If the viability of an intrauterine pregnancy is uncertain, repeat ultrasonography coupled with laboratory measurement of progesterone and/or serial hCG can be helpful. The absence of either intrauterine or ectopic pregnancy on imaging is suggestive of a complete early pregnancy loss (if the pregnancy was previously seen on imaging) or a pregnancy of unknown location (if the pregnancy was not previously seen on imaging). Management
The management of early pregnancy bleeding depends on its severity and cause.Patients with significant first-trimester bleeding (more than spotting) should have a red blood cell antibody screen. Patients who are Rh-negative are usually given anti-D immune globulin to prevent RhD isoimmunization. People with significant blood loss who become hemodynamically unstable require rapid intervention. Early pregnancy loss can be treated with watchful waiting, medication, or uterine aspiration based on shared decision-making between the patient and provider. For those with incomplete abortion, watchful waiting is the recommended method as more than 90% of these patients will complete the process spontaneously within four week. Patients who decide on expectant management may experience more days of bleeding and longer completion time as compared to surgical management. Serious complications of watchful waiting are rare. Effective medical management entails 200 mg of oral mifepristone (Mifeprex) followed 24 hours later by 800 mcg of vaginally administered misoprostol. Bed rest and progesterone therapy have not been shown to increase the likelihood of a viable outcome.Ectopic pregnancy is treated with methotrexate therapy or surgery.
Typically, an intramuscular injection of 50 mg per m^2 of methotrexate is given followed by close monitoring of b-hCG levels 4 and 7 days after injection. B-hCG levels should decrease by at least 15% between those two timepoints. Surgery is required for patients who have failed or have contraindications to methotrexate therapy, are experiencing significant blood loss, or have signs of ectopic rupture. Epidemiology
First trimester bleeding is more common than second or third trimester bleeding. First trimester bleeding may be associated with complications in later pregnancy, including placental abruption, smaller estimated fetal weight, stillbirth, and perinatal death. == References ==