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First-Trimester Emergencies: A Practical Approach To Abdominal Pain And Vaginal Bleeding In Early Pregnancy

November 2003


Abdominal pain and vaginal bleeding are common in the first trimester of pregnancy. Patients with these vague symptoms—which may be inconsequential or may herald the onset of a critical condition— frequently present to the ED and may represent more than 1% of all ED visits.1 The true incidence of one or both of these symptoms during the first trimester is unknown, as some women probably never seek medical attention, and those who do present to a variety of medical settings, including urgent care centers, primary care or OB/GYN offices, and EDs. While the presenting symptoms and severity of illness may be apparent upon presentation to the ED, quickly identifying those women who are ultimately at risk for death is not so clear-cut. When first-trimester pregnant patients present to the ED with abdominal pain and/or vaginal bleeding, the emergency physician is faced with two main questions: Is the pregnancy location intrauterine or ectopic? If intrauterine, is the pregnancy viable or nonviable? With a few simple tools such as quantifiable pregnancy testing and bedside ultrasound, the emergency physician is frequently able to make a definitive diagnosis at the initial visit. However, in a substantial minority of patients, significant diagnostic uncertainty remains at the conclusion of the ED visit, and management decisions must be made based on an assessment of risk.
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