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Despite advances in prenatal care and pregnancy planning, pregnant women still die at a high rate in the United States. The U.S. pregnancy-related mortality rate remained between 12.0–16.8 deaths per 100,000 live births between 1998–2005.1 This staggering rate was higher than in previous decades.2–4 African-American women continue to experience a pregnancy-related death rate up to four times greater than white women.1
Acute complications of pregnancy can occur in all trimesters. These include emergencies such as ectopic pregnancy in the first trimester, pregnancy-induced hypertension in the second and third trimesters, and abruptio placentae in the third trimester. Many acute complications of pregnancy are accompanied by vaginal bleeding, and this month’s article uses a case-based approach to explore some of the more life-threatening. We will use the process of working through a differential diagnosis to show how to evaluate and weigh the evidence for and against the various etiologies of vaginal bleeding in the pregnant patient and arrive at a best guess for a diagnosis. The listed possible diagnoses are not meant to be inclusive, but to serve as a starting point for discussion of causes of vaginal bleeding in the pregnant patient.
Abdominal pain and vaginal bleeding in a 42-year-old female. Differential to consider: ectopic pregnancy, miscarriage (spontaneous abortion), pelvic inflammatory disease.
A 42-year-old African-American female presents conscious, alert and oriented in moderate distress complaining of abdominal pain. She describes a three-day history of pain described as a constant ache in her lower left quadrant and rated a 4 on a scale of 0–10. The pain is not associated with eating or movement. She also describes some mild vaginal bleeding over the same period that has required 1–2 feminine pads a day. The bleeding has been steady and not related to movement or sexual activity. She reports no pain, urgency or unusual frequency with urination. She denies any chest discomfort or pain, difficulty breathing, nausea, vomiting, dizziness, weakness or syncope.
The patient has had three previous full-term pregnancies without complication, then had a tubal ligation five years ago after the birth of her last child. Her last menstrual period (LMP) was 5 weeks ago, though she says it is not uncommon for her to be up to a week late. She says she and her husband have had sex since her last menses, “but there is no way I could be pregnant.” She has no significant medical history, is a social drinker and smokes half a pack of cigarettes a day.
Your clinical exam reveals pain with palpation to her lower quadrants bilaterally, though it is much worse on the left. No abdominal masses are palpable, though her abdomen is rigid as she involuntarily guards while palpation is performed. Her vital signs are heart rate 102/min. and regular; respiratory rate 18/min. with good tidal volume; blood pressure 114/70; pulse oximetry 97% on room air; tympanic temperature 98.9ºF (37ºC). Her blood glucose is 114 mg/dL.
An ectopic pregnancy is a complication in which the fertilized and developing embryo implants outside the uterus. Possible sites of implantation include the Fallopian tube (the most common site, termed a tubal pregnancy), ovaries, cervix and in the peritoneal cavity (see Figure 1). Ectopic pregnancies are not viable and represent a potential life threat to the mother.