Discomfort in the middle of the abdomen is more closely associated with spontaneous abortion; discomfort on a side of the abdomen is more closely associated with ectopic pregnancy. Risk factors for ectopic pregnancy or spontaneous abortion should also be considered.The physical examination includes assessing vital signs and performing an abdominal and pelvic examination. Signs of hemodynamic instability or peritonitis require emergent intervention. A pelvic examination may reveal non-obstetric causes of bleeding such as bleeding from the vagina or cervix. It may also show visible products of conception suggestive of an incomplete abortion.If the person is stable and a pelvic exam is unrevealing, transvaginal ultrasonography and/or serial measurement of hCG is generally recommended to assess fetal location and viability. Reviewed data from observational studies determined that ultrasound examination and hCG concentration could replace pelvic examination in the initial evaluation of early pregnancy bleeding. Transvaginal ultrasound is frequently used in the evaluation of bleeding in early pregnancy.Before 10 weeks gestation, a slower than normal increase in hCG suggests early pregnancy loss or ectopic pregnancy. By approximately 10 weeks, hCG plateaus and ultrasound is preferred to determine the location of the pregnancy (i.e., intrauterine or ectopic). In the presence of prior pelvic imaging, fetal heart tracing with Doppler sonography is sufficient to assess fetal viability beginning at 10–12 weeks of gestation. Bleeding associated with an intrauterine, viable pregnancy suggests threatened early pregnancy loss. Bleeding associated with an intrauterine, nonviable pregnancy suggests early pregnancy loss.
Medical uses
The fixed-dose combination is indicated for the treatment of early breast cancer (EBC):

Use in combination with chemotherapy for:the neoadjuvant treatment of adults with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than two cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer;
the adjuvant treatment of adults with HER2-positive early breast cancer at high risk of recurrence.and for the treatment of metastatic breast cancer (MBC):

Use in combination with docetaxel for the treatment of adults with HER2-positive metastatic breast cancer (MBC) who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease. Adverse effects
The FDA label includes a boxed warning about the risk of potential heart failure, fetal harm, and lung toxicity. History
The fixed-dose combination of pertuzumab, trastuzumab, and hyaluronidase was approved for medical use in the United States in June 2020.The FDAs approval was based on the results of a non-inferiority study in participants with HER2-positive early breast cancer, which demonstrated the fixed-dose combination of pertuzumab, trastuzumab, and hyaluronidase had comparable efficacy and safety as IV pertuzumab and IV trastuzumab, except for administration-related reactions, which were higher with the fixed-dose combination due to the subcutaneous route of administration.Efficacy was investigated in FeDeriCa (NCT03493854), an open-label, multicenter, randomized trial enrolling 500 participants with operable or locally advanced HER2-positive breast cancer.