What is the best course of action for a female patient with abdominal pain and ongoing bleeding?

Immediate Management of 35-Year-Old Female with Lower Abdominal Pain and Ongoing Bleeding

This patient requires immediate assessment for ectopic pregnancy with urgent transvaginal ultrasound and quantitative β-hCG, regardless of hemodynamic stability, as up to 13% of symptomatic first-trimester patients with pain and bleeding are at risk for ectopic pregnancy. 1, 2

Initial Stabilization and Assessment

Assess hemodynamic stability immediately by evaluating the vital signs already obtained (BP 110/70, pulse 92) and looking for signs of ongoing hemorrhage including orthostatic changes, pallor, and altered mental status. 1, 2

• Establish IV access now, even though current vitals appear relatively stable, as this patient has ongoing bleeding with weakness suggesting possible volume depletion. 1
• Obtain immediate laboratory studies: quantitative β-hCG, complete blood count (hemoglobin/hematocrit to assess blood loss), blood type and Rh status, and coagulation studies if indicated. 1, 2
• Calculate weeks from LMP to determine gestational age - if approximately 7 weeks or more from amenorrhea, ectopic pregnancy risk is particularly elevated. 3

Critical Diagnostic Imaging

Perform transvaginal ultrasound immediately, regardless of β-hCG level. 1, 2 This is the single most important diagnostic step and should not be deferred.

• Transvaginal ultrasound is the preferred first-line imaging modality with 93% sensitivity and 98% specificity for detecting pregnancy complications. 2, 4
• Do not defer ultrasound because β-hCG might be "too low" - this is a critical pitfall that delays ectopic pregnancy diagnosis. 1, 2 Even with β-hCG below 1,500 mIU/mL, ultrasound provides valuable risk stratification information despite only 33% sensitivity for intrauterine pregnancy at these levels. 1
• Ultrasound will identify: intrauterine pregnancy (confirming viability), ectopic pregnancy (extrauterine gestational sac), free fluid in pelvis (suggesting rupture), or indeterminate findings requiring close follow-up. 5, 4

Specific Management Based on Findings

If Ectopic Pregnancy Confirmed or Highly Suspected:

• Immediate obstetrics/gynecology consultation for surgical versus medical management decision. 2
• If hemodynamically unstable or signs of rupture (free fluid, peritoneal signs), proceed to emergency laparoscopy/laparotomy. 5
• If stable with unruptured ectopic, medical management with methotrexate may be considered by obstetrics. 5

If Intrauterine Pregnancy with Threatened Abortion:

• Administer anti-D immunoglobulin (RhoGAM) if patient is Rh-negative - this applies to threatened abortion, complete abortion, or ectopic pregnancy. 1, 2
• Provide reassurance if viable intrauterine pregnancy confirmed, as most first-trimester bleeding with viable pregnancy progresses normally. 4
• Arrange obstetric follow-up within 48-72 hours. 1

If Ultrasound Indeterminate:

• Arrange concrete follow-up within 24-48 hours with repeat β-hCG and ultrasound - failing to arrange this is a critical pitfall. 1, 2
• Provide explicit return precautions: worsening pain, increased bleeding, dizziness, syncope, shoulder pain (suggesting hemoperitoneum). 1
• Consider admission for observation if patient unreliable for follow-up or lives far from medical care. 5

Additional Differential Considerations

While ectopic pregnancy is the most critical diagnosis to exclude, also consider:

• Spontaneous abortion (threatened, incomplete, or complete) - most common cause of first-trimester bleeding. 3
• Ovarian pathology including hemorrhagic corpus luteum cyst or ovarian torsion - ultrasound will identify adnexal masses. 2, 4
• Pelvic inflammatory disease with tubo-ovarian abscess - ultrasound has 93% sensitivity for this diagnosis. 2
• Non-obstetric causes (appendicitis, urinary tract pathology) if pregnancy excluded. 4, 6

Critical Pitfalls to Avoid

• Never assume normal pregnancy based on low β-hCG alone without ultrasound confirmation. 1, 2
• Never defer ultrasound based on β-hCG level being "too low to see anything." 1, 2
• Never discharge without concrete follow-up plan within 24-48 hours if diagnosis remains uncertain. 1, 2
• Never forget Rh status assessment and anti-D immunoglobulin administration in Rh-negative patients with any first-trimester bleeding. 1, 2

Disposition

• Admit if: hemodynamically unstable, ruptured ectopic pregnancy, severe pain requiring IV analgesia, unreliable for follow-up. 5
• Discharge with close follow-up if: stable vital signs, pain controlled, reliable patient, concrete 24-48 hour follow-up arranged, explicit return precautions given. 1, 2