Patient A is a woman, 24 years of age, gravida three para two, who reported she believes she is about seven weeks pregnant. Three days previous, she noted some pink vaginal spotting. She presented with painless, dark red vaginal spotting. Patient A reported her last intercourse was more than a week ago. She denied any itching, burning, or malodorous discharge prior to the onset of her symptoms. She denied fever but thinks she had been having chills. Some nausea was reported but no vomiting. She did have a positive home pregnancy test one month ago. She denied uterine cramping, but admitted to some mild upper abdominal cramping. The patient complained of suprapubic pain after urination. The pain occurred after each voiding. The pain did not localize elsewhere and lasted for just a few minutes. Patient A reported some frequency, but attributed this to her pregnancy. Bowel function has been normal. She was appropriately concerned, as her previous pregnancies were uncomplicated. During the previous six months, Patient A has been diagnosed and treated for gonorrhea once and chlamydia twice. Follow-up testing was negative. Patient A has also been treated for recurrent lower urinary tract infection and bacterial vaginosis during the same period of time.

The differential diagnosis for Patient A includes:

Examination revealed normal external genitalia. The vagina was pink with moderate amounts of maroon-colored watery discharge noted. The cervix was pink and appeared closed. No exudate or lesions were noted on the cervix. Cultures for gonorrhea and chlamydia were obtained. Bimanual examination revealed a nontender uterus, anteverted, enlarged to a six- to seven-week gestational size. No masses were appreciated. The uterus was normal shape and configuration. The cervix was long and closed. Cervical motion tenderness was absent. Adnexa were slightly tender to palpation, without mass. Rectal examination was confirmatory.

Urinalysis in the office revealed 10 to 20 WBCs per high-powered field, 20 to 30 RBCs, no bacteria, moderate epithelial cells, and some casts. A urine sample was forwarded to the lab for culture and sensitivity. The routine pregnancy laboratory tests were obtained, and an ultrasound exam was ordered.

Laboratory findings revealed that Patient A is Rh negative with a negative antibody screen. She was offered RhoGAM per protocol and accepted. Her hemoglobin was 12.4, with the remainder of her lab work within normal limits. Her quantitative beta hCG was 14,283 mIU/mL. With an hCG that high, one would expect to be able to identify a fetus or products of conception on ultrasound. The radiologist immediately called to report that Patient A's ultrasound demonstrated a thickened endometrium and a slightly enlarged uterus measuring 9 cm x 6 cm x 8 cm. No gestational sac was noted. The left adnexa revealed a significantly increased vascularity adjacent to the left ovary. The right ovary was normal, with several small follicles.

Ectopic pregnancy was suspected. The hCG levels were borderline for the administration of methotrexate. With the uncertainty of the location of the gestation and the question of the patient's ability to return for close follow-up, the patient was prepared for surgery. At the time of diagnostic laparoscopy, a 4 cm x 5 cm cornual pregnancy was noted on the left side. The tubes and ovaries were normal bilaterally. The left cornu was removed in its entirety to the level of the endometrium; however, the endometrium was not entered.

Cornual pregnancies implant in the area where the fallopian tube enters the uterus. Approximately 1% to 5% of ectopic pregnancies occur in the cornua [40,99,112,113]. The uterine muscle surrounding the cornua permits the pregnancy to grow to a more advanced age, often 12 to 16 weeks, before rupture. Because this area is so vascular, ruptured cornual pregnancies can result in a profuse, rapid, and fatal hemorrhage. This patient's cornual pregnancy was not ruptured at the time of identification, and her postoperative recovery was normal. Urine culture done at the time of the office visit was negative. However, the chlamydia culture was positive, and the patient was treated according to CDC guidelines [161].

Because additional pregnancies were desired, the patient was started on hormone contraception and advised not to conceive for at least one year after her surgery in an effort to allow the uterine incision site to completely heal.

Patient R is 38 years of age, gravida 4 para 2, who had a spontaneous abortion eight months previous. She presented at 15 weeks' gestation. Her initial obstetric appointment was completed at 11 weeks' gestation. No fetal heart tones were auscultated. Because the patient had a definite last menstrual period and the uterine size was appropriate at the time of the examination, no ultrasound was performed. Plans were made to schedule an ultrasound at 20 to 22 weeks' gestation for complete evaluation secondary to a family history of cardiac anomaly.

Laboratory results from her first appointment were as follows:

Physical examination at the time of her first examination revealed a height of 65 inches, weight 212 lbs, and pulse 80 beats/minute. Her blood pressure was 114/72 mm Hg. Uterine size was measured to be 10 to 12 weeks' gestation; cervix was noted to be long and closed.

The patient returned with complaints of brown spotting "off and on" for several days, headache, fatigue, nausea, vomiting, and swelling in her legs. She had been unable to keep food or fluids down for 24 hours.

Her second exam reported a weight of 222 lbs, pulse of 86 beats/minute, and blood pressure of 162/94 mm Hg. Fundal height was recorded as 20 cm, and no fetal heart tones were monitored. Urinalysis (dipped) revealed 1+ protein and negative glucose with large ketones. Mucous membranes are dry, and the patient appears pale. Pitting edema in the calves is noted.

The differential diagnosis for Patient R includes:

An ultrasound exam was ordered and revealed no fetus but the presence of characteristic grape-like clusters in the uterus, and the diagnosis of complete hydatidiform molar pregnancy was made.

The patient was referred to an obstetrician for evacuation and management of this pregnancy. Because diagnosis was made before surgical evacuation of the uterus, a chest x-ray was performed preoperatively. It was within normal limits. CBC, platelet count, PT, PTT, liver function tests, and renal function tests were obtained. An hCG level was also obtained for baseline. Blood type and Rh type were known from her prenatal work-up. The patient did not require RhoGAM.

Patient C is a married woman, 22 years of age, gravida 1 para 0, at seven weeks' gestation according to her last menstrual period. This is a planned and welcome pregnancy. She called the office with complaints of bright red bleeding, lighter than a menstrual period but requiring sanitary pad protection. She also reported intermittent cramping. She denied lightheadedness, dizziness, nausea, vomiting, or focal pain. Although she had not experienced any nausea or vomiting, she reported continued breast tenderness.

On arrival in the office, her vital signs were obtained. Her height was 65 inches; weight 142 lbs; blood pressure 112/68 mm Hg; pulse 76 beats/minute. She appeared to be in some discomfort from the cramping, but her color was good and she was able to answer questions without difficulty. Upon questioning, she denied any trauma, recent intercourse, or changes in discharge preceding the onset of bleeding. Her last Pap test was done four months previous and was normal. Routine cervical cultures at the time were negative for chlamydia and gonorrhea.

Pelvic examination reveals the following:

Bimanual exam indicated a seven- to eight-week gestation-sized, anteverted uterus, mildly tender to palpation. No adnexal masses were appreciated; the cervix felt closed.

The results of laboratory studies indicated:

An ultrasound examination was performed. An intrauterine pregnancy was noted, with a fetus and fetal cardiac activity of 136 beats per minute. A normal gestational sac was seen consistent with a pregnancy of seven weeks two days. The placenta was low lying but did not cover the cervical os. No subchorionic hemorrhage was apparent.

The differential diagnosis for Patient C includes:

Because the patient continued to bleed, a repeat quantitative beta hCG in 48 hours was ordered. When bleeding is light, it is also appropriate to repeat the ultrasound exam in two weeks to follow growth and viability.

The patient was educated about the warning signs and symptoms of spontaneous abortion. She was encouraged to call with changes in symptoms, including bleeding saturating more than a pad an hour, passage of clots, severe cramping, lightheadedness, dizziness, fever, chills, or any other symptoms that make her uncomfortable.

Two days later, the patient returned to have her hCG repeated. She was accompanied to the office by her husband. Her repeat hCG was 1,500 mIU/mL. She continued to bleed lightly but had not saturated a pad an hour. She denied fever, chills, or passing any clots. Her vital signs remained stable, and she was afebrile.

The pelvic exam was unchanged from two days previous, with the exception of the bimanual examination. Palpation of the uterus was more uncomfortable for the patient than noted in the previous exam.

Patient C and her husband were told that the falling hCG levels indicate a pregnancy loss or miscarriage. Definitive diagnosis was made when the ultrasound revealed intrauterine fetal death, no fetal cardiac activity, and a collapsing gestational sac. A diagnosis of incomplete abortion or abortion in progress was made.

The options of care were discussed with the patient and her husband. They were offered the choices of expectant management, medical management, or surgical evacuation of the uterus. This couple chose expectant management and was sent home with instructions to call if the bleeding saturated a pad an hour, the bleeding became foul smelling, or if she developed fever or chills. Vaginal abstinence was encouraged. The patient was instructed in NSAID pain relief measures but was asked to call if additional pain control is needed. Plans were made for a follow-up telephone call later that week, and the couple was encouraged to call with any questions or concerns. A follow-up appointment was scheduled in two weeks, at which time hCG levels could be measured if indicated, birth control provided, and the patient's grief response assessed.