You are working at an outpatient family medicine clinic with Dr. Hill. He has asked you to interview and examine Savannah, a 16-year-old who has come in for a routine sports physical before the softball season begins. Her mother, Leslie, accompanies her.
Dr. Hill informs you, “This is one of the special aspects I love about family medicine: I have cared for Savannah and her entire family since I helped Leslie deliver Savannah 16 years ago!”
He continues, “Today, in addition to performing a pre-participation physical examination, I would like to use this opportunity to perform prevention screening and counseling. Perhaps the most important ‘screening’ issue is the medical interview and developing a safe and trusting doctor-patient relationship. Since this can sometimes be challenging with adolescents, I have found it helpful to organize my interview around the adolescent interviewing mnemonic, HEEADSSS.”
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Logistically, you both decide that it would probably be best to begin the history with Savannah’s mother present and then delve into more of the interview after she has been invited to the waiting room during the conclusion of the visit.
HEEADSSS Adolescent Interview
Pre-participation exams are a great opportunity for prevention and counseling, as otherwise healthy adolescents may not come in for this routinely.
HEEADSSS covers the following issues:
· Education / Employment
· Suicide / Depression
· Safety / Violence
Remember that in caring for adolescents, every effort should be made to encourage the patient to involve parents in their health care decisions. Nevertheless, teens have a right to be interviewed and examined without a parent or guardian in the room.
SCREENING AND THE USPSTF
Dr. Hill reminds you, “Along with the psychosocial medical interview, we will want to consider prevention screening. First, you need to decide whether a screening test is worth ordering. The U.S. Preventive Services Task Force (USPSTF) has taken the qualities of a good screening test into account when they make recommendations of what screening tests we should do. Let’s take chlamydia for example and look online together and see what they have to say about chlamydia screening in a 16-year-old, such as Savannah.”
Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations
Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2007, more than 1.1 million chlamydia cases were reported to the CDC. It is thought that another million cases of chlamydia remain unreported.
Course of disease
Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality.
The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a positive test is more likely to be a false positive than a true positive, even with the most accurate tests available.
Qualities of a Good Screening Test
1. The condition should be an important health problem and the condition screened for must have a high prevalence in the population.
2. There should be a latent stage of the disease.
3. There should also be effective treatment for the condition being screened.
4. Facilities for diagnosis and treatment should be available.
5. There should be a test or examination for the condition.
6. The test should be acceptable to the population and the total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. 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 health care system) to take the test, financial cost of the test, potential psychological and physical harm of false positive results (such as labeling and overtreatment), and adverse effects of the treatment.
7. The natural history of the disease should be adequately understood.
8. There should be an agreed policy on whom to treat.
9. Case-finding should be a continuous process, not just a “once and for all” project.
10. An effective screening test should have very good sensitivity (identify most or all potential cases) and specificity (label incorrectly as few as possible as potential cases). Even a test with a sensitivity of 95% will lead to many false positives when the prevalence of the condition is very low.
· The USPSTF advises against screening women age 25 and older if not at increased risk, regardless of pregnancy status.
· Only the above categories are found to have a high enough pretest probability to recommend screening. Women (pregnant or non-pregnant) in general are not recommended for chlamydial screening as the overall benefit of screening would be small, given the low prevalence of infection among women not at increased risk.
· Risk factors for chlamydial infection include a history of chlamydial or other sexually transmitted infection, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the same as for nonpregnant women.
· The USPSTF states that there is “Insufficient” evidence for or against screening men.
· The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high risk behaviors overall.
1. The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high-risk behaviors overall.
2. The AAP recommends considering annual screening for chlamydia in sexually active males in settings with high prevalence rates, such as jail or juvenile correction facilities, national job training programs, STD clinics, high school clinics, and adolescent clinics (for patients who have a history of multiple partners), as well as routine annual screening for men who have sex with men.
There are several good sources for preventive screening recommendations. The Guidelines for Adolescent Preventive Services (GAPS) was developed by the AMA in 1993. Other recommendations include those from the American Academy of Pediatrics’ Bright Futures and the U.S. Preventive Services Task Force.
After discussing preventive screening, you and Dr. Hill review the sports pre-participation questionnaire that Savannah filled out in the waiting room.
Then, Dr. Hill tells you, “I think you are ready to go meet Savannah and her mother.”
You enter the room and see Savannah, a tall, athletic, 16-year-old, sitting with her mother.
You introduce yourself and explain, “Dr. Hill and I have been reviewing your sports pre-participation questionnaire together.
Would it be okay if I begin talking with you today, before Dr. Hill comes in?”
“Also, after the three of us spend some time talking together, I am going to take some time to talk with Savannah alone. Is this okay?”
“Yes. Dr. Hill has always been very good about taking time to talk with Savannah without me, so I’ll just step out for a bit.”
After reviewing and confirming the questionnaire as well as completing a brief medical history, you find that Savannah has no health problems that would limit participation in softball this year. To help put Savannah at ease, you talk with her a bit and discuss her hopes of being selected for the pitching rotation and batting higher in the order.
You then turn to Leslie and ask, “Would you mind if I speak with Savannah alone for a few minutes?” Leslie excuses herself from the room. With the HEEADSSS mnemonic in mind, you continue your conversation with Savannah.
“So, besides softball, tell me about school?”
“I’m having trouble with math, but I’m making mostly B’s and C’s in the other subjects. I’m going to try to get a softball scholarship at the junior college, and then maybe get a nursing degree.”
“Oh, really? What got you interested in nursing?”
“My younger brother has asthma and has been in the hospital a lot. He’s fine now, but I guess I just got interested in the medical field from helping my mom take care of him.”
“What do you and your friends do for fun?”
“Hmm … we mostly play softball and basketball. And sometimes we go to the mall in town.”
“Do any of your friends use drugs or alcohol?”
“Some have tried alcohol at parties. Not really any drugs. I don’t smoke either, but several of my friends do.”
During continued conversation, Savannah mentions several of her friends have begun to smoke cigarettes, but she does not like the taste of them. Similarly, neither she nor her female friends have experimented with dietary supplements or steroids, although she does know some on the baseball team that have tried them. She maintains a healthy diet and feels satisfied with her current weight and shape.
“Do you have a romantic relationship with anyone?”
“Yeah, I have been dating one of the baseball players for the past two years.”
“Has the relationship become sexual?”
“Yes. You don’t have to tell my mom this, do you?”
You explain to Savannah that everything here is confidential, while encouraging her to discuss things like this with her mother.
Savannah goes on to describe two other male sexual partners and says that she uses condoms “most of the time” but reports no other methods of contraception. She admits that the possibility of pregnancy worries her. She has had no sexually transmitted infections that she knows of.
“In this relationship or others, have you ever been pressured to do something sexually that you didn’t want to do?”
“No. Not really … I mean … I guess I would’ve preferred to take things slower in this relationship, what with our athletic and college goals and all, but I can’t say I was forced into sex.”
You then ask Savannah if she has any further questions and excuse yourself while she changes clothes for the physical exam.
On your way out the door, you remember that the preventive exam is an important opportunity to update immunizations. You tell Savannah, “By the way, Dr. Hill may recommend some shots today.” She responds with a groan, but she nods her head in assent.
You find Dr. Hill and present the interview and relevant findings, including your recommendations for Tdap, MCV, and varicella. You and Dr. Hill also conclude that as a sexually active woman under 24, she should be screened for chlamydia.
Dr. Hill praises you, “The adolescent interview can be challenging. You obviously developed a rapport with Savannah and conducted a thorough adolescent interview. How about if we go in together now and do the physical exam?”
After greeting Savannah, Dr. Hill walks you through a routine preparticipation sports physical exam. After she has finished the exam, Dr. Hill says, “Your examination shows that you are healthy. I have a few follow-up questions before your mom comes back in.”
“I understand that you are involved in a relationship. Have you ever felt any pressure to do something sexually, on a date or otherwise, that you didn’t want to do?”
Dr. Hill replies, “Well, if you ever feel unsafe or pressured, please don’t hesitate to contact me or my nurse. Anything you tell us is confidential. “Also, I would encourage you to speak with your mother about this relationship, if you feel comfortable. I’ve known you both for a long time, and I think that she would be an understanding mentor in this relationship.”
“I would like to recommend a few more things to you. Even though you haven’t had a sexually transmitted infection before, it is recommended that we test you for chlamydia.”
“Can we do that another day? I wasn’t expecting to have a female exam today.”
Dr. Hill replies, “Actually, that’s a good point. We can definitely defer your female pelvic exam and Pap test until you are 21 or until something else arises requiring this exam. We can, however, test for chlamydia with a urine sample.”
“Last question: have you considered using any form of birth control?”
After discussing various options of birth control, Savannah indicates that she wants to start Depo-Provera because it will be easier than “remembering to take pills every day,” but wants the chance to go home and discuss things with her mother first. She plans to schedule her follow-up visit with you in a week, and will let you know her final decision then.
You refer her to familydoctor.org for more information on contraceptive options.
You let Savannah know that she needs three vaccines today, and that the varicella vaccine is a live, attenuated vaccine and ideally would feature a one-month period before she conceived, so the birth control discussion really is important and relevant. You also mention that if her plans change and she decides to not start depo, the chances of her becoming pregnant are higher and in that case, she may want to consider taking a daily prenatal vitamin.
After bringing Savannah’s mother, Leslie, back for an update on the sports physical and the immunizations, the visit is concluded. Savannah plans to call for a follow-up visit after talking with her mother.
Adolescent Health Counseling and Screening: Preventing Sexually Transmitted Infection and Unintended Pregnancy
Counsel all sexually active adolescents regarding contraception.
· Options include: oral contraceptives, medroxyprogesterone (Depo-Provera) injections, long-acting reversible contraceptives such as implantable options and IUDs, as well as the vaginal ring (NuvaRing)
· Remind patients these options do not protect against sexually transmitted infections
· Discuss condoms and abstinence
· Discuss emergency contraception
· Recommend folic acid supplementation to prevent neural tube defects in the event of pregnancy
Two weeks later, Savannah returns to discuss her first Depo-Provera injection and chlamydia screening. When you go to see her, you notice Savannah is alone. You greet her and catch up a bit, and then you turn your attention to the ob-gyn and menstrual history.
“When did you begin having periods?
“I was 13 years old.”
“How long do they usually last?”
“They usually last three days and aren’t very heavy. I don’t have as much cramping as some people do.”
“When was your last normal menstrual period?”
“Five weeks ago.”
“Is that unusual for you, to miss a period?”
“Yes. I am very regular. I have periods every month. Do you think that I could be pregnant?”
You respond, “Well, missing a period is certainly one of the first signs of pregnancy, but that could be caused by several other things, too. Why don’t you tell me a few more things, then let me get Dr. Hill and we’ll ask her what the next step is. Then we’ll get a urine pregnancy test. Does that sound okay?”
Savannah nods in agreement.
Before leaving the room, you instruct her to not get changed because Dr. Hill may want to talk with her before she gets undressed.
Besides amenorrhea, which of the following are signs and symptoms of pregnancy? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Breast tenderness
· B. Cervix and vaginal walls have an increasingly purplish-blue hue
· C. Enlargement of the uterus
· D. Fatigue
· E. Fetal heart tones
· F. Fetal movement
· G. Nausea
· H. Softening of the cervix and uterus
· I. Urinary frequency
· J. Vomiting
The correct answers are A, B, C, D, E, F, G, H, I, J.
Signs and Symptoms of Pregnancy
Amenorrhea with fatigue, nausea, and/or vomiting as well as breast changes, including tenderness, are the classic presentations of pregnancy.
Urinary frequency can also occur. Although urinary frequency can be a normal symptom of pregnancy, the possibility of a UTI in a pregnant woman should also be considered.
Softening of the cervix is known as Goodell’s sign, while softening of the uterus is known as Hegar’s sign.
The bluish-purple hue in the cervix and vaginal walls is known as Chadwick’s sign and is caused by hyperemia.
Enlargement of the uterus can be detected by an experienced examiner as early as 8 weeks on bimanual exam. Around 12 weeks, the uterine fundus can be palpated above the symphysis pubis. Between 20 to 36 weeks of gestation, the uterine enlargement, measured in centimeters, approximates gestational age and will become a routinely elicited physical exam finding.
Fetal heart tones are typically elicited by hand-held Doppler between 10-12 weeks gestation.
Fetal movement or “quickening” is detected by the mother around 18-20 weeks of gestation.
Unfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report having missed a menses. Conversely, not every adolescent who misses a menses is pregnant because 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. We should also remember that 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.
After you update Dr. Hill on the interval history, you return to the exam room together.
Dr. Hill Greets Savannah:
“I heard about some of your concerns. How are you feeling?”
“I’m pretty nervous, Dr. Hill. I haven’t had intercourse since we talked. Really! Do you think that I could be pregnant?”
“It’s quite understandable and normal that you feel nervous under the circumstances. While pregnancy is one of the possibilities, that is not the only reason; therefore, I need to ask you a few more questions. Then, we can address your concerns and we can discuss management options. Would that be okay with you?”
“Yes, that would be great!”
“Have you had had any morning sickness or breast tenderness?”
“Yes, and I’ve just felt more tired than usual.”
“Savannah, after we last talked, did you ever talk to your mother or your father about your sexual relationship?”
“Yeah, and that’s the thing. The conversation didn’t go bad, it was just so intense. I can’t imagine turning around and telling them that I’m pregnant.”
“Does your partner know that you missed your period?”
“Oh, no. That’s going to be worse.”
“Do you feel safe in your relationship?”
“Oh, yes. I didn’t mean it that way.”
“Alright, I just wanted to be sure. You can always feel safe to share anything with me. So, listen, let’s take this a step at a time. First, why don’t you give me a urine sample so we can run a pregnancy test on it. We will also test your urine sample for chlamydia like we planned on doing. Then, we’ll have some information that we can sit down and review together.
Do you want your mother here for any part of this?”
“No, everything you’ve said sounds okay. No matter what we find, I really want to talk to her at home and not here. Thanks.”
You and Dr. Hill wait in the hall while Savannah collects a urine sample for the urinary human chorionic gonadotropin (UCG) testing and a urine PCR for chlamydia, and then returns to the exam room.
Calculating Estimated Gestational Age
Calculating the estimated gestational age (EGA) based on the last normal menstrual period (LNMP). Calculating the EGA in this manner is not only convenient but ubiquitous in clinical practice. Keep in mind, however, that the actual embryonic age (e.g., the age of the fetus since the date of conception) will typically be approximately two weeks less than the clinically calculated EGA based upon the LNMP.
The other calculation used in clinical practice—which patients care a great deal about—is the estimated due date.
Calculating the estimated due date (EDD—sometimes referred to as the estimated date of confinement or EDC) from the last menstrual period is a relatively simple process that can be done with an obstetric “wheel”, with an electronic calculator (e.g., http://www.mdcalc.com/pregnancy-due-dates-calculator ) or using Naegele’s Rule.
Naegele’s 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
For example, if a patient’s LNMP was 7/10/2009, then:
· 7/10/2010 (+1 yr)
· 4/10/2010 (-3 mo)
· 4/17/2010 (+1 wk)
Thus, the EDD is 4/17/2010.
There are a variety of error corrections to Naegele’s Rule and other ways to calculate the EDD in the first trimester that will be discussed later.
Dr. Hill says, “I can appreciate that you are in a difficult situation. Nevertheless, I think it is wise for you not to jump into making any decisions right this moment. I recommend that you take time to consider all of your options. It is a good idea for you to go home and talk to your parents and your boyfriend about this. Do you feel comfortable doing that?”
Savannah responds, “Yes, they will be upset, but I can talk to them.”
Dr. Hill continues, “Please feel free to call me if you have any questions. Even though I know that you are overwhelmed, you aren’t the first young woman to be in a similar situation. I can point you toward some people that can help and also to some good resources if you would like more information. I would like you to come back in one week. You can bring your parents or your boyfriend if you like, and we will discuss your options further then, when you have had a chance to think about things. All right?”
Savannah, although initially shaken, now appears reassured. She nods her head in agreement.
Dr. Hill concludes, “In the meantime, it is recommended to do a few blood tests today, just to make sure you don’t have any sexually transmitted infections like HIV, or other types of diseases that could affect pregnancy. Additionally, should you decide to continue your pregnancy, I would recommend taking a prenatal vitamin. Do you have any questions for me?”
Savannah replies, “No, that’s fine. Oh, and Dr. Hill. One more thing. The handout for the chickenpox vaccine said that I should not take the vaccine if I was planning on getting pregnant within the next month. I wasn’t planning on this. But what could happen to the baby? Why would they warn us about this?”
Dr. Hill replies, “That’s a good question, Savannah. Although a case of a birth defect in a fetus caused by the mother receiving the varicella vaccine has never been documented, getting the actual chickenpox illness naturally while pregnant has been attributed to some birth defects. So we are just really cautious. You don’t need to do anything. It is routine for us to report this to the health department. But I wouldn’t give this any more thought than this, okay?”
Savannah, “Fair enough. Thanks.”
Dr. Hill fills out a lab slip and hands it to Savannah. After you have directed her to the lab, she heads out.
Initial Pregnancy Laboratory Studies
· CBC is important to detect various nutritional and congenital anemias, and to detect platelet disorders.
· Hepatitis B surface antigen tests for hepatitis B, which is a major risk to the newborn. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)
· 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.
· RPR tests for syphilis, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus. Congenital infection is associated with several adverse outcomes, including:perinatal death, premature delivery, low birth weight, congenital anomalies, and active congenital syphilis in the neonate.
· Rubella immunity should be tested by assessing the presence of IgG antibodies. If the patient isn’t 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. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)
· Blood type to detect rhesus antibody presence. RH(D)-negative women should receive anti (D)-immune globulin to prevent hemolytic disease of the newborn.
· It is probably not necessary to test serum hCG as well as urine hCG to confirm pregnancy, in the setting of a positive urine hCG.
However, as early pregnancy urine hCG concentrations are lower than serum hCG concentrations, it is possible to have a positive serum hCG result, even with a negative urine hCG result.
Additionally, one must 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.
· An ultrasound would not be the best test to order at an early stage of pregnancy. For example, at five weeks estimated gestation, an embryo would typically not be seen. Furthermore, the results would be difficult to interpret without a serum quantitative beta human chorionic gonadotropin test (quantitative pregnancy test).
About one week later, the nurse, Mary, tells you, “Savannah called earlier complaining of vaginal bleeding. She said that she was not hurting, but she sounded worried. After talking with her I didn’t get the impression that her bleeding warranted going to the emergency room. I told her to go ahead and come here first. When Dr. Hill comes out of that room, tell her I’m going to go ahead and have Savannah in a gown. Oh, her mother is with her today too.”
As you are waiting on Dr. Hill, the nurse brings you Savannah’s labs from last week.
· CBC (WBC 8.4 x 103/mm3, Hgb 12.7 g/dl, Hct 37.4%, Plt 270)
· Rubella immune
· Hepatitis B surface antigen negative
· Blood type: O negative, Rh antibody negative
· RPR non-reactive
· HIV negative
· Gonorrhea / chlamydia PCR negative
A few moments later, Dr. Hill joins you and comments: “Obviously, I am concerned about this bleeding, but before we delve off into searching for the differential diagnosis and pathophysiological source, let’s remember some fundamentals. Two of the most urgent pieces of information about first-trimester bleeding are contained in the vital signs.”
· Temperature is 37.2 C (99 F)
· Pulse is 85 beats/minute
· Blood pressure is 98/66 mmHg
You and Dr. Hill greet Savannah and her mother, Leslie. Dr. Hill begins:
“How have you been, Savannah?”
“I’m okay, but I’ve been bleeding since Sunday.”
“How many pads have you had to change?”
“Only two or three per day, but I have noticed some clots. Is this bad?”
Leslie interjects, “Doctor, we are worried that this is a miscarriage. How will we know and is there anything that we can do?”
“I understand that is a concern. You should know that some sort of bleeding is relatively common during the first trimester. Incidentally, bleeding does not necessarily mean that you are having a miscarriage.”
Dr. Hill continues, “However, before I can give you a more educated answer about what may be the source of your bleeding, I need to ask you a few more questions, perform a brief examination, and perhaps obtain some diagnostic lab work and imaging.”
“Have you had any pain or cramping with this episode of bleeding?”
“Some. It has not been severe.”
“Have you fainted or been dizzy?”
“Okay, Savannah, I am going to need to do a pelvic exam in order to gather all the information we need to assess what is happening. I am going to insert a small plastic instrument called a speculum into your vagina to begin the pelvic examination. This instrument will allow me to see your cervix. Then, I will then use my gloved hand and examine your vagina, womb, and ovaries directly. If you are hurting or uncomfortable at any point, I want you to let me know. Are you ready?”
Savannah nods her head.
After washing her hands and applying gloves, Dr. Hill then approaches the patient as she described above and proceeds to a focused and appropriate physical exam.
· General: well-developed and athletic, but anxious adolescent
· CV: regular rate and rhythm, 2/6 soft decrescendo murmur in early systole
· Abdomen: normal bowel sounds on auscultation, non-tender during auscultation, and to both percussion and palpation; the uterine fundus was not palpable on the abdominal exam due to the gestation age
· Genital exam: external genital exam reveals a normal appearing labia without visible lesions and pubic hair that has been shaved. The speculum exam revealed minimal amount of fresh blood in the posterior fornix. The vaginal sidewall was found to be pink and moist, without obvious signs of trauma. The cervix revealed mild ectropion, no obvious masses or lesions, and appeared to be undilated. Both a wet prep and cultures for gonorrhea and chlamydia were obtained. On bimanual exam, the cervix was closed, the uterus was felt to be less than eight weeks size, and nontender. There were no obvious adnexal masses were palpable. Additionally, there was no unusual cervical motion tenderness nor adnexal tenderness.
As Dr. Hill re-drapes Savannah and helps her sit up, she informs her: “Savannah, I did see a little bit of blood, but nothing else I saw was conclusive… and that is not at all unusual. I would like to let you get dressed and do some diagnostic testing at this time. I think that we can get an ultrasound and some lab work done. If you have time to come back to the waiting room and sit for a little while, I think the results will be back this morning. That way we can review everything today.”
Recommended Laboratory Studies to Investigate First Trimester Vaginal Bleeding
· CBC: The main utility of the CBC is for the hemoglobin / hematocrit. The white blood cell (WBC) count is limited in its usefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have a mild leukocytosis. Nevertheless, 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 trichomonas, as well as PCR testing for gonorrhea and chlamydia: All sexually transmitted infections can cause vaginal bleeding. These tests should be obtained in this clinical context, despite a previously normal recent result.
· Progesterone: Laboratory testing for progesterone is most useful in extreme situations. If the result is >25, it is highly associated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage or ectopic 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 a higher use of surgical management and 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.
· Quantitative beta-human chorionic gonadotropin (quant. beta-hCG): This test has enormous significance, and when combined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can be challenging to interpret, especially without the ultrasound results. Human chorionic gonadotropin is secreted by the trophoblastic cells very early in embryonic life (day 7, post-ovulation). Additionally, 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). By the expected date of menses, the beta-hCG is usually > or = 100 mIU/mL.
Furthermore, in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first six to seven weeks of gestation. However, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 1500-1800. To detect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 mIU/mL. In both ectopic gestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during early gestation. Molar pregnancy and multiple gestations are both associated with higher-than-normal hCG levels.
Type and screen: Knowing the Rhesus status is critical, as all Rh negative women who are pregnant need to be given RhoGam during any episode of bleeding. However, this does not need to be repeated after initial type and screen, especially in a setting that does not appear that this is a major bleed. If the bleeding is of great volume, a type and screen would be warranted both for potential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the maternal circulation and with dosing RhoGam.
Later that morning, Savannah’s laboratory and imaging come back with the following results:
· CBC: WBC = 9.3 x103/μL (9.3 x109/L), Hgb = 12.1 g/dL (121 g/L), Hct = 36.3% (0.36), Platelets = 176000/mm3( 176 x109/L)
· Wet prep: no trichomonas, no yeast, no clue cells
· GC/chlamydia: pending
· Quantitative beta-hCG = 1492 mIU/mL
· Progesterone = 14.5 nmol/L
Transabdominal and transvaginal ultrasound report:
· No intrauterine pregnancy is noted
· Left ovarian cyst 3cm
· Cannot rule out ectopic pregnancy
Dr. Hill asks, “What do you think are the three most likely causes of Savannah’s vaginal bleeding?” Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Cervical abnormalities (e.g., excessive friability, malignancy, polyps, trauma)
· B. Ectopic pregnancy
· C. Idiopathic bleeding in a viable pregnancy
· D. Molar pregnancy (gestational trophoblastic disease)
· E. Spontaneous abortion (miscarriage)
· F. Vaginal trauma
DISCUSSING THE ULTRASOUND
After seeing the ultrasound, Savannah seems visibly relieved.
Dr. Hill asks her:
“Savannah, would you like me to show you and explain to you what I am seeing?”
“Your baby is now visible and you are hearing its heartbeat.”
Hear the heartbeat
“How do you feel?”
“I’ve been unsure about what to do about this pregnancy. We’ve talked about all the options, and I guess I had begun to think that I wanted to try to keep the pregnancy, but not seeing a baby last time has made it hard to know what to think. I’m just relieved and a little scared about the whole thing.”
“I think that you are a remarkable young woman, Savannah. You are brave, strong, intelligent, and you have a loving family, who are going to help you through this, whatever course of action you decide to pursue.”
As Dr. Hill helps Savannah cover herself and reposition, you print a photograph from the machine for Savannah. Dr. Hill explains that she would like to see Savannah in two to four weeks in follow-up for a routine prenatal visit. She reassures her and her mother about the ultrasound findings, but reminds them that if the bleeding returns, or there is significant pain, dizziness, lightheadedness, or fainting, that they should call her office or after-hours answering service. They will page her immediately. Finally, she reminds her to continue taking her prenatal vitamin daily.
Ten days later, you are covering the emergency room with Dr. Hill. The nurse approaches you to inform Dr. Hill that Savannah is here:
Nursing Note: Patient presenting with vaginal bleeding. Her mother says that she is two months pregnant. Her vitals signs are BP 105/75 mmHg, pulse of 90 beats/minute, and a temperature of 36.9 C (98.4 F).”
Dr. Hill thanks the nurse and asks you to accompany her. As you enter the room, Savannah recognizes you and begins to cry. She tells you she has been bleeding on and off for about an hour, with some clots, and a fair amount of pain, but when you ask she tells you she hasn’t had any dizziness or light-headedness.
Dr. Hill says, “Savannah, we need to examine your abdomen and cervix like we did a few weeks ago in the office. Like before, it will involve the speculum to allow us to see, then it will involve a hand in your vagina and another on your abdomen. Is it all right with you if the student performs the exam?”
Savannah responds, “That’s fine. I don’t have any questions yet.”
Dr. Hill assists you in performing a pelvic exam. You find:
Pelvic Exam: Some pooled blood in the vaginal vault. On both the speculum and digital exam, the os appears to be opened to about 1-2 cm. Her abdominal exam reveals normal bowel sounds on auscultation, no tenderness on palpation, and is soft.
Dr. Hill then states to Savannah and Leslie, “I’m going to ask the ultrasound technician to perform another ultrasound, that will allow me to assess the fetus’ heart rate. We should be able to obtain the ultrasound images through your lower abdomen this time.”
Several minutes later, you and Dr. Hill are called to the ultrasound room.
Abdominal Ultrasound: No detectable fetal heart rate. The fetus’ crown-rump length measures 0.65 cm, or approximately 6w4d gestation, similar to the last ultrasound.
“Savannah,” Dr. Hill begins, “your fetus does not have a heart beat. That means that the fetus has died. I’m sorry.”
Leslie gently but tearfully indicates that they would like a few moments alone.
Dr. Hill excuses you and herself from the room so you may discuss the findings, promising to return in a moment.
In the hallway, Dr. Hill asks you,
“What do you think are the key findings?”
Dr. Hill replies, “That’s right. So, based on these key findings, what do you think is our diagnosis?” Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Complete abortion
· B. Incomplete abortion
· C. Inevitable abortion
· D. Missed abortion
· E. Septic abortion
· F. Threatened abortion
The correct answer is C.
Spontaneous abortion is the loss of a pregnancy without outside intervention before 20 weeks’ gestation. Spontaneous abortions can be subdivided into:
· Threatened abortion: bleeding before 20 weeks gestation.
Threatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is, in some ways, a “catch-all” descriptive diagnosis.
· 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 dilitation 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.
Savannah’s situation is most compatible with an inevitable abortion (B). Her vaginal bleeding is associated with a dilated cervix, distinguishing this situation from a mere threatened abortion or missed abortion where there is usually no uterine activity. Yet, no products of conception have been expelled, distinguishing Savannah’s condition from both complete and incomplete abortions. Finally, there are no findings to suggest a septic abortion.
What are the management options for an inevitable abortion? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Expectant management
· B. Medical therapy
· C. Surgical management
The correct answers are A, B, C.
Management of Inevitable Abortion
In the setting of an inevitable (or similarly, an incomplete) spontaneous abortion, the traditional choices for management are expectant management or surgical management.
Expectant management means watchful waiting with precautions regarding unusual amounts of bleeding or pain, or fever, and is effective in over 75% of cases in this setting. The disadvantage with this course of action is that it can take up to a month for the products of conception to be completely expelled. This timeframe might not normally be a problem, but a spontaneous abortion is usually complicated by sadness, grief, and even guilt. Expectant management can delay emotional closure. Nevertheless, this is a viable course of action.
Surgical options include dilation and curettage (D&C), with or without vacuum aspiration, or manual or electric vacuum aspiration. These choices depend on a variety of factors, including primarily local resources and the surgeon’s preference and experience. The main indication for suction D&C is unusually heavy bleeding and patient preference. The main contraindication is active pelvic infection and patient refusal.
Medical management, despite being off-label, 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%, and the time to completion is generally three to four days (but may take up to two weeks), as opposed to two to six weeks with expectant management.
Finally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given previously, it should now be administered.
When you and Dr. Hill present these options to Savannah, she chooses medical management. Dr. Hill places the vaginal misoprostol per the above protocol, the precautions and side-effects to expect, and asks to see her back again in a week for follow-up.
About a week later, you are in the office with Dr. Hill, when Savannah is scheduled for a follow-up from her emergency room visit and misoprostol placement.
Savannah has brought her boyfriend, the father of the baby, to this visit. Upon questioning, she reports that about two days later, she had several hours of pain and bleeding, but it was not worse than her normal menstrual period.
Her vital signs are normal and her hemoglobin is 11.7 g/dL (117 g/L).
Her boyfriend asks:
“Did we do anything wrong? I mean, should we not have had sex? Would the baby have been okay if she hadn’t been playing softball?”
“You didn’t do anything wrong. There is nothing to suggest 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. You are not alone in this, it is very common: about one-third of all pregnancies end in miscarriage.”
Savannah says: “I’m sad that my baby miscarried, but I’m also really relieved, and I feel guilty about that. Is that wrong? You know, I really want to finish school first, but I think that I do want to have children.
Will I have another miscarriage?”
Savannah says, “No, I think we’ll be okay. Thank you both for all of your help, though.”
Dr. Hill reminds Savannah, “You were considering Depo-Provera for birth control. Would you like us to get you started on that today?”
Savannah blushes, “How could I forget about that?! Yes, it would be a good idea to start it today.”
Dr. Hill encourages Savannah to return with any questions she may come up with, or if she finds herself having trouble dealing with the grief. You wish Savannah luck, and she and Jim head out the door to the nurse for the Depo-Provera.
Spontaneous Abortion: Incidence, Causes, and Recurrence
Miscarriages are very common: about one-third of all pregnancies end in miscarriage.
Women who have a spontaneous abortion and their partners frequently struggle with guilt about their role in the loss. Physicians should address the issue of guilt with their patients and allay any concerns that they may have “caused” the spontaneous abortion. There is no proof that stress or physical / sexual activity causes miscarriage. About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities.
Most women (87 percent) who have miscarriages have subsequent normal pregnancies and births.