Vaginal Bleeding in Pregnancy
Basics
Description
Major cause of maternal/fetal morbidity and mortality
Early pregnancy hemorrhage (≤20 wk):
Occurs in 30% of all pregnancies
50% lead to spontaneous abortion
Late pregnancy hemorrhage (>20 wk):
Occurs in 3–5% of all pregnancies
Risk factors:
Advanced maternal age
Substance abuse
Pelvic inflammatory disease (PID)
Previous cesarean section
Previous termination of pregnancy
Previous dilation and curettage (D&C)
Previous ectopic pregnancy
Increased parity
Multiple gestation
Preeclampsia
Hypertension
Trauma
Use of assisted reproductive technology
Genetics:
50–60% of miscarriages due to chromosomal abnormalities
Etiology
Vaginal
Cervical
Uterine
Uterine–placental interface
Hematologic dysfunction
Diagnosis
Signs and Symptoms
History
Intensity and duration of bleeding:
Amount (clots, number of pads)
Color (dark or bright red)
Painful or painless
Watery, blood-tinged mucus
Life-threatening conditions may present with only minimal bleeding
Last normal menstrual period
Passage of tissue
Estimated duration of gestation
Gravidity/parity
Fever
Syncope or near-syncope
Last intercourse
Intrauterine device
Previous obstetric–gynecologic complications
Use of assisted reproductive technology
Spontaneous abortion: Classically crampy, diffuse pelvic pain
Ectopic pregnancy: Classically sharp pelvic pain with lateralization
Placenta previa: Classically painless bright red hemorrhage
Placental abruption: Classically painful dark red hemorrhage
Physical Exam
Vital signs:
Tachycardia
Hypotension
Orthostatic changes
Signs of hemodynamic instability may be absent due to pregnancy-related physiologic increase in blood volume
Fetal heart tones:
Fetal cardiac activity seen on transvaginal US at 6.5 wk
Auscultated with hand-held Doppler past 10 wk gestation
Normal fetal heart rate: 120–160 beats/min
Abdominal exam:
Uterine size:
12 wk: Palpable in abdomen
20 wk: Palpable at umbilicus
Peritoneal signs
Firm or tender uterus in late pregnancy suggests abruption
Pelvic exam – perform only in early pregnancy:
Evaluate source and intensity of bleeding
Determine patency of cervical os (only in first trimester):
Threatened abortion: Os closed
Inevitable abortion: Os open
Incomplete abortion: Os open or closed
Complete abortion: Os closed
Embryonic demise (missed abortion): Os closed
Products of conception (POC) may be noted in incomplete or completed abortion:
POC in the cervical os can result in profuse bleeding
Evaluate uterine size, tenderness
Evaluate for uterine fibroids or adnexal masses
Late pregnancy: External exam OK, but do not perform pelvic exam unless in controlled OR setting:
Severe hemorrhage may ensue
Placenta previa or vasa previa must be ruled out by US prior to pelvic exam
Essential Workup
CBC
Type and screen
Quantitative human chorionic gonadotropin (hCG) in early pregnancy
Urinalysis
US:
Transvaginal US provides more information than transabdominal US in early pregnancy
Diagnostic Tests and Interpretation
Lab
CBC:
Dilutional “anemia” is a normal physiologic change in pregnancy:
Blood volume expands by 45%
Qualitative beta-human chorionic gonadotropin (β-hCG)
Quantitative β-hCG:
Imperfect correlation with US findings
Detectable 9–11 d following ovulation
Blood typing and Rh typing:
Cross-match if significant bleeding
Disseminated intravascular coagulation (DIC) panel in embryonic demise, placental abruption
Blood cultures with septic abortion
Suspected POC to lab for identification of chorionic villi
Imaging
US:
Should be obtained in symptomatic patients with any β-hCG level:
Confirms intrauterine pregnancy (IUP)
Detects gestational sac at 5 wk (usually with β-hCG ≥1,000–2,000 IU), yolk sac at 6 wk, and cardiac activity at
5–6 wk of gestation
Essentially rules out ectopic pregnancy by showing IUP (except in women at high risk for heterotopic
pregnancy)
Proves ectopic pregnancy by showing fetal pole outside uterus
Suggests ectopic pregnancy by detecting free fluid in cul-de-sac or adnexal mass
Detects retained POC
Demonstrates “snowstorm” appearance within uterus with gestational trophoblastic disease
Diagnostic Procedures/Other
Culdocentesis:
Limited use
Identifies free fluid in cul-de-sac
D&C or vacuum aspiration:
Indicated if suspected incomplete or septic abortion, embryonic demise, gestational trophoblastic disease, or
anembryonic gestation to evacuate retained POC
Laparoscopy/laparotomy:
Indicated for unstable patients
Definitive diagnosis and treatment of ectopic pregnancy
Differential Diagnosis
Early pregnancy (<20 wk):
Implantation bleeding
Threatened abortion
Complete, incomplete, inevitable, embryonic demise (missed abortion), and septic abortion
Ectopic pregnancy
Heterotopic pregnancy
Gestational trophoblastic disease (molar pregnancy)
Subchorionic hemorrhage
Anembryonic gestation (blighted ovum)
Infection (e.g., cervicitis)
Trauma
Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
Bleeding disorders
Late pregnancy (>20 wk):
Placental abruption (30%)
Placenta previa (20%)
Bloody show (associated with cervical insufficiency or labor)
Vasa previa
Cervical/vaginal trauma or pathology
Uterine rupture (uncommon)
Infection (e.g., cervicitis)
Trauma
Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
Bleeding disorders
Treatment
Pre Hospital
Unstable vital signs warrant aggressive resuscitation
In late pregnancy, position patient on left side to decrease uterine compression of inferior vena cava (IVC)
Consider preferential transport of a woman with late pregnancy to a facility with obstetric capabilities
Initial Stabilization/Therapy
Airway management
Oxygen
Pulse oximetry
Cardiac monitor
2 large-bore IV lines
Blood transfusion as indicated
Continuous fetal monitoring in later pregnancy
Ed Treatment/Procedures
All women with early pregnancy vaginal bleeding must be evaluated for ectopic pregnancy (preferably by transvaginal
US)
Administer anti-Rh0 (D) immune globulin if patient is Rh-negative
Suspected ectopic pregnancy:
Unstable: Consider bedside US with emergent OB/GYN consultation for laparoscopy/laparotomy
Stable: Perform US:
If confirmatory or suggestive of ectopic pregnancy, obtain OB/GYN consultation for surgery or methotrexate
therapy
If inconclusive, obtain OB/GYN consultation and arrange for repeat β-hCG testing in 2 d
Threatened abortion:
Emergent OB/GYN consultation for heavy/uncontrolled bleeding
Arrange OB/GYN follow-up for minimal bleeding
Inevitable/incomplete/missed (embryonic demise) abortion:
POC in the cervical os can result in profuse bleeding
If POC cannot be removed with gentle traction, obtain emergent OB/GYN consultation
Arrange OB/GYN follow-up if bleeding minimal
Complete abortion:
Emergent OB/GYN consultation for heavy/uncontrolled bleeding
Arrange OB/GYN follow-up if bleeding minimal
Septic abortion:
Initiate broad-spectrum antibiotic therapy
Emergent OB/GYN consultation for D&C
Late pregnancy vaginal bleeding:
Hemodynamic stabilization:
Fluid resuscitation
Positioning of patient onto left side or displacement of uterus laterally to relieve compression on IVC
DIC:
Associated with late pregnancy bleeding
Especially with placental abruption
Treated with blood products
Immediate obstetric consultation and rapid transfer to obstetric unit
Medication
First Line Medication:
Anti-Rh0 (D) immune globulin: <12 wk–50 mcg IM; >12 wk–300 mcg IM
Methotrexate:
Variable dosing regimens
Only recommended for hemodynamically stable women with unruptured ectopic pregnancy with low β-hCG
Should always consult OB/GYN prior to administration
Antibiotics for septic abortion:
Multiple acceptable antibiotic regimens
Must provide polymicrobial coverage
Second Line Medication:
Misoprostol has been used in completed abortion to facilitate uterine evacuation in completed miscarriage
Ongoing Care
Disposition
Admission Criteria
Early pregnancy vaginal bleeding with:
Unstable vital signs or significant bleeding
Ruptured ectopic pregnancy
Incomplete abortion (open os)
Septic abortion
All patients with late pregnancy vaginal bleeding need to be admitted to a labor and delivery unit
Discharge Criteria
Stable patients with threatened abortion, complete abortion, embryonic demise, or anembryonic gestation
Asymptomatic, hemodynamically stable patient with small, unruptured ectopic (or suspected ectopic) pregnancy after
OB/GYN consultation
Controlled bleeding from vaginal/cervical source
Issues for Referral
Patients with embryonic demise, anembryonic gestation, or gestational trophoblastic disease need to be referred for
uterine evacuation if D&C not performed in ED
Women with threatened, inevitable, complete, or missed (embryonic demise) abortion should have OB/GYN follow-up
within 24–48 hr
Consult OB/GYN for patients with a pregnancy of unknown location on US
Follow-Up Recommendations
Discharge instructions:
No strenuous activity, tampon use, douching, or intercourse
Seek medical advice for increased pain, bleeding, fever, or passage of tissue
All pregnant women with vaginal bleeding during pregnancy who are discharged from the ED require follow-up care
Women with threatened abortions, known or suspected ectopic pregnancy require repeat β-hCG testing and repeat
exams in 2 d
Pearls and Pitfalls
Failure to check Rh status in pregnant women with vaginal bleeding
Failure to give anti-Rh0 (D) immune globulin in Rh-negative women with vaginal bleeding
Failure to obtain pelvic US in symptomatic pregnant women with first-trimester pregnancy regardless of β-hCG level
Placenta previa or vasa previa must be ruled out by US prior to pelvic exam in late pregnancy
Additional Reading
Hahn SA, Promes SB, Brown MD, et al. Clinical policy: Critical issues in the initial evaluation and management of patients
presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017;69(2):241–250.e20.
Robertson JJ, Long B, Koyfman A. Emergency medicine myths: Ectopic pregnancy evaluation, risk factors, and
presentation. J Emerg Med. 2017;53(6):819–828.
Tubal ectopic pregnancy. ACOG Practice Bulletin No. 193. American College of Obstetricians and Gynecologists. Obstet
Gynecol. 2018;131(3):e91–e103.
See Also
Abortion, Spontaneous
Ectopic Pregnancy
Hydatidiform Mole
Placental Abruption
Placenta Previa
Postpartum Hemorrhage
Authors
Paul Ishimine
© Wolters Kluwer Health Lippincott Williams & Wilkins