Early Symptoms May Mimic Those of a Aashaka C. Shah, Kara Donovan ¹Department of and Gynecology, University of Illinois at Chicago, Chicago IL, United States

Chief Complaint: Abdominal Pain Current Research and New Treatments Diagnosis Vaginal and abdominal pain are very common (20 to 40% of women) in the first trimester History of Present Illness: 18-year-old female, G2P0010 and no significant past medical history, of pregnancy, however these symptoms are also associated with early pregnancy loss and ectopic presents to OBER with abdominal pain for two weeks. Pain has been intermittent for the past two ❖ 18-year-old female, G2P0010 and no significant past medical history presents to OBER with chief pregnancy.1 Both early pregnancy loss and can be diagnosed with ultrasound and weeks, but worse and constant today. Pain feels similar to menstrual cramps, except worse. Patient concern of abdominal pain, onset two weeks ago. Patient also reports vaginal bleeding since earlier human chorionic gonadotropin (hCG) levels at around 3 to 5 weeks of pregnancy. If no gestational sac also reports vaginal spotting today. Home pregnancy test was positive last week. LMP November 23, today. Home pregnancy test was positive two weeks ago. An ultrasound was performed at bedside is seen on ultrasound and hCG levels are decreasing in early pregnancy, this can almost certainly be 2019. Patient had a miscarriage at 7 weeks in September 2019. Otherwise, periods are normal and showing yolk sac within gestational sac and seen in . STD and GBS swabs were sent to come every month. Patient was seen at Rush and Holy Cross earlier this week. Holy Cross informed culture. Patient is approximately 6 weeks pregnant. Symptoms are consistent with early pregnancy. diagnosed as an early pregnancy loss, especially if the physical examination and patient history reveals her of the possibility of an ectopic pregnancy, so patient came to UI Health. No history of ovarian cysts Patient will follow-up during her appointment at Rush in three days. Patient was informed to return to . By 3 to 5 weeks of pregnancy, the gestational sac should be visible on or uterine fibroids. No history of UTIs. Patient was treated for chlamydia in Summer 2019, and reports OBER if she noticed bleeding through more than two pads in one hour, vomiting, fever, or worsening ultrasound and hCG levels should be consistently increasing. 2,3 If by 6 weeks, no intrauterine testing negative recently. Last bowel movement was earlier today. Patient denies constipation. Patient abdominal pain. gestational sac is seen on ultrasound and hCG levels are steadily increasing or above 2000, this plans to continue with this pregnancy. suggest a possible ectopic pregnancy and a follow-up ultrasound should be scheduled. Women with an Discussion of Disease Process/Clinical Correlations ectopic pregnancy will not have an intrauterine gestational sac seen on ultrasound and will have Past Medical History: None elevated hCG levels. If diagnosed early enough (hCG < 5000, no cardiac activity in the fetus, and Past Surgical History: None patient is table) can be used for treatment. Laparoscopic salpingectomy, or removal of About 25% of pregnant women are positive for Group B Strep (GBS). Although this bacteria is common in adults affected fallopian tube, can also be performed if the patient is unstable (ruptured tube, hemorrhage, Medications: OTC Claritin as needed for seasonal allergies and is generally not harmful, there is a possibility that it can be transferred to the baby during delivery. Due to etc.). 4 this reason, pregnant women are tested at the end of their pregnancy in order to provide the necessary Allergies: None antibiotics if cultures turn out positive. This regulation has dramatically decreased the number of early and late onset GBS disease in newborns. The figure on the left is a graph of the incidence of GBS disease in newborns Social History: No tobacco or drug use. Alcohol 1-2x a month from 1990 to 2008. First trimester are a common phenomenon and generally do not indicate an underlying problem. Review of Systems: General: No changes in weight, chills, night sweats, decreased appetite, fatigue, weakness Skin: No skin changes or rashes Head: No headaches Eyes:No itching, redness Respiratory: However, multiple miscarriages in the second and third trimesters is something that needs to be explored No hemoptysis, SOB, dry cough Cardiac: No palpitations, chest pain Gastrointestinal: No hemorrhoids, further. This can be due to a various number of causes such as autoimmune diseases (lupus) or uterine in stool, black stool, constipation Urinary Tract: No hematuria, dysuria, burning, nocturia, abnormalities. The figure on the right is a graph of the probability of miscarriage risk in the early weeks of frequency, urgency Musculoskeletal: No joint aches or pains Central Nervous System: No , pregnancy. dizziness Psychiatric: No depression, anxiety. About 50% of first trimester miscarriages are due to chromosomal abnormalities. Although most of these Figure A. An Intrauterine gestational sac Pregnancy Figure B. An ectopic pregnancy at 6 weeks with OBJECTIVE: abnormalities are due to chance, recurrent miscarriages in the first trimester can indicate that a parent has a seen at 6 weeks.5 no intrauterine gestation sac seen on balanced chromosomal translocation. However, since first trimester miscarriages are so common, genetic ultrasound.5 Vital Signs: Temp: 36.4 DegC, Pulse Rate: 73 bpm, Respiratory Rate: 19 Resp, BP: 117/67 General testing is usually performed after three or more first trimester miscarriages are observed. ❖CONCLUSIONS Pain Score: 8 First trimester miscarriage is a common phenomenon. Many early pregnancy symptoms can be confused with those of a miscarriage. An ultrasound is a great technique to view the gestational sac and embryo in uterus to rule Physical Exam: General: Alert and oriented, no acute distress Respiratory: Lungs are clear to out miscarriage. Frequent miscarriages should be investigated further to see if there is an underlying cause. auscultation bilaterally, respirations are non-labored Cardiovascular: Normal rate, regular rhythm. No murmur. Gastrointestinal: Soft, non-tender, non-distended Obstetric Exam: Vulva: within normal limits. ❖REFERENCES Perineum: within normal limits. : within normal limits, scant amount of dark brown old blood in 1. Harville EW, Wilcox AJ, Baird DD, Weinberg CR. Vaginal bleeding in very early pregnancy. Hum Reprod. 2003;18(9):1944. vault. : within normal limits, does not appear dilated. Integumentary: Warm, Dry, Pink Psychiatric: 2. Sapra KJ, Joseph KS, Galea S, Bates LM, Louis GM, Ananth CV. Signs and Symptoms of Early Pregnancy Loss: A Systematic Cooperative, Appropriate mood and affect, normal judgment Review Reprod Sci. 2017 Apr;24(4):502-513. 3. Magnus MC, Wilcox AJ, Morken NH, Weinberg CR, Håberg SE. Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. BMJ. 2019 Mar 20;364:l869. Labs/Imaging: STD and GBS lab/cultures pending, Ultrasound: yolk sac within gestational sac and 4. Huynh TQ, Patel NR. Ferri’s Cinical Advisior. 2020 2481-482. embryo seen in uterus 5. Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011 Oct;37(4):231-40. 6. Jordan HT, Farley MM, Craig A, et al. Revisiting the need for vaccine prevention of late-onset neonatal group B streptococcal disease. Pediatr Infect Dis J 2008;27:1057--64. 7. Sudeshna Mukherjee, Digna R. Velez Edwards, Donna D. Baird, David A. Savitz, Katherine E. Hartmann, Risk of Miscarriage Among Black Women and White Women in a US Prospective Cohort Study, American Journal of Epidemiology, Volume 177, Issue 11, 1 June 2013, Pages 1271–1278, Thank you Elizabeth Majewski for your contributions and time!