# Clinical Cases: First Trimester Complications

## Case 1: Ectopic Pregnancy

### Patient Demographics
- **Age:** 27 years
- **Sex:** Female
- **Occupation:** Physical therapist

### Chief Complaint
"I have right-sided pelvic pain and some spotting. I might be pregnant."

### History of Present Illness
The patient reports her last menstrual period was 7 weeks ago. She has had 5 days of right-sided pelvic pain that is sharp and intermittent. She noticed light vaginal spotting 3 days ago. She took a home pregnancy test yesterday, which was positive. She denies heavy bleeding, fever, or shoulder pain. She rates her pain 5/10 and has been managing with ibuprofen.

### Past Medical History
- Chlamydia infection treated 3 years ago
- Appendectomy at age 16
- No other surgeries

### Obstetric/Gynecologic History
- G2P0010 (one prior spontaneous abortion at 8 weeks, managed expectantly)
- Copper IUD removed 4 months ago when she began trying to conceive
- Regular 28-day menstrual cycles

### Risk Factors for Ectopic Pregnancy
- Prior chlamydia infection (tubal damage)
- Prior IUD use (if pregnant while IUD in place, higher ectopic rate - but IUD now removed)
- Prior pelvic surgery (appendectomy)

### Physical Examination Findings
- **Vital Signs:** BP 118/74 mmHg, HR 82 bpm, Temperature 98.4F, stable
- **Abdomen:** Soft, mild right lower quadrant tenderness, no rebound or guarding
- **Pelvic:** Minimal dark blood at introitus, cervix closed, right adnexal tenderness without palpable mass, mild cervical motion tenderness

### Diagnostic Workup
- **Urine pregnancy test:** Positive
- **Quantitative beta-hCG:** 2,850 mIU/mL
- **Hemoglobin:** 12.4 g/dL
- **Blood type:** O positive, antibody screen negative
- **Transvaginal Ultrasound:**
  - No intrauterine pregnancy visualized
  - Endometrial stripe 10 mm
  - Right adnexal mass 2.5 cm with "ring of fire" vascularity (tubal ring sign)
  - Small amount of free fluid in posterior cul-de-sac
  - Left ovary normal

### Diagnosis
**Right Tubal Ectopic Pregnancy**
- Beta-hCG above discriminatory zone (1,500-2,000 mIU/mL) with no IUP
- Adnexal mass with characteristics of ectopic pregnancy
- Small amount of free fluid (minimal hemoperitoneum)

### Treatment Options Discussed

**Medical Management with Methotrexate:**
Eligibility assessment:
- Hemodynamically stable: YES
- Beta-hCG <5,000 mIU/mL: YES (2,850)
- Ectopic size <4 cm: YES (2.5 cm)
- No fetal cardiac activity: YES
- Able to comply with follow-up: YES
- No contraindications (immunodeficiency, liver disease, breastfeeding): NONE

**Surgical Management:**
- Laparoscopy with salpingostomy or salpingectomy
- Indicated if: unstable, contraindications to MTX, or patient preference

### Management Plan (Patient Chose Medical Management)

**Pre-treatment Workup:**
- CBC, liver function tests, creatinine: All normal
- Blood type confirmed: O positive (RhoGAM not needed)

**Methotrexate Protocol (Single-Dose):**
- Methotrexate 50 mg/m2 intramuscularly = 85 mg (BSA 1.7 m2)
- Administered after counseling

**Post-Treatment Instructions:**
- Avoid alcohol, folic acid supplements, NSAIDs
- No intercourse until beta-hCG undetectable
- Avoid sun exposure (photosensitivity)
- Pelvic rest
- Return immediately if severe pain, heavy bleeding, dizziness

**Follow-up Protocol:**
- Beta-hCG on Day 4: 3,100 mIU/mL (may initially rise - expected)
- Beta-hCG on Day 7: 2,100 mIU/mL (28% decrease - SUCCESS requires >15% drop)
- Weekly beta-hCG until undetectable

### Clinical Course
- Day 7 beta-hCG showed appropriate decline
- Serial weekly levels continued to drop
- Beta-hCG undetectable at 6 weeks post-treatment
- Counseled to wait 3 months before attempting pregnancy (folate repletion)
- Future pregnancy: early ultrasound to confirm intrauterine location

### Clinical Image
![Ectopic Pregnancy Ultrasound](case_01_image.jpg)

**Image Description:** Transvaginal ultrasound image demonstrating an empty uterus with a "tubal ring" sign in the right adnexa, representing an ectopic pregnancy. The ring of fire pattern on color Doppler shows increased vascularity around the ectopic gestational sac.

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Yuranga Weerakkody. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/tubal-ectopic-pregnancy

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## Case 2: Threatened Abortion Progressing to Incomplete Abortion

### Patient Demographics
- **Age:** 34 years
- **Sex:** Female
- **Occupation:** Financial analyst

### Chief Complaint
"I'm having heavy bleeding and cramping. I'm 9 weeks pregnant."

### History of Present Illness
The patient had vaginal spotting starting 4 days ago. Her OB saw her 3 days ago and ultrasound showed a viable intrauterine pregnancy at 9 weeks with fetal heart activity. She was diagnosed with threatened abortion and placed on pelvic rest. This morning, she developed heavy vaginal bleeding with clots, soaking 4 pads in 2 hours, and severe cramping. She passed some tissue that she brought with her in a container.

### Past Medical History
- Hypothyroidism on levothyroxine
- Two prior uncomplicated term pregnancies

### Physical Examination Findings
- **Vital Signs:** BP 110/70 mmHg, HR 96 bpm, Temperature 98.2F
- **General:** Pale, anxious, moderate distress from cramping
- **Abdomen:** Soft, suprapubic tenderness, no rebound
- **Pelvic:** Moderate active bleeding, cervix dilated to 2 cm with tissue visible at os, uterus 8-week size, tender
- **Tissue examination:** Grayish tissue consistent with products of conception

### Diagnostic Workup
- **Hemoglobin:** 10.2 g/dL (was 12.5 at first prenatal visit)
- **Blood type:** A negative
- **Quantitative beta-hCG:** 45,000 mIU/mL
- **Transvaginal Ultrasound:**
  - Irregular gestational sac with no fetal pole identified (previously seen)
  - Heterogeneous material in lower uterine segment and cervical canal
  - No fetal cardiac activity
  - Small amount of free fluid in pelvis

### Diagnosis
**Incomplete Abortion** (previously viable pregnancy)
- Open cervical os with tissue at os
- Incomplete passage of products of conception
- Significant anemia from blood loss

### Management Options

**Option 1: Expectant Management**
- Wait for spontaneous passage
- Higher failure rate with incomplete abortion
- Not ideal given significant bleeding

**Option 2: Medical Management**
- Misoprostol 800 mcg vaginally
- May expedite passage
- Success rate 80-90% for incomplete abortion

**Option 3: Surgical Management (D&C)**
- Suction dilation and curettage
- Most definitive and rapid option
- Appropriate given heavy bleeding and anemia

### Chosen Management: Surgical (D&C)

**Rationale:**
- Significant ongoing hemorrhage
- Anemia (Hgb drop of 2.3 g/dL)
- Tissue at cervical os causing incomplete passage
- Patient preference for definitive management

**Procedure:**
- Performed under IV sedation in operating room
- Cervix already dilated
- Suction curettage performed
- Products of conception sent to pathology
- Estimated blood loss 150 mL
- Uterus firm post-procedure

**RhoGAM Administration:**
- Patient is Rh negative
- RhoGAM 300 mcg IM administered (standard dose for pregnancy losses after 12 weeks, but 50 mcg mini-dose acceptable <12 weeks at some institutions)

### Post-Procedure Care
- Tolerated procedure well
- Bleeding reduced to light
- Hemoglobin check in 1 week
- Iron supplementation started
- Counseled on grief resources
- May attempt conception after 1 menstrual cycle
- Pathology confirmed products of conception (no molar pregnancy)

### Emotional Support
- Validated grief and loss
- Reassured that miscarriage is common (10-20% of recognized pregnancies)
- Reassured this was not her fault
- Support group resources provided
- Follow-up call scheduled for 48 hours

### Clinical Image
![Incomplete Abortion Ultrasound](case_02_image.jpg)

**Image Description:** Transvaginal ultrasound demonstrating heterogeneous echogenic material within the uterine cavity and cervical canal, representing retained products of conception in incomplete abortion.

**Attribution:** Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.

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## Case 3: Complete Hydatidiform Mole

### Patient Demographics
- **Age:** 19 years
- **Sex:** Female
- **Occupation:** College student

### Chief Complaint
"I have severe nausea and vomiting. I'm pregnant and my uterus seems too big."

### History of Present Illness
The patient reports her LMP was 12 weeks ago. She has had severe nausea and vomiting for the past 6 weeks, far worse than expected "morning sickness." She has lost 10 pounds. She has had intermittent vaginal bleeding with passage of "grape-like" tissue 2 days ago. She is concerned because she "looks more pregnant than she should."

### Past Medical History
- No significant medical history
- No prior pregnancies

### Physical Examination Findings
- **Vital Signs:** BP 142/88 mmHg (elevated), HR 100 bpm, Temperature 98.6F
- **General:** Thin, appears uncomfortable, tremulous
- **Thyroid:** Slightly enlarged, no nodules
- **Abdomen:** Soft, uterine fundus palpable at umbilicus (consistent with 20-week size but patient is 12 weeks by LMP)
- **Pelvic:** Small amount of blood at introitus, cervix closed, uterus dramatically large for dates, bilateral adnexal fullness

### Diagnostic Workup
- **Urine pregnancy test:** Strongly positive
- **Quantitative beta-hCG:** 425,000 mIU/mL (markedly elevated for gestational age)
- **Hemoglobin:** 10.8 g/dL
- **TSH:** 0.1 mIU/L (suppressed)
- **Free T4:** 2.8 ng/dL (elevated)
- **Liver function tests:** Normal
- **Chest X-ray:** No pulmonary nodules
- **Transvaginal Ultrasound:**
  - Enlarged uterus filled with heterogeneous echogenic material
  - Classic "snowstorm" or "cluster of grapes" appearance
  - No identifiable fetus
  - Bilateral enlarged ovaries with multiple theca lutein cysts (8 cm and 6 cm)

### Diagnosis
**Complete Hydatidiform Mole** with:
- Markedly elevated beta-hCG
- Uterus large for dates
- Characteristic ultrasound findings
- Theca lutein cysts (hCG-induced)
- Gestational hyperthyroidism (hCG cross-reactivity with TSH receptor)
- Hypertension (concerning for early preeclampsia, rare before 20 weeks except with molar pregnancy)

### Management Plan

**Pre-operative Preparation:**
- Type and crossmatch 2 units PRBCs
- Anesthesia consultation
- Beta-blocker (propranolol) for hyperthyroid symptoms
- Blood pressure management

**Surgical Treatment:**
- Suction dilation and curettage (D&C)
- Performed in operating room with anesthesia support
- Sharp curettage avoided initially (risk of perforation)
- Oxytocin infusion started after cervical dilation to promote contraction
- Tissue sent to pathology for confirmation

**Operative Findings:**
- Large amount of vesicular tissue evacuated
- Uterus contracted well after evacuation
- Estimated blood loss 400 mL
- No complications

### Pathology
- Confirmed complete hydatidiform mole
- Hydropic villi with circumferential trophoblastic proliferation
- No fetal tissue identified
- p57 immunostaining negative (confirms complete mole - paternally derived)

### Post-Molar Surveillance Protocol

**Contraception:**
- Started on combined oral contraceptive pills
- CRITICAL: Must avoid pregnancy during surveillance period
- Hormonal contraception is safe and does not affect hCG interpretation

**Beta-hCG Monitoring:**
- Weekly beta-hCG until undetectable for 3 consecutive weeks
- Then monthly for 6 months
- If levels plateau or rise: suspect gestational trophoblastic neoplasia

**Clinical Course:**
- Week 1: 85,000 mIU/mL
- Week 2: 22,000 mIU/mL
- Week 4: 1,200 mIU/mL
- Week 6: 45 mIU/mL
- Week 8: <5 mIU/mL (undetectable)
- Continued undetectable for 3 consecutive weeks

**Surveillance Completion:**
- Monthly hCG for 6 additional months - all undetectable
- Counseled that 15-20% of complete moles develop GTN requiring chemotherapy
- She was in the 80-85% who resolved spontaneously
- May attempt pregnancy after completing surveillance

### Clinical Image
![Molar Pregnancy Ultrasound](case_03_image.jpg)

**Image Description:** Transvaginal ultrasound demonstrating the classic "snowstorm" or "bunch of grapes" appearance of a complete hydatidiform mole, with heterogeneous echogenic material filling the uterine cavity and no identifiable fetus.

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/complete-hydatidiform-mole