Notes

With a heterotopic pregnancy, there should be a visible pregnancy in the uterus. With a missed abortion there should also be some visible tissue or a fetal pole within the uterus.
Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy. These include: hemodynamic stability; non-ruptured ectopic pregnancy; size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate; normal liver enzymes and renal function; normal white cell count; and the ability of the patient to follow up rapidly (reliable transportation, etc.) if her condition changes.
This scenario is consistent with the patient having a ruptured ectopic pregnancy. Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy. - perform laparoscopy
Hematometra can develop after an abortion, but the patient would complain of cyclic midline abdominal cramping pain. Retained products of conception would cause profuse vaginal bleeding and if not removed may lead to a septic abortion.
Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. The patient’s history of mild chronic hypertension and one prior termination of pregnancy do not increase her risk of a first trimester loss. Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion.
This patient is actively bleeding and is anemic. She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage
antiphospholipid antibody syndrome - 2nd trimester abortion
incompetent cervix - cervical cerclage
It is important to rule out systemic disease in a patient with recurrent abortion (three successive first trimester losses). Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained. Infectious causes should also be considered. Uterine imaging to exclude a septum or other anomaly is routinely done using hysteroscopy or hysterography and not CT or MRI scanning.
Neither controlled trials nor surveillance data support the contention that a single, prior first trimester surgical abortion increases the risk of subsequent first trimester pregnancy loss.