Workup for 11 Weeks Pregnant and Bleeding
The workup for an 11-week pregnant patient with vaginal bleeding should begin with a pelvic ultrasound regardless of beta-hCG levels to determine pregnancy viability and location, rule out ectopic pregnancy, and assess for subchorionic hemorrhage. 1, 2
Initial Assessment
History
- Quantify bleeding (light, moderate, heavy)
- Associated symptoms (cramping, pain, passage of tissue)
- Risk factors for ectopic pregnancy
- Previous pregnancy complications
- Trauma history
Physical Examination
- Vital signs to assess hemodynamic stability
- Abdominal examination for tenderness, guarding, or rebound
- Avoid digital pelvic examination until placenta previa is ruled out by ultrasound 1
Diagnostic Workup
Laboratory Tests
- Quantitative beta-hCG
- Complete blood count
- Blood type and Rh status
- Coagulation panel including fibrinogen 1
Imaging
- Transvaginal ultrasound is the primary imaging modality 1
- Confirm intrauterine pregnancy
- Assess fetal cardiac activity
- Measure crown-rump length
- Evaluate for subchorionic hematoma
- Rule out ectopic pregnancy
- Assess adnexal structures
Differential Diagnosis
Viable Intrauterine Pregnancy
- Threatened abortion (viable pregnancy with bleeding)
- Subchorionic hematoma
Non-viable Pregnancy
- Inevitable abortion
- Incomplete abortion
- Missed abortion
Ectopic Pregnancy
- Tubal, cervical, or other non-uterine implantation
Other Causes
- Gestational trophoblastic disease
- Cervical lesions (polyps, erosion)
- Vaginal trauma or infection
Management Considerations
For Viable Intrauterine Pregnancy
- Approximately 90% of pregnancies with bleeding but confirmed fetal cardiac activity will continue to viability 3
- Risk of miscarriage increases with heavier bleeding (moderate/heavy bleeding has twice the risk compared to light bleeding) 3
- Presence of subchorionic hematoma increases miscarriage risk 2.6 times 3
For Suspected Ectopic Pregnancy
- Immediate obstetric consultation
- Surgical intervention may be necessary
For Non-viable Pregnancy
- Options include expectant management, medical management with misoprostol, or surgical evacuation
Special Considerations
- Anti-D immunoglobulin should be given to all Rh-negative pregnant patients with bleeding 1, 4
- Patients with moderate to heavy bleeding, significant pain, or concerning ultrasound findings should be admitted for observation
Follow-up
- For patients with continuing viable pregnancy, follow-up ultrasound in 1-2 weeks
- For patients with pregnancy of uncertain viability, serial beta-hCG measurements and repeat ultrasound
Pitfalls to Avoid
- Delaying ultrasound evaluation due to low beta-hCG levels
- Performing digital vaginal examination before ruling out placenta previa
- Misdiagnosing a pseudogestational sac as an intrauterine pregnancy
- Discharging patients without Rh immunoglobulin when indicated
- Failing to consider ectopic pregnancy in all cases until definitively ruled out
Remember that first-trimester bleeding occurs in 20-40% of pregnancies, and about half of these will continue to have viable pregnancies 5. However, prompt and thorough evaluation is essential to identify potentially life-threatening conditions such as ectopic pregnancy.