Patient Name; Age

Henrietta Willoughby, 23 yo female 2/14/1989

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 necessa ry. If to be used in sim lab, requires mannequin with appropriate moulage, standa rdized patient and/or actors to play patient and “significant other”..

1 Henrietta Willoughby, 23 yo female 2/14/1989

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

Learner Stimulus #8

Pelvic Ultrasound:

Transabdominal image

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 PC, MK, PBL results. Obtain Rh factor PC, MK Administer Rhogam due to negative PC, MK Rh factor Counsel patient regarding Rhogam, PC, MK, ICS the fact that it is a blood product, etc. Set up follow up with OB/GYN clinic PC, MK, SBP, for repeat B-Hcg or offer return to ICS, P the emergency department if unable to be seen in clinic. (More aggressive OB consultation also acceptable) Provide appropriate discharge PC, MK, SBP, instructions including return for ICS worsening bleeding or worsening pain. Counsel patient regarding possible PC, MK, ICS diagnoses: early normal pregnancy, ectopic, missed abortion Demonstrate / utilize effective MK, ICS communication techniques 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

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 www.uptodate.com on March 22, 2011.

Hosek, William T. "OB/GYN Pelvic Ultrasound in Early Pregnancy." Sonoguide.com. 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