A patient in early pregnancy presents with pelvic pain and heavy vaginal bleeding. She has been bleeding heavily over the last hour. She tells you she had an ultrasound 2 weeks ago, at 5 weeks gestation which showed an intrauterine pregnancy, but was too early to detect cardiac activity.
Describe and interpret these scans
Image 1: Longitudinal pelvic view transabdominal scan.
The uterus is seen in longitudinal section. It appears empty with no sac obvious within the endometrial cavity. A recent ultrasound confirming an intrauterine pregnancy makes ectopic very unlikely. Posterior to the empty bladder the vagina is distended with blood clot. Clot appears heterogenous with some more echogenic areas and other hypoechoic areas. Within the clot is a hypoechoic area that may represent the collapsed sac.
It is almost certain that if the patient stands or goes to the toilet a large clot will be delivered. In this instance the miscarriage may then be complete, however the patient should be monitored to ensure bleeding has stopped or at least slowed a great deal. Repeat ultrasound, transvaginal ultrasound or clinical examination to ensure products are no longer in the cervix would be required if any doubt remained.
Miscarriage with blood and products in the vagina
Patients having a miscarriage often bleed very heavily whilst products remain within the cervix. Here there has clearly been heavy bleeding with blood clot remaining in the vagina. It is necessary to remove this (either passively or actively) to determine whether bleeding continues or has now slowed after a complete miscarriage. Where products are found to remain within the os they require removal and occasionally the patient needs to go to theatre for adequate removal of products and control of bleeding.