CHAPTER 8 EXERCISES: EARLY PREGNANCY LOSS MANAGEMENT

EXERCISE 8.1: Purpose: To review key steps in early pregnancy loss evaluation, counseling and management.

1. A person at 7 weeks LMP presents for an urgent visit reporting moderately heavy bleeding (saturating 1 pad/hour) and abdominal cramping. Past history includes irregular periods, managed with OCPs. Urine hCG is positive.
   1. How would you proceed with evaluation?
   2. How would you counsel while waiting for results?
   3. If an ultrasound reveals an intrauterine pregnancy with the presence of fetal cardiac activity, how would you discuss the result?
   4. How would your counseling differ if the person travelled to see you from somewhere with abortion bans?

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2. A person at 8 weeks by LMP is seeing you in clinic for vaginal bleeding for 5 days, now decreasing. They are sexually active and use condoms intermittently. Urine pregnancy test is positive. They bring in tissue with a gestational sac and chorionic villi.
   1. How would you proceed with evaluation?
   2. How would you respond to the following questions:
      • “Was this miscarriage my fault?”
      • “Will this happen again?”
   3. What other evaluation or management would you initiate? When can they attempt to conceive again?

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3. A person is 6 weeks by LMP with vaginal spotting for 2 days but no abdominal pain or passage of tissue. They have been trying to get pregnant with their partner. Urine hCG is positive.
   1. Does this person need an ultrasound? How would you assess them without ultrasound?
   2. On exam, you find a closed cervical os, no gestational tissue, and a nontender uterus consistent with 6-week gestation in size without adnexal tenderness or enlargement. A transvaginal ultrasound shows an intrauterine gestational sac with a MSD of 16 mm with a YS and no embryo. How do you interpret these results? What are the next steps in evaluation?
   3. An initial hCG is 4000, and 3200 48 hours later. What is the next step?
   4. A repeat US 12 days after the initial US shows a MSD of 26 mm with a YS and no embryo. How do you interpret these results?
   5. If EPL is confirmed and completed, what kind of person-centered support may be of use?
   6. How would your counseling be different if this person had 3 prior miscarriages?

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4. A person at 10 weeks by LMP calls in for a telehealth visit for vaginal bleeding. They had a positive pregnancy test and intend to continue the pregnancy, but their  bleeding concerns them for EPL given weekly cocaine use. They want to know if they should obtain an ultrasound, but have fears about legal consequences of their substance use during this pregnancy. How would you advise this person?

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