normal in the early postmenarcheal years.
Bleeding can occur in early pregnancy around the time of the missed
menses as a result of an invasion of the trophoblast into the decidua
(implantation bleed). Some adolescents mistake this bleeding for a
menses, leading to a delay in diagnosis of pregnancy and potential
misdating of the pregnancy.
Young women who have not yet menstruated, but are sexually active,
may be at risk for pregnancy because ovulation can occasionally occur
before the first menstrual period.
Fatigue, nausea, and/or vomiting as well as breast changes, including
tenderness are the classic symptoms of pregnancy.
Urinary frequency can also occur.
Gestational development

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Gestational age

5 weeks

Findings
Embryo is an eighth of an inch in size, but most
likely has a heartbeat.
The brain and spinal cord are also rapidly
developing during this stage.

8 weeks

Enlargement of uterus detected on bimanual

exam.

10-12 weeks

Fetal heart tones elicited by hand-held Doppler.

12 weeks

Uterine fundus palpated above the symphysis

pubis.

18-20 weeks

Fetal movement (quickening) detected by the

mother.

20-36 weeks

Uterine enlargement, measured in centimeters,

approximates gestational age and will become a
routinely elicted physical exam finding.

Estimate delivery date (EDD)or estimated date of confinement (EDC)

Use an obstetric wheel calculating from the last menstrual period
Use an electronic calculator - http://www.mdcalc.com/pregnancydue-dates-calculator
Use Naegeles Rule is commonly described as starting with the first day of
the last normal menstrual period, then:
Add 1 year
Subtract 3 months
Add 1 week
Reproductive choice counseling
Continue the pregnancy...
...and raise the child, with assistance finding support among family
and friends as appropriate, or with the healthcare professional
assisting the young mother with identifying the available resources
and social safety net.

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...and create an adoption plan and allow someone else to raise the
child.
Terminate the pregnancy:
Medication
The first pill is taken in the office, and the patient doesnt feel
any different after taking it.
The second medication is taken at home, usually one or two
days later.
Within a couple of hours after taking the second medication,
cramping and heavy bleeding then occur, for a couple of hours.
Follow up appointment about a week later.
Aspiration
A doctor uses special instruments in the vagina and uterus to
remove the pregnancy.
Follow up appointment a week or two later to be sure everything
is okay.
Abortion is legal up to 22 weeks of pregnancy.
Miscarriage
There is no proof that stress, or physical or sexual activity causes
miscarriage.
About half of all miscarriages that occur in the first trimester are caused by
chromosomal abnormalities.
About one-third of all pregnancies end in miscarriage.
Most women (87 percent) who have miscarriages have subsequent normal
pregnancies and births.
First Trimester bleeding
One in four pregnant patients will have some sort of bleeding during the
first trimester.
Women with significant first trimester bleed have 25-50% chance of
miscarriage.
Non-emergent
If there is a benign abdominal exam, stable pulse and blood pressure,
normal hemoglobin.
Emergent
Typically, a significant bleed will first cause the pulse to rise and then
the blood pressure to drop.
Bleeding can continue for a while before the blood pressure reflects
this, requiring urgent intervention.
If the abdominal exam suggests intraperitoneal bleeding, immediate
diagnostic laparoscopy may be warranted.

Skills
History

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Pre-participation sports exams

Opportunity for prevention and counseling.
Develop a safe and trusting doctor-patient relationship to facilitate health
promotion and disease treatment.
Encourage the teenage patient to involve parents in their healthcare
decisions.
Adolescents have a right to be interviewed and examined without a parent
or guardian in the room.
Explain to adolescents that everything they discuss with you is confidential,
while encouraging them to discuss things with their parents.
Adolescent interview: HEEADSSS
Home
Education / Employment
Eating
Activities
Drugs
Sexuality
Suicide / Depression
Safety / Violence
Obstetric / Gynecology and menstrual history:
"When did you begin having periods?
"How long do they usually last?"
"When was your last normal menstrual period?"
"Is it unusual for you to miss a period?"
Physical Exam
Pregnancy
Goodell's sign - Softening of the cervix
Hegar's sign - softening of the uterus
Chadwick's sign - The bluish-purple hue in the cervix and vaginal walls is
caused by hyperemia.
An unremarkable pelvic exam does not rule out either a spontaneous
abortion, ectopic pregnancy, or a normal pregnancy.
A cervical os dilated with obvious bleeding lends support to the diagnosis of
a spontaneous abortion.
A distended, acute abdomen may turn ones attention to the immediate
possibility of a ruptured ectopic pregnancy.
Ectropion
When the central part of the cervix appears red from the mucus
producing endocervical epithelium protruding through the cervical os
onto the face of the cervix.
No clinical significance.

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Common in women taking oral contraceptive pills.

Differential Diagnosis
First trimester bleeding
More likely causes
1. Spontaneous abortion syndrome
The loss of a pregnancy without outside intervention before 20 weeks
gestation.
Spontaneous abortions can be subdivided into:
Inevitable abortion

Dilated cervical os

Incomplete abortion

Some but not all of the

intrauterine contents (or products
of conception) have been expelled

Missed abortion

Fetal demise without cervical

dilatation and/or uterine activity
(often found incidentally on
ultrasound without a presentation
of bleeding).

Septic abortion

With intrauterine infection

(abdominal tenderness and fever
usually present).

Complete abortion

The products of conception have

been completely expelled from
the uterus.

Threatened abortion

Simply a pregnancy complicated

by bleeding before 20 weeks
gestation, and is - in some ways a catch-all descriptive
diagnosis.

2. Ectopic pregnancy
Not ruled out by an ultrasound without an intrauterine pregnancy and with
an adnexal mass.

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One should be neither cavalier that such an ultrasound finding is a benign

finding nor overly aggressive in treating for a suspected ectopic pregnancy
in a stable patient.
Better to make the diagnosis more certain.
It would be a mistake to assume that this ultrasound finding confirmed a
left-sided ectopic pregnancy and to begin either medical or surgical
treatment for ectopic pregnancy.
A left adnexal something may, after all, prove in 48 hours to be the corpus
luteum cyst supporting a normal intrauterine pregnancy.
3. Idiopathic bleeding in a normal intrauterine pregnancy
Less likely causes
1. Gestational trophoblastic disease, or molar pregnancy
hetergeneous constellation of conditions whereby the placenta acts like a
tumor.
GTDs are usually benign, but can sometimes be malignant.
Typically, they have a characteristic appearance on ultrasound and are
associated with markedly (>100,000 mIU/mL) quantitative hCG levels.
2. Vaginal trauma and cervical pathology
Unlikely when nothing abnormal is seen on physical exam.
Can not rule this out conclusively until the gonorrhea and chlamydia results
are obtained.

Studies
Initial pregnancy evaluation
Serum hCG
When urine hCG is positive, it is not necessary to obtain a serum hCG.
It is possible to have a positive serum hCG result, even with a
negative urine hCG result, as early pregnancy urine hCG
concentrations are lower than serum hCG concentrations.
Specify a qualitative (positive vs. negative) vs. a quantitative serum
hCG.
Quantitative serum hCG levels rise at a predictable rate, so
serial testing of serum hCG levels can be useful to determine
viability or to diagnose an ectopic pregnancy, although one
measurement alone is not sufficient to accurately estimate
gestational age.
CBC
Detect various nutritional and congenital anemias
Detect platelet disorders
Rubella
Assess the presence of IgG antibodies.

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If the patient is NOT immune, they should receive a postpartum

immunization.
The Rubella and the MMR vaccine is a live-virus vaccine and should
not be used during pregnancy.
Hepatitis B
Tests for Hepatitis B surface antigen
A major risk to the newborn.
Blood type
Detect rhesus antibody presence.
Rh D negative women should receive 50mcg dose of Rho(D) Immune
Globulin (e.g., RhoGAM) to prevent hemolytic disease of the newborn.
When an Rh negative mother detects enough fetal Rho-D antigen, she
forms antibodies to this antigen.
This immune response is usually not robust enough to impact the first
gestation, but subsequent gestations are at significant risk of an
immune response.
When this occurs, the maternal antibodies attack the fetus red blood
cells, causing hemolytic anemia, which can lead to fetal hydrops and
even fetal death.
Rho(D) Immune Globulin administered at appropriate times interrupts
the maternal immunologic process.
You can visualize this process by imagining the RhoGAM attaching to
all of the fetal Rho-D antigenic load, making it immunologically
invisible to the maternal immune system.
RPR
Tests for syphilis
Risk of transplacental infection of the fetus.
Congenital infection is associated with several adverse outcomes in
the neonate:
Perinatal death
Premature delivery
Low birth weight
Congenital anomalies
Active congenital syphilis
HIV
Status should be checked as the risk of perinatal transmission can be
reduced from 15-40% without treatment to less than 2% with
antiretroviral therapy and avoidance of breastfeeding and labor.
First trimester bleeding
Complete blood count (CBC)
Red blood cell count provides the hemoglobin and hematocrit.
White blood cell (WBC) count
Limited in its usefulness to detect infection (and thus a septic
abortion) during pregnancy because most pregnant patients have a
mild leukocytosis.

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If significantly elevated, or associated with a bandemia, this test

would need to be factored into the consideration of a septic abortion.
Wet mount preparation for Gonorrhea, Chlamydia, and Trichomonas
All sexually transmitted infections can cause vaginal bleeding.
These tests should be obtained in this clinical context, despite a
previously normal recent result.
Culture should not be obtained as it is very expensive.
Chlamydia cultures should only be used in cases of forensic
investigation, such as rape or child abuse.
Type and screen
Knowing Rhesus status is critical, as all Rh negative women who are
pregnant need to be given RhoGam during any episode of bleeding.
Warranted for:
Potential transfusion
When the history, vital signs, and physical exam
consistent with a major bleed.
Kleihauer-Betke testing
To estimate the quantitative amount of fetal hemoglobin
in the maternal circulation and help with dosing RhoGam.
Quantitative beta-human chorionic gonadotropin (quant. beta-hcg)
In isolation, one beta-hCG can be challenging to interpret.
Combined with pelvic ultrasound, has definitive diagnostic modalities.
Human chorionic gonadotropin is secreted by the trophoblastic cells
very early in embryonic life (day 7, post-ovulation).
Testing for the beta-subunit is exquisitely sensitive (down to 5
mIU/mL) and specific (the placenta is the only normal tissue that
excretes beta-hCG).
The velocity of increase or decrease is a more useful diagnositic
modality than a point value in a stable patient.
If the patient is stable, 1-2 serial hCG measurement(s) can prove
diagnostically useful and often conclusive when combined with a
repeat ultrasound.
Gestational age or condition

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Beta-hCG level

Expected date of menses

>= 100 mIU/ml

Conception until first 6-7 weeks

gestation

Levels double every 48 hours

Conclusive pregnancy by transvaginal

ultrasound

1500-1800 mIU/ml

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Gestational age or condition

Beta-hCG level

Pregnancy detected by transabdominal

ultrasound

>5000mIU/ml

Ectopic gestations and spontaneous

abortions

hCG levels are usually lower than

normal and increase at less-thannormal rates during early gestation

Molar pregnancy and multiple gestations Higher-than-normal hCG levels

Progesterone levels
Laboratory testing for progesterone is most useful in extreme
situations.
Levels <5 nmol/L have been highly associated with an evolving
miscarriage or ectopic pregnancy with a high level of sensitivity and
specificity.
Levels >25 nmol/L have been associated with a sustainable
intrauterine pregnancy.
Levels between 5 and 25 have minimal diagnostic value in
distinguishing intrauterine from ectopic pregnancy.
Algorithms for the diagnosis of ectopic pregnancy emphasizing
progesterone measurements have been associated with:
Higher use of surgical management
Often miss ectopic pregnancy since 85% of ectopic pregnancies
will have a normal progesterone level.
Nevertheless, the test remains valuable because of its positive and
negative predictive value at the extremes of the reference range.
In many labs, it is a common and quick test, which makes it
frequently ordered.
Transabdominal and transvaginal ultrasound results:
Doesnt rule out ectopic pregnancy.
Ultrasound and estimating date of delivery
First trimester
A crown-rump length is measured.
The accuracy and precision of this measurement is +/- 1 week.
If the estimated gestational age (EGA) & estimated delivery date (EDD)
from the ultrasound measurements are within 1 week of the EGA / EDD
calculated from the last known menstrual period (LNMP), then the
estimated gestational age today, as well as the estimated due date, should
be based on the calculations using the LNMP.
If, however, the ultrasound measurements suggest an EGA & EDD that is

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>7 days from the EGA & EDD calculated from the LNMP (or, in some cases,
if the LNMP is historically inaccurate), then the estimated gestational age
today, as well as the estimated due date, should be changed to reflect the
ultrasound measurements and estimates.
Second trimester,
Four measurements are taken:
Biparietal diameter
Head circumference
Abdominal circumference
Femur length
The accuracy and precision increases to +/- 2 weeks. The same rules
apply to keeping or changing the EGA / EDD.
Third trimester (i.e., after 24 weeks),
Accuracy and precision falls to a range of +/- 3 weeks.
Additionally, fetal size cannot be used accurately to assess EGA or
EDD and should not change a due date.

Management
Spontaneous abortion
Intrauterine contents (e.g., gestational sac, fetal pole, etc.) are not
expected to be seen until the quantitative beta-hCG reaches > 1500 IU/L,
so a serial reading (in the stable patient) is needed.
In a stable patient without active bleeding, serial readings every 48-72
hours would be appropriate.
At each lab reassessment, a clinical assessment should be done as well.
At any time, a spontaneous abortion can cause hemodynamic instability
requiring a dilitation and curettage.
At any time, a ruptured ectopic can prove life threatening, requiring a
diagnostic laparoscopy or laparotomy.
Inevitable abortion
Expectant management
Watchful waiting with precautions regarding unusual amounts of bleeding or
pain, or fever is effective in over 75% of cases in this setting.
Disadvantages
Process can take up to a month for the products of conception to be
completely expelled.
Process can be complicated by sadness, grief, and even guilt and can
delay emotional closure.
Surgical management
Options
Dilatation and curettage (D&C), with or without vacuum aspiration

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Main indication for suction D&C:

Unusually heavy bleeding
Patient preference
Main contraindication:
Active pelvic infection and patient refusal
Manual or electric vacuum aspiration
These choices depend on a variety of factors, including primarily local
resources and the surgeons preference and experience
Medical management
Despite being off-label, medical management with misoprostol is a useful
third option that is becoming more common
The most common protocol involves the vaginal administration of 800 mcg
of misoprostol (Cytotec), possibly repeated on day three
Success with this method is generally around 95%
Time to completion is generally 3-4 days (but may take up to 2 weeks), as
opposed to 2-6 weeks with expectant management
RH-negative patients
Confirming the receipt of rhesus immune globulin (RhoGam) is critical. If it
was not given previously, it should now be administered
Miscarriage counseling
Its normal for couples to feel a wide-range of emotions including sadness,
relief, and guilt after a miscarriage.
Patients often blame themselves for the miscarriage. It is important for the
health care provider to gently and expertly listen and counsel that this was
not their fault
Direct patients to counseling or a pregnancy loss support group as
appropriate
Copyright 2012 iInTIME. All Rights Reserved.

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