What is the approach for a 7-week pregnant patient experiencing spotting and cramping?

Management of Spotting and Cramping at 7 Weeks Gestation

Perform immediate transvaginal ultrasound to differentiate between viable intrauterine pregnancy, nonviable pregnancy, and ectopic pregnancy—this single test determines all subsequent management decisions. 1

Immediate Assessment Priorities

Critical Red Flags Requiring Emergency Evaluation

• Hemodynamic instability (tachycardia, hypotension, syncope) suggesting ruptured ectopic pregnancy 1
• Severe unilateral pelvic pain with peritoneal signs indicating possible ectopic rupture 1
• Heavy vaginal bleeding (soaking through pad in <1 hour) 2

Obtain Quantitative β-hCG Level

• Draw serum β-hCG simultaneously with ultrasound scheduling 1
• At 7 weeks gestation, β-hCG should be >10,000-20,000 mIU/mL and a gestational sac with fetal pole should be visible on transvaginal ultrasound 1
• If β-hCG is positive but ultrasound shows no intrauterine pregnancy, this defines "pregnancy of unknown location" (PUL) and requires serial β-hCG monitoring 1

Ultrasound Findings and Management Algorithm

If Viable Intrauterine Pregnancy Confirmed

• Gestational sac with fetal pole and cardiac activity visible 1
• Reassure the patient: Spotting occurs in 24% of early pregnancies, and when accompanied by cramping, the cumulative incidence of pregnancy loss is approximately 27% for cramping alone versus 52% for vaginal bleeding alone 2
• Provide expectant management with pelvic rest (no intercourse, no tampons) 3, 4
• Schedule follow-up ultrasound in 1-2 weeks to confirm continued viability 1
• Instruct patient to return immediately if bleeding becomes heavy (soaking pad in <1 hour) or pain becomes severe 3

If Nonviable Intrauterine Pregnancy (Miscarriage)

• Findings include: Empty gestational sac >25mm, fetal pole >7mm without cardiac activity, or previously documented cardiac activity now absent 1
• Offer three management options 1:
  • Expectant management (wait for spontaneous passage)
  • Medical management (misoprostol)
  • Surgical management (dilation and curettage)
• Monitor for retained products of conception (RPOC) if bleeding persists or β-hCG plateaus—ultrasound showing endometrial mass with Doppler flow suggests RPOC 1

If Ectopic Pregnancy Suspected or Confirmed

• Ultrasound findings: Extraovarian adnexal mass, free fluid with echoes (blood) in pelvis, or empty uterus with β-hCG >1,500-2,000 mIU/mL 1
• Do not diagnose ectopic based solely on absence of intrauterine pregnancy—positive findings are required to avoid inappropriate treatment 1
• Immediate obstetric consultation required for consideration of methotrexate (if hemodynamically stable, β-hCG <5,000, no cardiac activity, mass <3.5cm) versus surgical management 1, 3

If Pregnancy of Unknown Location (PUL)

• Definition: Positive β-hCG with no intrauterine or extrauterine pregnancy visible on transvaginal ultrasound 1
• Most common outcome (>70%): Early nonviable intrauterine pregnancy that will miscarry 1
• 7-20% risk of ectopic pregnancy (likely closer to 7%) 1
• Management if hemodynamically stable 1:
  • Repeat β-hCG in 48 hours (should rise >53% if viable IUP, fall if miscarrying, plateau or rise slowly if ectopic)
  • Repeat transvaginal ultrasound when β-hCG reaches discriminatory zone (1,500-2,000 mIU/mL)
  • Do not initiate treatment (medical or surgical) until diagnosis is clarified

Prognostic Indicators

Favorable Signs (Decreased Loss Risk)

• Presence of vomiting reduces pregnancy loss risk by approximately 50% (HR 0.51), even in the setting of vaginal bleeding 2
• Spotting only (versus light/moderate/heavy bleeding) 2

Unfavorable Signs (Increased Loss Risk)

• Vaginal bleeding increases loss risk 3.6-fold (HR 3.62) 2
• Bleeding with lower abdominal cramping increases loss risk 5-fold (HR 5.03) 2
• Severity of bleeding correlates with loss risk: 52% cumulative incidence with any bleeding, 81% with bleeding plus cramping 2

Critical Pitfalls to Avoid

• Never perform digital vaginal examination before ultrasound excludes placenta previa if gestational age is uncertain 5
• Do not rely on β-hCG level alone to exclude ectopic pregnancy—ultrasound correlation is mandatory 1
• Do not diagnose gestational trophoblastic disease (molar pregnancy) without histopathologic confirmation, as early complete moles can mimic retained products of conception 1
• Recognize that nausea alone (without vomiting) does not reduce pregnancy loss risk 2

Patient Counseling Points

• Approximately 28% of all pregnancies end in loss, with the majority occurring in the first trimester 2
• Spotting is common and does not always indicate pregnancy loss 4, 2
• Contact provider immediately for heavy bleeding (soaking pad in <1 hour), severe pain, dizziness, or shoulder pain (suggesting hemoperitoneum from ruptured ectopic) 3