What could be causing severe cramping, heavy bleeding, and passage of white membranous tissue with a small blood clot in a female with a history of prolonged menstrual period and strange watery discharge?

Immediate Evaluation for Possible Spontaneous Abortion or Pregnancy Complication

This patient requires urgent evaluation with pelvic ultrasound (transabdominal and transvaginal with Doppler) to assess for spontaneous abortion, retained products of conception, or ectopic pregnancy, as passage of white membranous tissue with severe cramping strongly suggests pregnancy loss. 1

Critical Initial Assessment

The clinical presentation—prolonged menstrual period, watery discharge, passage of white membranous tissue with blood clot, and severe cramping—is highly concerning for:

Most Likely Diagnoses

• Spontaneous abortion (miscarriage) is the primary consideration when white membranous tissue is passed with severe cramping, as this tissue likely represents decidual cast or products of conception 1, 2
• Incomplete abortion with retained products of conception (RPOC) should be suspected if bleeding and cramping persist after tissue passage, as RPOC appears as vascular endometrial mass on ultrasound 3, 1
• Ectopic pregnancy must be excluded immediately, as this is a life-threatening condition that can present with cramping, bleeding, and passage of decidual tissue without actual pregnancy expulsion 1, 2

Diagnostic Workup Algorithm

Step 1: Obtain quantitative serum β-hCG immediately to confirm pregnancy status, as this is essential before any imaging interpretation 1, 2

Step 2: Perform pelvic ultrasound (transabdominal and transvaginal with Doppler) to:

• Identify intrauterine pregnancy versus ectopic pregnancy 1, 3
• Assess for RPOC by detecting vascularity within thickened endometrial echo complex using Doppler 3, 1
• Evaluate for free fluid in pelvis suggesting ruptured ectopic pregnancy 1

Step 3: Assess hemodynamic stability by checking vital signs for tachycardia, hypotension, or orthostatic changes indicating significant blood loss 4, 2

Critical Red Flags Requiring Emergency Intervention

• Severe abdominal pain with peritoneal signs suggests ruptured ectopic pregnancy requiring immediate surgical evaluation 1, 2
• Heavy ongoing bleeding (soaking through pad per hour) indicates need for urgent intervention and possible transfusion 3
• Fever with foul-smelling discharge raises concern for septic abortion, which can be life-threatening and requires immediate antibiotics and evacuation 1
• Hemodynamic instability (tachycardia, hypotension) mandates immediate resuscitation and surgical consultation 4

Management Based on Diagnosis

If Incomplete Abortion with RPOC Confirmed

• Surgical evacuation (dilation and curettage) is typically required for symptomatic RPOC with ongoing bleeding and cramping 3, 1
• Doppler ultrasound improves diagnostic accuracy by identifying vascularity within retained tissue, distinguishing it from blood clots 3, 1

If Complete Abortion Suspected

• Serial β-hCG monitoring to confirm decline to undetectable levels, ensuring no retained tissue 1
• Follow-up ultrasound in 1-2 weeks if symptoms persist or β-hCG plateaus 1

If Ectopic Pregnancy Identified

• Immediate surgical or medical management depending on hemodynamic stability, β-hCG level, and ectopic mass size 1, 2
• Methotrexate therapy may be appropriate for hemodynamically stable patients with unruptured ectopic pregnancy meeting specific criteria 5

Important Caveats

• The passage of tissue does NOT confirm complete abortion—ultrasound verification is essential as decidual cast can be passed without actual pregnancy expulsion in ectopic pregnancy 1, 2
• Pain with urination may indicate bladder irritation from pelvic blood rather than urinary tract infection, particularly if ectopic pregnancy has ruptured 1
• Watery discharge preceding tissue passage may represent rupture of gestational sac or amniotic fluid leak in early pregnancy loss 2
• If patient has IUD in place, pregnancy with IUD carries increased risk for septic abortion and requires immediate IUD removal if strings visible 1

Immediate Next Steps

• Obtain β-hCG, complete blood count, blood type and screen before any intervention 2
• Perform pelvic ultrasound urgently (same day) to establish diagnosis 1, 3
• Ensure patient has emergency contact information and clear instructions to return immediately for worsening pain, heavy bleeding, fever, or syncope 1
• Avoid pelvic examination until ultrasound excludes placenta previa if patient could be beyond first trimester based on dates 1