EXERCISES: EARLY PREGNANCY LOSS MANAGEMENT

EXERCISE 8.1

Purpose: To practice person-centered management in early pregnancy loss.

1. A 25-year old patient you have been seeing for 5 years presents for an urgent visit. Past history includes irregular periods, which you have managed with OCPs. They report not having had a period for 7 weeks, and now are having abdominal cramping and moderately heavy bleeding, up to a pad every hour. Urine hCG is positive.
   1. How would you proceed with their 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?

See Teaching Points

2. A 38-year-old G2 P1 patient is seeing you in clinic for vaginal bleeding. They are sexually active with a partner who makes sperm, and using condoms intermittently. They began having vaginal bleeding 5 days ago, and it is now decreasing. Their last menstrual period was 8 weeks ago. Urine pregnancy test is positive. They bring in tissue and you see 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?

See Teaching Points

3. A 24 yo G1P0 patient with vaginal spotting for 2 days. They are in a relationship with one partner and are interested in becoming pregnant. The last menstrual period was 6 weeks 2 days ago and the urine hCG is positive. They deny abdominal pain or passage of tissue. The patient is tearful and distraught.
   1. Does this patient need an ultrasound? How would you assess them without the use of ultrasound?
   2. On examination, 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. You are able to obtain a transvaginal US, which shows Mean sac diameter of 16mm with a yolk sac and no embryo. How do you interpret these results? What are the next steps in evaluation?
   3. An hCG level drawn at the initial evaluation is 4000. The hCG done 48 hours later is 3200. What is the next step?
   4. A repeat ultrasound was done 12 days after the initial ultrasound showed a mean sac diameter was 26mm with a yolk sac and no embryo. How do you interpret these results?
   5. If EPL is confirmed and completed, what kind of patient support may be of use?

See Teaching Points

4. A 29 yo patient at 10 weeks by LMP calls in for a telehealth visit for vaginal bleeding. The patient had a visit 3 weeks ago confirming a viable intrauterine pregnancy, and intends to continue the pregnancy. Upon reviewing medical history, the patient discloses weekly cocaine use, and wants to know if they should go to the emergency room to see if this is an early pregnancy loss, but has fears about legal consequences of their substance use during this pregnancy. How would you manage and advise this patient?

See Teaching Points