GP · pregnancy-and-reproductive-health
Bleeding and pain in early pregnancy
Also known as First trimester bleeding · Threatened miscarriage · Pregnancy of unknown location
GP-fellowship guide to bleeding and pain in early pregnancy: the differential from threatened and missed miscarriage through ectopic (the can't-miss) and molar pregnancy, hCG trends and the discriminatory zone, management of miscarriage by expectant, medical and surgical routes with Cochrane equivalence data, methotrexate criteria for ectopic including two-dose evidence, anti-D indications, recurrent loss work-up and psychological follow-up.
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Red flags
- Shoulder-tip pain with peritonism in early pregnancy = ruptured ectopic until proven otherwise — emergency admission, not scan-queue
- hCG above the discriminatory zone with an empty uterus on transvaginal scan is an ectopic until located — do not label PUL and discharge without follow-up
- The grape-like vesicles of a molar pregnancy or hCG far higher than dates demands histology — every products of conception goes to pathology
Overview
First-trimester bleeding is a common reason for urgent GP and early-pregnancy-unit review. The GP's job is triage: exclude ectopic (can kill), stage the miscarriage (threatened, inevitable, missed, complete), and detect molar disease. Psychological care runs alongside — miscarriage carries depression and anxiety consequences that outlast the physical event.[4]
References6ShowHide
- [1]Solangon SA, Van Wely M, Van Mello N, et al. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: an individual participant data meta-analysis Acta Obstet Gynecol Scand, 2023.PMID 37345445
- [2]Jurkovic D, Memtsa M, Sawyer E, et al. Single-dose systemic methotrexate vs expectant management for treatment of tubal ectopic pregnancy: a placebo-controlled RCT Ultrasound Obstet Gynecol, 2017.PMID 27731538
- [3]Alur-Gupta S, Cooney LG, Senapati S, et al. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis Am J Obstet Gynecol, 2019.PMID 30629908
- [4]Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage Cochrane Database Syst Rev, 2012.PMID 22419288
- [5]Seckl MJ, Sebire NJ, Berkowitz RS Gestational trophoblastic disease Lancet, 2010.PMID 20673583
- [6]de Haas M, Finning K, Massey E, et al. Anti-D prophylaxis: past, present and future Transfus Med, 2014.PMID 25121157