Bleeding & abdominal pain in early pregnancy: is it ectopic?

Vaginal bleeding and abdominal pain in early pregnancy can be associated with miscarriage, ectopic pregnancy, or a normal intrauterine pregnancy. Factors such as estimated gestational age, risk factors for ectopic pregnancy, ultrasound findings, and beta-hCG test results help determine the need for urgent obstetric consultation.

In this lesson from our First Trimester Ultrasound Power Hour course you'll learn how to:

• Use gestational age to guide the initial evaluation of early pregnancy symptoms
• Identify risk factors that increase the likelihood of ectopic pregnancy
• Interpret beta-hCG test results in the context of ultrasound findings
• Recognize when ultrasound findings may suggest ectopic pregnancy
• Determine when urgent obstetric consultation may be needed
   

Assessment of gestational age: early pregnancy ultrasound

[0:00]
Your patient presenting with lower abdominal pain and vaginal bleeding has a positive urine pregnancy test. Now what do you do? If you haven't already, you need to clarify with the patient when her last menstrual period, or LMP, was. You can work out the expected gestational age based on this information. Of note, there are patients who do not even know an estimate of their LMP. These patients will need to have an ultrasound, either formally or at the bedside, if there are staff who are trained to do so, to determine the gestational age.

OB / GYN consultation for bleeding and abdominal pain in early pregnancy

[0:36]
If she is greater than 13 weeks, you should consult an OB / GYN, as they typically will need to be involved in second-trimester pregnancies. If she falls within the first trimester, which is less than 13 weeks, then your main concern should be ectopic pregnancy, and it needs to be ruled out. An ectopic pregnancy is an emergency, as it can be fatal to the patient if left untreated.

Ectopic pregnancy risk factors

[1:00]
Ectopic pregnancy can occur without any risk factors at all, but there are also some helpful risk factors for you to be aware of. If the patient has had a prior ectopic pregnancy, any previous tubal surgery, and/or any history of PID, or pelvic inflammatory disease, or if they've had an STI, which is a sexually transmitted infection, your suspicion of ectopic pregnancy should be higher.

Evaluating suspected ectopic pregnancy

[1:28]
To evaluate for an ectopic pregnancy, order a blood test for a quantitative beta-hCG, as well as an ultrasound. Remember, most facilities will provide you a range of levels for beta-hCG that match an estimate of how many weeks pregnant the patient is. However, I encourage you not to follow those ranges to predict gestational age. They often are very inaccurate for this and lead to more confusion than help. What you can use those ranges for is ultrasound comparison. 

Using beta-hCG testing and early pregnancy ultrasound

[2:00]
The general rule is that if a patient has a beta-hCG level between 1,000 to 2,000, a gestational sac should be visible in the uterus with an ultrasound. The yolk sac, which confirms an intrauterine pregnancy, usually appears when a beta-hCG level rises above 5,000 to 7,000 mIU/mL.

Interpreting beta-hCG test results and ultrasound findings

[2:22]
However, in my experience, it is not this black and white. Individual variation exists when correlating beta-hCG levels and ultrasound findings. Ultrasound findings and beta-hCG levels should always be interpreted alongside clinical presentations. I have had patients who had levels in the 2,500 range, and I was not able to see anything in the uterus, nor did they have anything seen on ultrasound in the pelvis that was suspicious for an ectopic.

Pregnancy of unknown location: when OB / GYN consultation is needed

[2:52]
The point here is that once you have that beta-hCG result and the ultrasound, as well as your exam completed, you should call and consult with an OB / GYN physician if your suspicion for an ectopic pregnancy is high. The OB / GYN physician will follow up closely with these patients for repeat visits, laboratory tests, and ultrasounds.

Normal intrauterine pregnancy, miscarriage, or ectopic pregnancy?

[3:14]
Aside from an ectopic, other possibilities could be an early intrauterine pregnancy, a finding that does not yet require an OB / GYN intervention, or a miscarriage. If the ultrasound reveals an obvious ectopic pregnancy, the patient is hemodynamically unstable, and/or the location of the pregnancy cannot be determined, then an immediate consult is needed for further evaluation and treatment.

In the next Medmastery lesson, my colleague, Dr. Lobo, will guide you through identifying an ectopic pregnancy on ultrasound.