What is the appropriate clinical notation and management plan for a patient at approximately 8 weeks gestation with a subchorionic hematoma that has increased in size from 3 cm to 4 cm, using Mod Med (Modern Medicine)?

Clinical Documentation for 8-Week Gestation Patient with Enlarging Subchorionic Hematoma

For a patient at 8 weeks gestation with a subchorionic hematoma that has increased from 3 cm to 4 cm, the primary impression should be "threatened abortion with subchorionic hematoma" (ICD-10: O20.0), with documentation emphasizing the enlarging nature of the hematoma and its associated risks for adverse pregnancy outcomes.

Primary Impression (ICD-10 Codes)

The impression section should include:

• O20.0 - Threatened abortion - Primary diagnosis given vaginal bleeding in early pregnancy with documented subchorionic hematoma 1
• O26.89 - Other specified pregnancy-related conditions - Secondary code for the specific finding of enlarging subchorionic hematoma 1
• Z3A.08 - 8 weeks gestation of pregnancy - Document exact gestational age 1

Assessment and Plan Documentation

Diagnostic Workup Completed Today

• Transvaginal ultrasound performed - Document fetal cardiac activity status (present/absent), as this is the most important prognostic factor 1
• Subchorionic hematoma measurements: Document exact size (4 cm), location relative to placenta, and comparison to prior imaging (previously 3 cm) 1
• Rh status verification - Critical for determining need for anti-D immunoglobulin 1

Orders and Interventions

Immediate interventions:

• Anti-D immunoglobulin (RhoGAM) 50 μg IM - Administer today if patient is Rh-negative to prevent alloimmunization 1
• Quantitative beta-hCG level - Baseline value for trending 2
• Complete blood count - Assess for anemia from bleeding 2
• Blood type and screen - If not already on file 2

Follow-up imaging orders:

• Repeat transvaginal ultrasound in 1-2 weeks - Monitor hematoma size progression and confirm fetal viability, as enlarging hematomas carry higher risk 3, 4
• Avoid pulsed Doppler ultrasound in first trimester - Use M-mode or video clips to document cardiac activity due to potential bioeffects on developing embryo 1

Management Plan

Activity and restrictions:

• Pelvic rest - No intercourse, no tampons, no douching until hematoma resolves 3
• Modified activity - Avoid heavy lifting and strenuous exercise, though strict bed rest is not evidence-based 3
• Monitor bleeding - Patient to track pad usage and report increased bleeding immediately 3

Medications:

• No proven pharmacologic treatment exists for subchorionic hematoma - Progesterone supplementation may be considered but lacks strong evidence 4
• Prenatal vitamins - Continue daily 4

Patient Counseling Documentation

Prognosis discussion:

• Counseled that presence of fetal cardiac activity is the most important favorable prognostic factor 1
• Discussed that enlarging hematomas (3 cm to 4 cm) carry increased risk for adverse outcomes including miscarriage, though many pregnancies with SCH proceed normally 3, 4
• Explained that subchorionic hematomas occur in 7-27% of pregnancies and most resolve spontaneously 1

Warning signs requiring immediate evaluation:

• Heavy vaginal bleeding - Soaking more than 2 pads per hour for 2 consecutive hours 3
• Severe abdominal pain or cramping - Beyond mild cramping 3
• Fever >100.4°F - May indicate infection 3
• Dizziness, lightheadedness, or syncope - Signs of significant blood loss 3

Potential complications discussed:

• Risk of pregnancy loss - Higher with enlarging hematomas, though exact risk difficult to quantify 3, 4
• Preterm birth risk - If hematoma persists into second/third trimester 3
• Preterm prelabor rupture of membranes - Associated with larger hematomas 3
• Fetal growth restriction - Rare but possible with large persistent hematomas 3, 5

Reassurance provided:

• Many pregnancies with subchorionic hematoma result in healthy term deliveries 4
• Close monitoring allows early detection of complications 3

Follow-Up Plan

Scheduled appointments:

• Return in 1-2 weeks for repeat ultrasound - Assess hematoma size and fetal viability 3
• Establish routine prenatal care if not already done - First prenatal visit should occur by 10-12 weeks 1
• Serial ultrasounds every 2-4 weeks until hematoma resolves or stabilizes 3

Contact instructions:

• 24/7 access to on-call provider for warning signs 3
• Return to emergency department for heavy bleeding, severe pain, or concerning symptoms 3

Clinical Pitfalls to Avoid

• Do not perform pulsed Doppler in first trimester - Use alternative methods to document cardiac activity 1
• Do not miss Rh-negative status - Anti-D immunoglobulin must be given with any first trimester bleeding 1
• Do not provide false reassurance - Enlarging hematomas warrant closer surveillance than stable small ones 3
• Do not delay follow-up imaging - Growth from 3 cm to 4 cm requires reassessment in 1-2 weeks, not routine 4-week interval 3