Can Internal Exam Be Performed in Threatened Abortion?
Yes, an internal pelvic examination can be performed in threatened abortion, but it is not routinely necessary for diagnosis or initial management, as transvaginal ultrasonography is the diagnostic method of choice and provides superior information about fetal viability without requiring a speculum or bimanual examination. 1
When Internal Examination Is Indicated
A complete pelvic examination is always indicated in cases of lower abdominal pain to identify the source of pain, which may be caused by pelvic inflammatory disease, ovarian mass or torsion, and/or normal or ectopic pregnancy. 2
Specific Clinical Scenarios Requiring Examination:
Persistent symptomatic vaginal discharge warrants a speculum examination, though vaginal swabs can be obtained by either the provider or patient without full pelvic exam. 2
Evaluation of lower abdominal pain requires examination to differentiate between threatened abortion and other causes such as ectopic pregnancy, ovarian torsion, or pelvic inflammatory disease. 2
Assessment of cervical status may require speculum examination when determining whether the cervix is open (indicating inevitable or incomplete abortion) versus closed (consistent with threatened abortion). 3
When Internal Examination Is NOT Necessary
Transvaginal ultrasonography is the diagnostic method of choice to confirm fetal viability and detect the presence of subchorionic hematoma, and should also rule out other complications such as ectopic pregnancy. 1
Key Points About Avoiding Unnecessary Examination:
A speculum or bimanual examination is now considered unnecessary before prescribing most forms of contraception, as there is nothing that would be found on pelvic examination that would be a contraindication to prescribing hormonal contraception. 2
Pelvic examinations are not needed routinely to provide contraception safely to a healthy client, unless inserting an intrauterine device (IUD) or fitting a diaphragm. 2
Ultrasound provides superior diagnostic information without the need for internal examination in most cases of threatened abortion, demonstrating viable pregnancies in approximately one-third of clinically diagnosed cases. 4
Diagnostic Approach Without Internal Exam
Serial ultrasound examinations should be performed to assess fetal growth and development in threatened abortion cases. 1
Ultrasound Findings Guide Management:
Transvaginal ultrasound can identify viable pregnancy (37.3% of cases), embryonic death (27.3%), anembryonic pregnancy (17.2%), molar pregnancy (2.2%), ectopic pregnancy (1.1%), complete abortion (5.2%), or inconclusive findings (9.7%) in patients presenting with vaginal bleeding. 4
Diagnostic ultrasound is excellent for accurate prognosis in threatened abortion, avoiding unnecessary operations and reducing hospitalization in suspected ectopic pregnancies. 5
The presence and size of subchorionic hematoma can be detected by ultrasound, with hematomas larger than 20 cm² associated with higher rates of spontaneous abortion. 6
Common Pitfalls to Avoid
Do not delay ultrasound imaging based on β-hCG levels below a discriminatory threshold, as ectopic pregnancies can present at almost any β-hCG level, and rupture has been documented at very low levels. 2
Do not assume that internal examination is required for diagnosis when ultrasound can provide definitive information about intrauterine pregnancy, fetal viability, and gestational age without the discomfort and potential risks of pelvic examination. 1, 5
Avoid performing internal examination if there is heavy bleeding until ultrasound evaluation has been completed, as the examination itself does not change immediate management and ultrasound provides more critical diagnostic information. 1
Special Considerations for Rh-Negative Patients
Administer 50 μg of anti-D immunoglobulin to Rh-negative women in all cases of documented first-trimester loss of established pregnancy to prevent Rh-D alloimmunization. 2, 1
Fetomaternal hemorrhage occurs in 48% of threatened abortion cases, with an overall rate of 32% in patients undergoing spontaneous abortion. 2
The American College of Obstetricians and Gynecologists states there is no evidence-based recommendation for anti-D immunoglobulin administration in threatened abortion with a viable fetus, and many physicians do not treat when there is a live embryo or fetus. 2, 1