What should be done for a pregnant patient at 4 months gestation experiencing sharp pain and slight bleeding?

Management of Sharp Pain and Bleeding at 4 Months Gestation

Perform immediate transvaginal ultrasound to establish fetal viability, exclude placental abruption, and rule out placenta previa before any digital pelvic examination. 1, 2

Immediate Assessment and Diagnostic Workup

Critical First Steps

• Obtain transvaginal ultrasound immediately as the primary diagnostic tool, which provides superior resolution for pregnancy assessment and can identify intrauterine pregnancy, placental location, and signs of abruption. 2
• Avoid digital pelvic examination until ultrasound excludes placenta previa, low-lying placenta, and vasa previa, as examination before imaging can precipitate catastrophic hemorrhage. 2
• Assess hemodynamic stability by checking blood pressure, heart rate, and orthostatic vital signs to identify occult hemorrhage. 3

Laboratory Evaluation

• Order complete blood count to establish baseline hemoglobin and assess for anemia from blood loss. 2
• Obtain quantitative beta-hCG level regardless of ultrasound findings to correlate with gestational age and assess pregnancy viability. 2
• Consider coagulation studies only if there is concern for underlying bleeding disorder, not routinely indicated for simple first or second trimester bleeding. 2

Management Based on Ultrasound Findings

If Viable Intrauterine Pregnancy Confirmed

• Provide reassurance and implement conservative management, as approximately 50% of patients with bleeding in pregnancy continue to have successful pregnancies. 1
• Schedule follow-up ultrasound in 1-2 weeks if bleeding persists or patient remains anxious to confirm continued viability. 1
• Counsel patient to return immediately for severe pain, heavy bleeding, dizziness, or passage of tissue, which are signs of progression to inevitable abortion or other complications. 1

If Subchorionic Hemorrhage Identified

• Schedule follow-up ultrasound in 1-2 weeks to monitor resolution and confirm ongoing fetal viability. 2
• Advise pelvic rest (no intercourse, no tampons, no douching) until bleeding resolves, though evidence for this is limited. 1

If Placental Abruption Suspected

• Activate emergency protocols immediately if patient shows signs of hemodynamic instability (hypotension, tachycardia, severe pain). 3
• Establish large-bore IV access and begin aggressive fluid resuscitation in patients with suspected abruption and hemodynamic compromise. 3
• Activate massive transfusion protocol and prepare for emergency cesarean section, as disseminated intravascular coagulation occurs in over 80% of severe abruption cases. 3

Contraindicated Interventions

Never administer uterotonic agents (oxytocin, methylergonovine) in the setting of a viable pregnancy, as these induce uterine contractions and would cause abortion of a wanted, viable pregnancy. 1

Common Pitfalls to Avoid

• Do not perform digital pelvic examination before ultrasound, as this can cause life-threatening hemorrhage if placenta previa or vasa previa is present. 2
• Do not be falsely reassured by normal fetal heart tones alone, as fetal status can deteriorate rapidly in placental abruption due to shunting of oxygenated blood away from the uterus. 3
• Do not delay ultrasound for laboratory results when clinical presentation suggests significant pathology. 3

Long-Term Counseling

Counsel patients that bleeding in pregnancy is associated with increased risk of preterm delivery, placental abruption later in pregnancy, and small for gestational age infants, even when the pregnancy continues successfully. 2, 4