SAEM Clinical Images Series: One Month of Vaginal Bleeding

heterogenous uterus

A 28-year-old female G3P2002 presented to the emergency department for one month of vaginal bleeding. The patient was seen in the emergency department one month earlier for vaginal bleeding in the first trimester of pregnancy. Her estimated gestational age was six weeks by last menstrual period. At the time her beta-hCG was 7225 mlU/mL with no intrauterine pregnancy demonstrated on transvaginal ultrasound. Three days later, the patient had declining b-hCG and transvaginal ultrasound again with no intrauterine pregnancy. The patient was discharged home with a diagnosis of miscarriage. Since discharge, she endorsed an initial slowing of vaginal bleeding but over the last two weeks bleeding had become heavier and continuous; soaking up to eight pads a day. She endorsed worsening nausea and vomiting over the past two weeks. She has been sexually active since her last encounter. She denied abdominal pain, pelvic pain, cramping, dizziness, shortness of breath, or fevers.

Vitals: BP 136/70; Pulse 96; Temp 97.8°F; Resp 16; SpO2 100%

Constitutional: No distress

Cardiovascular: Normal rate, regular rhythm, normal heart sounds

Abdomen: Soft and non-tender; Gravid uterus approximately 10 weeks

Pelvic exam: Active vaginal bleeding of dark red blood originating from the cervical os. Cervical os is closed and otherwise normal in appearance. Multiple clots are seen in the vaginal canal and posterior fornix. Vaginal canal and external genitals are normal in appearance.

Beta-HCG: 91,401 mlU/mL

Hemoglobin: 12.8 g/dL

Our patient’s case is convoluted by reporting a miscarriage the month prior, with declining beta-HCG and transvaginal ultrasounds with no intrauterine pregnancy. While her symptoms never fully resolved she endorsed that her vaginal bleeding slowed and only started getting worse after resuming intercourse.

Her physical exam of a gravid uterus of approximately 10 weeks (despite reporting a miscarriage four weeks prior), persistent vaginal bleeding, and intractable nausea and vomiting are concerning for molar pregnancy [1]. Molar pregnancies typically present as abnormal uterine bleeding in the first or second trimester and are accompanied by symptoms of hyperemesis gravida secondary to the increase in beta-hCG [2]. The two main risk factors for gestational trophoblastic disease are the extremes of maternal age and prior molar pregnancy. However, there is an increased risk for molar pregnancy in patients with a history of prior spontaneous abortions and infertility [4]. Beta-hCG are typically greater than > 100,000 mlU/mL signifying excessive trophoblastic growth, however a value < 100,000 mlU/mL does not exclude the diagnosis of molar pregnancy as partial moles tend not to produce as much beta-HCG [3].

These images, taken by point of care ultrasound, show a heterogenic mass with mixed echogenicities within the uterine cavity consistent with gestational trophoblastic disease or molar pregnancy. Obstetrics and Gynecology was consulted for definitive management. The patient was taken to the operating room for dilation and curettage and was discharged the following day.

Take-Home Points

  • Physical exam findings of an enlarged uterus inconsistent with gestational age, vaginal bleeding, and intractable nausea and vomiting should clue you into a possible molar pregnancy.
  • Point-of-care ultrasound is an invaluable tool when assessing vaginal bleeding and will often help the clinician in the management or diagnostic pathway.
  • Beta-hCG < 100,000 mlU/mL does not rule out molar pregnancy. Obtain a good history, perform a thorough physical exam, and pick up your ultrasound probe.

  • Soper, John T. “Gestational Trophoblastic Disease.” Obstetrics & Gynecology, vol. 137, no. 2, 2021, pp. 355–370.,
  • Cline, David, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill Education, 2020.
  • Berkowitz, Ross S., and Donald P. Goldstein. “Molar Pregnancy.” New England Journal of Medicine, vol. 360, no. 16, 2009, pp. 1639–1645.,
  • Acaia, Barbara, et al. “Increased Frequency of Complete Hydatidiform Mole in Women with Repeated Abortion.” Gynecologic Oncology, vol. 31, no. 2, 1988, pp. 310–314.,

By |2024-02-11T20:06:03-08:00Feb 12, 2024|Ob/Gyn, SAEM Clinical Images|

SAEM Clinical Images Series: Utility of Bedside Ultrasonography


A 24-year-old G1P0010 female with a PMHx of ovarian cyst (unknown laterality) and emergency contraceptive use 3 months prior presented with sudden onset abdominal pain (upper > lower) that awoke her from sleep four hours prior to presentation with associated nausea and mild lower back pain. The pain is 10/10, sharp, stabbing, and diffuse. Additionally, she reported trace white vaginal discharge at baseline. No acute increase. She had intermittent vaginal bleeding since contraception use over the past two months, which has now resolved. She denied fever, chills, vomiting, chest pain, shortness of breath, diarrhea, or constipation. No pertinent surgical history.

Constitutional: Uncomfortable. Appearing to be in acute pain.

Cardiovascular: Tachycardia. Regular rhythm and normal heart sounds.

Pulmonary: No respiratory distress. Breath sounds normal.

Abdominal: Diffusely tender abdomen with voluntary guarding, otherwise soft. Normoactive bowel sounds. Negative Murphy’s sign.

Pelvic: Scant white vaginal discharge and CMT. No vaginal bleeding, lacerations, or external lesions.

Neurologic: A&O x 3

WBC: 18.9 k/uL

Hgb: 10.5 g/dL

BMP, lipase, Alk phos/Bili/ALT/AST, PT/PTT, and lactate: Unremarkable

Serum HCG: Negative

Urinalysis (UA): Unremarkable

COVID: Negative

An ideal RUQ ultrasound visualizes the liver, Morrison’s pouch, superior and inferior poles of the right kidney, and diaphragm in the coronal plane. Here, we see a thickened hepatic capsule, septations, and trace ascites.

Fitz-Hugh-Curtis syndrome (FHCS) is characterized by perihepatitis in the setting of pelvic inflammatory disease (PID). It traditionally presents with right upper abdominal pain with associated nausea, vomiting, and fever in women of childbearing age. While overall considered a rare manifestation of PID, the true incidence of FHCS is poorly defined in the literature [1]. The pathophysiology of spread is also poorly understood. It is speculated that bacteria (N. gonorrhoeae, C. trachomatis) travel to the liver via blood, lymphatics or peritoneal fluid, causing perihepatitis [1]. Diagnosing FHCS poses a diagnostic challenge to clinicians. Traditionally, the diagnosis is made via laparoscopic exploration of the abdomen with visualization of the characteristic “violin-string” adhesions, with growing evidence also supporting the use of contrast-enhanced CT [1]. Limited evidence exists to support the use of ultrasonography in diagnosing FHCS. One case report published in 1993 used RUQ abdominal ultrasound to identify septations (violin-string adhesions) and ascites to ultimately diagnose FHCS, later confirmed by serologic and operative evidence [2]. Another case report from 2018 used ultrasonography to identify a thickened hepatic capsule in an 18-year-old female with RUQ pain, later confirming FHCS by CT without the need for laparotomy [3]. While more research is needed, identification of FHCS via bedside ultrasonography in the emergency setting followed by appropriate antibiotic therapy can be an effective approach to FHCS, ideally reserving laparoscopy only for lysis of adhesions in refractory cases.

Take-Home Points

  • RUQ abdominal ultrasound findings of a thickened hepatic capsule, ascites, and septations should raise suspicion for Fitz-Hugh-Curtis syndrome in the emergency setting.

  • Moon, Y.H., Kim, J.H., Jeong W.J., Park, S.Y. Ultrasonographic findings in Fitz-Hugh-Curtis syndrome: a thickened or three-layer hepatic capsule. Yeungnam Univ J Med 35(1), 127-129 (2018).
  • Theofanakis, C.P., Kyriakidis, A.V. Fitz-Hugh–Curtis syndrome. Gynecol Surg 8, 129–134 (2011).
  • van Dongen PW. Diagnosis of Fitz-Hugh-Curtis syndrome by ultrasound. Eur J Obstet Gynecol Reprod Biol. 1993 Jul;50(2):159-62. doi: 10.1016/0028-2243(93)90181-b. PMID: 8405645.

SAEM Clinical Images Series: Pediatric Genitourinary Bleeding

A 4-year-old female with no significant past medical history is brought to the Emergency Department by her grandmother for concern for two days of progressive vaginal bleeding. The grandmother first noted blood in the patient’s underwear the previous morning when she was helping the patient wipe and she noticed it again prior to arrival, this time saturating the patient’s underwear. There is no history of any recent falls or trauma, abdominal pain, pain to the vagina, dysuria, prior incidents of vaginal bleeding, or any noticeable behavioral changes per the grandmother. The patient lives at home with her mother but has been at her grandmother’s house for the past four days (the household consists of female cousins, grandmother, and grandfather). Of note, the patient’s father took her to a trampoline park with her younger sister two days ago.

Vitals: BP 95/68; HR 96; RR 24; 98% on room air; Temp 36.2°C; Wt 18.2 kg

General: Well-appearing 4-year-old female acting appropriately with grandmother and mother at the bedside.

Abdomen: Soft, nontender, nondistended.

Genitourinary: Normal appearing external genitalia without any skin tears/lacerations. Vaginal exam: Slow oozing bleed noted with round “doughnut” shaped tissue protruding at the vaginal opening.

Hemoglobin: 12.2 g/dL

Urinalysis (clean catch): Blood: Large; >200 RBCs, Ketones: 20, Nitrite: Negative, Leukocytes: Moderate, 19 WBCs

FSH/LH/Testosterone: Within normal limits

Urethral prolapse is a rare condition occurring in prepubertal female pediatric patients. It often presents to the emergency department with complaints of vaginal bleeding, difficulty urinating, or dysuria. The most common predisposing factors to this condition include obesity, cough, trauma, constipation, or a history of any activity that causes a sudden recurrent increase in pelvic pressure, such as a trip to the trampoline park as was the case in this patient [1]. On physical examination, urethral prolapse appears as an annular-like mucosal mass with a central dimple located between the labia majora on examination [1]. Initial treatment is medical management with topical estrogen cream in conjunction with Sitz baths and outpatient follow-up with pediatric urology or gynecology. However, persistence of the prolapse or necrosis of the distal urethra often warrants emergent pediatric urology consultation [2,3]. Recurrent cases or cases refractory to medical management will often require surgery. The patient in this case was treated with a 4-week estrogen cream taper. The patient followed up with pediatric gynecology without further complication or need for further intervention.

Child Abuse, Vaginal Trauma, Malignancies (ie: sarcoma botryoides), Infection, Vaginal foreign body, Urethral Prolapse, Precocious puberty, Hypothyroidism, and Exogenous hormone

Take-Home Points

  • Consider urethral prolapse in any prepubertal female who presents to the Emergency Department with a triage complaint of vaginal bleeding.
  • Treatment for urethral prolapse is typically conservative with topical estrogen cream and prompt follow up with pediatric urology or gynecology.
  • Always keep a broad differential for prepubertal pediatric patients with genitourinary and vaginal bleeding complaints
  • HHillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology. 2009 May;73(5):1008-11. doi: 10.1016/j.urology.2008.10.063. Epub 2009 Mar 13. PMID: 19285715.
  • Laufer M, Emans S. Overview of vulvovaginal conditions in the prepubertal child. Published 2021. Accessed January 5, 2022.
  • Teach S. Evaluation of vulvovaginal bleeding in children and adolescents. Published 2021. Accessed January 5, 2022.

By |2023-11-12T14:19:13-08:00Nov 17, 2023|Ob/Gyn, Pediatrics, SAEM Clinical Images|

The 4 T’s of Postpartum Hemorrhage

Blood transfusion Drip Chamber

A 28-year-old G4P3 at 41 weeks presents to the ED via EMS. She is in active labor. On exam, a neonatal head is visible. Two minutes later, you deliver a healthy vigorous baby boy and hand him to your colleague. You notice persistent bleeding from her vaginal canal. Her tachycardia climbs to 110 bpm and her latest blood pressure is 78/48 mm Hg. We review postpartum hemorrhage (PPH) and the 4 T’s – a memory aid to help ED providers manage this life-threatening presentation.

By |2019-03-29T19:00:18-07:00Feb 6, 2019|Critical Care/ Resus, Ob/Gyn|

ALiEMU AIR Obstetrics and Gynecology Module

Welcome to the Obstetrics and Gynecology (Ob/Gyn) Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to Ob/Gyn emergencies. 10 blog posts within the past 12 months (as of July 2018) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 8 Honorable Mentions. We recommend programs give 4 hours (about 25 minutes per article) of III credit for this module.


Trick: Linear Ultrasound Transducers in Intrauterine Pregnancy Evaluation

Ultrasound in Intrauterine PregnancyThe volume of women presenting to the emergency department (ED) with newly diagnosed first-trimester pregnancies and suspected ectopic pregnancies sometimes seems like an infinitely growing number. As ED physicians, proper identification of an intrauterine pregnancy (IUP) in these patients is of paramount importance and the initial imaging test of choice for many has become bedside point-of-care ultrasound (POCUS).


By |2019-11-10T21:32:28-08:00Jun 4, 2017|Ob/Gyn, Tricks of the Trade, Ultrasound|

Ultrasound For The Win! – 20F with First Trimester Vaginal Bleeding #US4TW

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where point-of-care ultrasound changed the management of a patient’s care or aided in the diagnosis. In this case, a 20-year-old woman presents with first-trimester vaginal bleeding.


By |2019-11-10T23:20:22-08:00May 15, 2017|Ob/Gyn, Ultrasound, Ultrasound for the Win|
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