In a 17‑year‑old primigravida at 9 weeks gestation presenting with mild vaginal bleeding and abdominal cramping, with a viable intrauterine pregnancy confirmed on transvaginal ultrasound, what is the most appropriate next step in management?

Pelvic Assessment is the Most Appropriate Next Step

In a 17-year-old primigravida at 9 weeks gestation with mild vaginal bleeding and cramping but a confirmed viable intrauterine pregnancy, the most appropriate next step is pelvic assessment with speculum examination to identify the bleeding source and evaluate cervical status.

Rationale for Pelvic Assessment

The clinical scenario represents threatened abortion—first trimester bleeding with a viable intrauterine pregnancy and closed cervical os. 1

Key Diagnostic Goals of Pelvic Examination

• Speculum examination identifies the bleeding source, distinguishing between cervical pathology (polyps, cervicitis, trauma) versus uterine bleeding, which have different prognostic implications. 1

• Assessment of cervical os status is essential: A closed cervical os supports threatened abortion with better prognosis (approximately 80-90% continue to viable delivery), while an open os suggests inevitable or incomplete abortion requiring different management. 1

• Any woman with abnormal premenopausal bleeding should undergo appropriate components of pelvic examination to identify benign or malignant disease, even when ultrasound has already confirmed intrauterine pregnancy. 2

Why Other Options Are Inappropriate

Hospital Admission (Option B) is Premature

• Threatened abortion is managed expectantly on an outpatient basis when the patient is hemodynamically stable, has mild bleeding, and ultrasound confirms viability. 1

• Admission would only be indicated for heavy bleeding, hemodynamic instability, severe pain, or inability to follow up—none of which are present in this stable patient with mild symptoms. 1

Ultrasound for Placental Localization (Option C) is Irrelevant

• Placental localization for previa assessment is not relevant at 9 weeks gestation, as the placenta has not yet formed its final position and will migrate significantly during the second and third trimesters. 1

• Digital pelvic examination should be avoided in second and third trimester bleeding until placenta previa is excluded, but this concern does not apply to first trimester bleeding. 3

Intravenous Progesterone (Option D) Has No Evidence Base

• Progesterone supplementation provides no benefit in women without prior recurrent miscarriage history presenting with threatened abortion. 1

• Treatment of threatened abortion is expectant management, not hormonal intervention. 1

• There is no indication for intravenous progesterone in routine threatened abortion management, and this route is not standard of care even when progesterone is indicated (oral or vaginal routes are used in recurrent loss populations). 1

Clinical Algorithm for This Patient

1. Perform speculum examination to visualize the cervix, assess cervical os status (open vs. closed), and identify any cervical pathology (polyps, cervicitis, lacerations). 1, 2

2. If cervical pathology is identified (e.g., friable cervix, polyp, cervicitis), provide appropriate treatment such as polyp removal or cervicitis management. 1

3. If examination shows closed cervical os with no identifiable cervical source, diagnose threatened abortion and provide expectant management with outpatient follow-up. 1

4. Provide reassurance that with a viable intrauterine pregnancy at 9 weeks and closed cervical os, approximately 80-90% of threatened abortions continue to term. 1

5. Arrange follow-up ultrasound in 1-2 weeks to confirm continued viability if bleeding persists or patient remains anxious. 1

Important Clinical Pitfalls to Avoid

• Do not omit pelvic examination simply because ultrasound has confirmed intrauterine pregnancy—the examination provides critical information about cervical status and bleeding source that ultrasound cannot provide. 1, 2

• Do not prescribe progesterone without evidence of recurrent pregnancy loss, as this provides no benefit and may give false reassurance. 1

• Do not admit stable patients with threatened abortion, as this increases healthcare costs without improving outcomes. 1

• In one prospective study of 50 patients with early pregnancy complaints and confirmed intrauterine pregnancy on ultrasound, pelvic examination did not change immediate obstetric management in any case, though it did identify occult cervical infections in 2.5% of patients. 4