Could the issue be something higher up in the uterus?

Intrauterine Pathology in Early Pregnancy

Yes, several conditions "higher up in the uterus" can cause first-trimester bleeding and symptoms, including retained products of conception, gestational trophoblastic disease, subchorionic hematoma, and congenital uterine anomalies. 1

Retained Products of Conception (RPOC)

RPOC is a common intrauterine cause of persistent bleeding after a nonviable pregnancy has been documented. The key diagnostic features include: 1

• Endometrial mass, focal endometrial thickening, or marked diffuse thickening on grayscale ultrasound 1
• Doppler flow detected within the endometrial abnormality strongly suggests RPOC 1
• Clinical context of continued bleeding or persistent/rising hCG after documented pregnancy loss 1

Gestational Trophoblastic Disease (GTD)

Complete molar pregnancy presents as a hyperechoic intrauterine area with multiple cystic spaces, though early first-trimester appearance may be variable. 1

Key distinguishing features:

• Classic "snowstorm" appearance may be absent in early first trimester 1
• Can mimic RPOC sonographically 1
• Partial molar pregnancy is more difficult to diagnose but should be considered if an embryo is present with cystic placental changes 1
• hCG is often (but not always) inappropriately elevated 1
• Definitive diagnosis requires histopathological evaluation 1

Subchorionic Hematoma

Subchorionic hematomas are intrauterine collections of blood between the chorion and uterine wall that commonly cause first-trimester bleeding in otherwise viable pregnancies. 1

• Identified on transvaginal ultrasound as anechoic or hypoechoic crescent-shaped collections 1
• Can coexist with normal intrauterine pregnancy 1
• Most resolve spontaneously without intervention 1

Congenital Uterine Anomalies

Uterine malformations, particularly septate uterus, can contribute to recurrent pregnancy loss and may be discovered during evaluation of bleeding or miscarriage. 2

• Septate uterus (partition dividing the uterine cavity) is associated with increased miscarriage risk 2
• 3D ultrasound or MRI confirms diagnosis 2
• Most CUAs do not prevent pregnancy but may increase complications 2

Critical Diagnostic Approach

For any suspected intrauterine pathology with bleeding, transvaginal ultrasound with grayscale and Doppler evaluation is the primary diagnostic modality. 1, 3

The evaluation should systematically assess:

• Presence or absence of intrauterine gestational sac with yolk sac or embryo 1, 4
• Endometrial thickness and characteristics (normal <8mm virtually excludes IUP; ≥25mm virtually excludes ectopic) 3
• Presence of intrauterine masses or abnormal echogenicity 1
• Doppler flow patterns within any endometrial abnormality 1
• Correlation with serial hCG levels 1, 5

Important Caveats

Never make management decisions based on a single ultrasound or single hCG value in hemodynamically stable patients. 1, 5, 4

• Guard against overinterpretation that could harm a normal early pregnancy 1, 5
• Follow-up imaging and serial hCG monitoring are essential when findings are indeterminate 5, 4
• Even with hCG >3,000 mIU/mL and no visible IUP, ectopic pregnancy must be excluded before assuming intrauterine pathology 1, 3