What is the diagnosis and management for a 22-year-old woman at 9 weeks gestation with mild, bright red vaginal bleeding, no associated pain or clotting, and a closed cervix on speculum examination, with a history of normal antenatal blood results and a normal dating scan two weeks ago showing an intrauterine pregnancy?

Threatened Abortion (Threatened Miscarriage)

This patient has a threatened abortion, characterized by first-trimester vaginal bleeding with a closed cervix and confirmed viable intrauterine pregnancy. 1

Diagnosis

The clinical presentation meets all criteria for threatened abortion:

• Confirmed viable intrauterine pregnancy with fetal cardiac activity documented on dating scan two weeks ago at 7 weeks gestation 1
• Closed cervix on speculum examination, which distinguishes this from inevitable or incomplete abortion 1
• Mild vaginal bleeding without passage of tissue or clots 1
• No pain, which helps differentiate from other complications like ectopic pregnancy or placental abruption 1

This presentation occurs in 7-27% of all pregnancies, with an overall miscarriage risk of approximately 12%. 1 The presence of previously documented fetal cardiac activity is a reassuring prognostic sign. 1

Immediate Management

Primary Diagnostic Step

Obtain transvaginal ultrasound immediately as the primary diagnostic tool to:

• Confirm continued fetal cardiac activity and viability 1, 2
• Assess for subchorionic hematoma, a common associated finding 1, 2
• Measure crown-rump length to ensure appropriate growth since the prior scan 3
• Exclude early pregnancy loss using established criteria (embryonic CRL ≥7 mm without cardiac activity would be diagnostic of loss) 3

Additional Testing

• Quantitative beta-hCG level should be obtained regardless of ultrasound findings to establish baseline and guide interpretation 2
• Complete blood count to assess hemoglobin if bleeding becomes moderate to heavy 2
• Rh status must be confirmed, as anti-D immune globulin is warranted for all Rh-negative patients with first-trimester bleeding 4

Follow-Up Care

Schedule follow-up ultrasound in 1-2 weeks to confirm continued viability and appropriate fetal growth. 1, 2

Patient Counseling

Counsel the patient that first-trimester bleeding increases risk of:

• Preterm delivery 1
• Placental abruption later in pregnancy 1
• Small for gestational age infants if the pregnancy continues 1

However, emphasize that the presence of fetal cardiac activity significantly improves the prognosis. 1

Critical Pitfalls to Avoid

• Never perform digital pelvic examination before ultrasound imaging, as this can precipitate catastrophic hemorrhage if placental abnormalities exist (though less likely at 9 weeks, this principle applies throughout pregnancy) 2, 5
• Do not assume ectopic pregnancy is completely excluded despite the prior intrauterine pregnancy confirmation—heterotopic pregnancy occurs in <1% of spontaneous conceptions but remains possible 2
• Avoid overinterpretation of a single ultrasound that could lead to inappropriate intervention potentially harming a normal early pregnancy 2
• Ultrasound may miss up to 74% of ectopic pregnancies initially, making serial beta-hCG monitoring critical if the current ultrasound becomes non-diagnostic 2

What This Is NOT

• Not incomplete abortion because there is a confirmed viable intrauterine pregnancy, whereas incomplete abortion involves partial passage of products of conception with retained tissue 1
• Not inevitable abortion because the cervix remains closed 1
• Not ectopic pregnancy given the confirmed intrauterine pregnancy two weeks ago, though heterotopic pregnancy remains theoretically possible 2