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Background
Emergency department evaluation of pelvic pain and vaginal bleeding often relies on transvaginal and transabdominal pelvic ultrasound (US) as a first-line diagnostic tool. In conjunction with testing of human chorionic gonadotropin (B-HCG), pelvic US can aid clinicians in differentiating between multiple pelvic pathologies, and more importantly exclude conditions that have high risk of morbidity or mortality for the patient. The purpose of this presentation is to review the normal course of embryologic fetal development and provide radiologists and trainees with accepted guidelines for evaluating first trimester pregnancy ultrasounds in the emergency department setting.

Educational Goals / Teaching Points
Review workup and imaging evaluation of patients presenting to the emergency department for pelvic pain and vaginal bleeding. Explore imaging appearance of potential etiologies for patient’s presenting symptoms to include pregnancy complications and its mimics with emphasis on differentiating imaging features. Understand important imaging features diagnostic of and suspicious for pregnancy failure. Provide succinct reporting elements needed in ultrasound reports for evaluation of early pregnancy based on standard guideline definitions.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Emergency department evaluation of pelvic pain and vaginal bleeding have a higher incidence of pregnancy complications like ectopic pregnancy, spontaneous abortion, and nonviable intrauterine pregnancies (IUP). Also discussed are risk factors for ectopic pregnancies, pitfalls regarding extra-fallopian ectopic pregnancies or rare heterotopic pregnancies, and other acute pathologies like ovarian torsion, which is more common in 1st trimester pregnancy, can have similar acute pelvic symptoms, and can be more easily missed with detriment to the patient if clinician and radiologist are focused only on evaluating pregnancy viability.

Conclusion
Evaluation of pelvic pain and vaginal bleeding in the emergency department can have a high degree of morbidity and mortality due to risks of pregnancy complications. For most patients, “watchful waiting” with serial B-HCG measurements and repeat pelvic ultrasound in the setting of questionable IUP viability or pregnancies of unknown location is the safest and least invasive option for the patient. By reinforcing guidelines and reviewing common imaging pathologies, we aim to improve care for pregnant patients in emergent situations.