A 29-year-old woman comes to the emergency department due to vaginal spotting and discharge. She had a positive pregnancy test last week after missing her last menstrual period and estimates that she is at 5 weeks gestation. The patient has had increased vaginal discharge for the past 2 days but no pelvic pain or cramping. Today, she started having vaginal spotting, which prompted her to come to the emergency department. The patient had a spontaneous abortion 3 years ago that was treated with medication, but she has no chronic medical conditions. Temperature is 37.6 C (99.7 F), blood pressure is 100/60 mm Hg, and pulse is 90/min. The abdomen is soft, nontender, and without rebound or guarding. The cervix appears closed and without lesions, and there is bloody, yellow mucus at the external cervical os. The remainder of the physical examination is normal. Quantitative β-hCG level is 5,200 IU/L and blood type is O, Rh positive. Ultrasound shows an intrauterine fetal pole with a positive fetal heartbeat. Which of the following is the best next step in management of this patient?
Acute cervicitis | |
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Management |
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*Ceftriaxone + azithromycin in pregnancy. | |
This patient at 5 weeks gestation has first-trimester bleeding. A common cause is spontaneous abortion (particularly in patients with a prior spontaneous abortion), but there are many other etiologies of first-trimester bleeding that range from benign (eg, cervical polyp) to life threatening (eg, ectopic pregnancy, septic abortion). Therefore, initial evaluation is with speculum examination to determine the source of bleeding and with pelvic ultrasound to determine pregnancy location. This patient's nontender abdomen, closed cervix, and viable intrauterine pregnancy on ultrasound indicate that a spontaneous abortion is unlikely to be the cause of her bleeding.
In this patient, the vaginal spotting with associated mucopurulent endocervical discharge (eg, bloody, yellow mucus at the external os) is classic for acute cervicitis, which is cervical inflammation and friability typically caused by a sexually transmitted infection (eg, gonorrhea, chlamydia). Acute cervicitis is diagnosed clinically and requires empiric antibiotic therapy. Nonpregnant patients are typically treated with ceftriaxone and doxycycline; however, because doxycycline is a potential teratogen, pregnant patients are treated with ceftriaxone and azithromycin. Because untreated, undertreated, or recurrent infection can ascend to the uterus and increase the risk of obstetric (eg, spontaneous abortion, preterm prelabor rupture of membranes) and neonatal (eg, conjunctivitis) complications, pregnant patients also require a test of cure after treatment.
(Choice A) Anti-D immune globulin administration is administered to Rh-negative women after pregnancy-related bleeding (eg, spontaneous abortion, ectopic pregnancy) due to the risk of fetomaternal hemorrhage and possible Rh alloimmunization that can lead to hemolytic disease of the newborn in future pregnancies. This patient is Rh positive.
(Choice B) Cervical biopsy is indicated in patients with suspected cervical cancer, which can cause vaginal spotting and mucopurulent discharge (particularly when there is associated tissue necrosis); however, patients typically have a visible cervical lesion, which is not seen in this patient.
(Choices D, E, and F) Patients with spontaneous abortion can be treated with either medical (eg, mifepristone, misoprostol) or surgical (eg, suction curettage) management based on patient preference and hemodynamic status. Suction curettage is also indicated in patients with a septic abortion, which can present with mucopurulent cervical discharge; however, this diagnosis is unlikely in this patient with no other signs of infection (eg, afebrile, soft and nontender abdomen).
Educational objective:
Acute cervicitis can present with first-trimester bleeding and mucopurulent endocervical discharge. Pregnant patients with acute cervicitis require empiric treatment with ceftriaxone and azithromycin followed by a test of cure.