What is the most appropriate next step in management for a 40-year-old, gravida (number of times pregnant) 2, nulliparous (never given birth) woman at 14 weeks' gestation, presenting with light vaginal bleeding, lower abdominal discomfort, and elevated serum beta-human chorionic gonadotropin (β-hCG) concentration, with a history of spontaneous abortion?

From the Guidelines

The most appropriate next step in management for this patient is a transvaginal ultrasound. This recommendation is based on the patient's presentation with light vaginal bleeding, lower abdominal discomfort, and elevated serum beta-human chorionic gonadotropin (β-hCG) concentration at 14 weeks' gestation, which suggests a potential complication in the pregnancy that requires immediate evaluation. Given her history of spontaneous abortion and the current symptoms, it is crucial to determine the cause of the vaginal bleeding to guide further management and optimize outcomes for both the mother and the fetus.

According to the American College of Radiology Appropriateness Criteria 1, ultrasound, particularly transvaginal ultrasound, is usually appropriate for the evaluation of women with vaginal bleeding in pregnancy, as it can help identify the etiology of the bleeding, such as placenta previa, low-lying placenta, or other complications. The use of transvaginal ultrasound in this context is supported by evidence-based guidelines that consider the outcomes of pregnancies to be directly related to the specific etiology of the vaginal bleeding.

Key points to consider in the management of this patient include:

• The need for immediate evaluation of vaginal bleeding in pregnancy to determine the underlying cause
• The role of transvaginal ultrasound in providing detailed images of the uterus and placenta to guide diagnosis and management
• The importance of considering the patient's history of spontaneous abortion and current symptoms in selecting the most appropriate diagnostic approach
• The potential complications associated with vaginal bleeding in pregnancy, such as hemorrhage, preeclampsia, and gestational trophoblastic neoplasia, which underscore the need for prompt and accurate diagnosis.

Given these considerations, transvaginal ultrasound is the most appropriate next step in the management of this patient, as it offers a non-invasive means of quickly and accurately diagnosing the cause of vaginal bleeding and guiding further management to optimize outcomes for both the mother and the fetus 1.

From the Research

Diagnosis and Management

• The patient's symptoms, including light vaginal bleeding, lower abdominal discomfort, and elevated serum beta-human chorionic gonadotropin (β-hCG) concentration, suggest a possible ectopic pregnancy 2, 3, 4.
• Given the patient's history of spontaneous abortion and current symptoms, a transvaginal ultrasound (TVS) is the most appropriate next step in management to confirm or rule out an ectopic pregnancy 2, 3, 4.
• TVS has been shown to be a highly sensitive and specific diagnostic tool for ectopic pregnancy, and its use can help reduce the need for invasive diagnostic procedures and decrease surgical morbidity 2, 3, 4.

Ultrasound Evaluation

• The use of TVS can help identify an adnexal mass, which is a key finding in the diagnosis of ectopic pregnancy 2, 3, 4.
• TVS can also help evaluate the presence of a gestational sac, embryo, and fetal heart, as well as detect fluid in the rectal fossa of the uterus 4.
• The diagnostic accuracy of TVS has been shown to be higher than that of transabdominal ultrasound (TAS), with a lower misdiagnosis rate 4.

Management of Ectopic Pregnancy

• If an ectopic pregnancy is diagnosed, management options may include expectant or medical management, or surgical intervention 3.
• In cases where vasa previa is suspected, transvaginal ultrasound with color Doppler may be used to facilitate the diagnosis, and an elective Caesarean section may be offered prior to the onset of labor 5.