Vaginal bleeding in the first trimester is a common concern during pregnancy. The amount of bleeding and associated symptoms, such as nausea and vomiting, can be of prognostic value. Timely evaluation with vital signs, physical examination, laboratory tests (eg, Rh factor, hemoglobin and possibly progesterone levels), and pelvic ultrasound (US) can distinguish among viable pregnancy, nonviable pregnancy, intrauterine pregnancy (IUP) of uncertain viability, and pregnancy of unknown location. Serial pelvic US can be obtained in patients with IUP of uncertain viability after 11 to 14 days, and in pregnancy of unknown location in as little as 48 hours. Quantitative human chorionic gonadotropin (hCG) levels are of minimal clinical utility after IUP is visualized on US. Serial quantitative hCG levels should be measured in patients with pregnancy of unknown location. After an early pregnancy loss has been identified, as long as the patient is hemodynamically stable, options include expectant, medical, and surgical management. The treatment plan can be guided by shared decision-making. Ectopic pregnancy can be managed surgically via laparoscopy, medically with methotrexate, or expectantly (in certain circumstances). Progesterone for patients with early pregnancy bleeding and no history of miscarriage likely is of no benefit.

Case 1. Sylvia is a 36-year-old primigravida woman with a history of impaired fasting glucose, elevated body mass index, and polycystic ovary syndrome. She recently learned she was pregnant after conceiving via ovulation induction with letrozole. She comes to you for a first obstetric visit but appears worried today, noting that she has been having intermittent spotting this week. The date of her last menstrual period indicates she is 5 weeks, 6 days pregnant. A bedside ultrasound (US) reveals a small gestational sac with no fetal pole or yolk sac observed.