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Picture Quiz: Vaginal bleeding and vommiting in early pregnancy

BMJ 2003; 326 doi: (Published 01 February 2003) Cite this as: BMJ 2003;326:030215
  1. Ebube Obi, senior house officer1
  1. 1Royal Free Hospital, London NW3 2QG

Case history

A 45 year old woman was in the 14th week of her second pregnancy. Fourteen years ago she gave birth to a normal baby at term. She now complained of heavy vaginal bleeding to her general practitioner. She missed her ultrasound scan at 12 weeks because she did not think that any information from her scan would make her change her decision to keep the baby. She had lost some weight, which she attributed to morning sickness, but her weight loss had been more severe than in her first pregnancy. She sometimes had abdominal pain.


  1. What is your differential diagnosis?

  2. What main aspects of a physical examination should be carried out?

  3. On examination the uterus is larger than that expected for a normal 14 week pregnancy. What would be the main investigation in this case?

  4. The figure shows her ultrasound scan. Which blood test may help with the diagnosis?

  5. If concentrations of serum ß human chorionic gonadotrophin were high, what would the most likely diagnosis be?

  6. What could be the differential diagnosis if her concentrations of human chorionic gonadotrophin were normal?


  1. Threatened abortion, missed abortion, inevitable abortion, incomplete abortion, ectopic pregnancy, or molar pregnancy.

  2. Palpation--To ascertain abdominal distension (uterine enlargement)/fetal parts compatible with pregnancy. Fundal height--At 14 weeks the uterus should be felt per abdomen. Fetal heart sound--At 14 weeks should be audible using an ultrasound device. Speculum examination--To see …

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