Management of Bleeding in Early
Pregnancy
Best Practices in Maternal
and Newborn Care
JHPIEGO in partnership with
Save the Children, The Futures Group,
The Academy for Educational Development,
The American College of Nurse-Midwives and
Interchurch Medical Assistance
Session Objectives
• To describe best practices for diagnosis of
vaginal bleeding in early pregnancy
• To describe best practices for management of
vaginal bleeding during early pregnancy
• To list post-abortion family planning options
Vaginal Bleeding in Early
Pregnancy
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Case Study
• Let everyone read Case Study 1 and discuss in
group.
Vaginal Bleeding in Early
Pregnancy
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Definition and Incidence
•Bleeding in Early Pregnancy is:
–Vaginal bleeding that occurs during
the first 22 weeks of pregnancy
–May occur in up to 25% of all
pregnancies
Vaginal Bleeding in Early
Pregnancy
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What may cause bleeding . . .
. . . in early pregnancy?
Vaginal Bleeding in Early
Pregnancy
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Bleeding in Early Pregnancy:
Diagnosis of Abortion
• Threatened abortion
• Inevitable abortion
• Incomplete abortion
• Complete abortion
• Septic abortion
• Missed abortion
• Ectopic pregnancy
• Molar pregnancy
Vaginal Bleeding in Early
Pregnancy
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Types of abortions (1)
• Inevitable Abortion
• Threatened
Abortion
– Uterine bleeding
– Cervix closed
– Risk of Complete
Abortion: 50%
– Bleeding and/or
rupture of gestational
sac <20 weeks
– Cervix dilated
– Menstrual-type
cramping
– No products of
conception expelled yet
Vaginal Bleeding in Early
Pregnancy
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Types of abortions (2)
• Incomplete
• Complete Abortion
Abortion
– Incomplete
evacuation of
products of
conception
– Complete evacuation
of products of
conception
– Difficult to
differentiate from
Incomplete Abortion
• May require dilatation
and curettage for
diagnosis
Vaginal Bleeding in Early
Pregnancy
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Types of abortions (3)
• Missed Abortion
(fetal demise)
– Retained non-viable
products of
conception, up to 4
weeks
– May cause
coagulopathy
• Septic abortion
– Abortion
complicated by
infection
Vaginal Bleeding in Early
Pregnancy
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Types of abortions (4)
• Spontaneous
Abortion
– Gestational age
<20 weeks
– Weight <500 grams
• Induced Abortion
– Elective Abortion or
– Therapeutic
Abortion
Vaginal Bleeding in Early
Pregnancy
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Ectopic pregnancy
• The result of an
abnormality in human
reproductive physiology
that allows the conceptus
to implant and mature
outside the endometrial
cavity, which ultimately
ends in the death of the
fetus.
Ectopic pregnancy sites
Source: Vicken Sepillan, MD. Dept. of
OB/GYN, Univ. of Texas
Vaginal Bleeding in Early
Pregnancy
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Bleeding in Early Pregnancy:
General Management
• Rapid evaluation of woman’s general condition
including vital signs (pulse, blood pressure,
respiration, temperature)
• If shock suspected, immediately begin
treatment.
• If woman is in shock, consider ruptured ectopic
pregnancy.
• Start an IV infusion and infuse IV fluids.
Vaginal Bleeding in Early
Pregnancy
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Management of Threatened
Abortion
• Medical treatment usually not necessary.
• Advise woman to avoid strenuous activity and sexual
intercourse; bed rest not necessary.
• If bleeding stops, followup in antenatal clinic. Reassess if
bleeding recurs.
• If bleeding persists, assess for fetal viability (pregnancy
test/ultrasound) or ectopic pregnancy (ultrasound).
Persistent bleeding, esp. in the presence of uterus larger
than expected may indicate twins or molar pregnancy.
Do not give medications such as hormones (e.g. estrogens or
progestins) or tocolytic agents (e.g. salbutamol or
indomethacin) as they will not prevent miscarriage.
Vaginal Bleeding in Early
Pregnancy
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Management of Inevitable
Abortion
• If pregnancy is less than 16 weeks, plan for
evacuation of uterine contents. If evacuation
not immediately possible:
– Give ergometrine 0.2 mg IM (repeated after 15 min. if
necessary) OR misoprostol 400 mcg by mouth
(repeated once after 4 hours if necessary);
– Arrange for evacuation as soon as possible.
• Ensure follow-up after treatment.
Vaginal Bleeding in Early
Pregnancy
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Inevitable abortion contd.
• If pregnancy is greater than 16
weeks:
– Await spontaneous expulsion of
products of conception and then
evacuate uterus to remove any
remaining products of conception
– If necessary, infuse oxytocin 40
units in 1 L IV fluids at 40
drops/min to help expulsion of
products of conception
Vaginal Bleeding in Early
Pregnancy
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Management of Incomplete
Abortion: Less than 16 Weeks
• If bleeding light to moderate, use fingers or ring
(or sponge) forceps to remove products of
conception protruding through cervix.
• If bleeding heavy, evacuate uterus:
– Manual vacuum aspiration (MVA) is preferred method.
Sharp curettage should only be done if MVA not available
– If evacuation not immediately possible, give ergometrine
0.2 mg IM (repeated after 15 min. if necessary) OR
misoprostol 400 mcg orally (repeated once after 4 hours if
necessary).
– Ensure followup of the woman after treatment.
Vaginal Bleeding in Early
Pregnancy
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Manual Vacuum Aspiration
(MVA) of uterus
Vaginal Bleeding in Early
Pregnancy
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Management of Incomplete
Abortion: Greater than 16
Weeks
• Infuse oxytocin 40 units in 1 L IV fluids at 40
drops/min. until expulsion of POC occurs
• Evacuate any remaining products of conception
from uterus by dilatation and curettage
• If necessary, give misoprostol 200 mcg vaginally
every 4 hours until expulsion, but do not administer
more than 800 mcg.
• Ensure followup of the woman after treatment.
Vaginal Bleeding in Early
Pregnancy
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Bleeding in Early Pregnancy:
Management of Complete
Abortion
• Evacuation of the uterus usually not
necessary
• Observe for heavy bleeding
• Ensure followup of woman after
treatment
Vaginal Bleeding in Early
Pregnancy
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Bleeding in Early Pregnancy:
Followup after Abortion
• Tell woman that spontaneous abortion is
common.
• Reassure woman that chances for
subsequent successful pregnancy are good
unless there has been sepsis or unless cause
of abortion is identified that may have an
adverse effect on future pregnancies (rare).
Vaginal Bleeding in Early
Pregnancy
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Follow-up after spontaneous
abortion
• Encourage her to delay next pregnancy until
completely recovered.
• Provide counseling for women who have had
unsafe abortion. If pregnancy not desired, certain
FP methods can be started immediately (within
7 days) if:
– There are no severe complications requiring further
treatment
– Woman receives adequate counseling and help in selecting
most appropriate FP method.
Vaginal Bleeding in Early
Pregnancy
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Family Planning Methods after
Post-abortion Care
Type of FP
Method
Hormonal
Condoms
IUD
Or
Voluntary
Tubal Ligation
Advise to Start
Immediately
Immediately
Immediately
If infection present or suspected, delay
insertion/surgery until cleared
If Hb < 7 g/dL, delay until anemia
improves
Provide interim method (e.g. condom)
Vaginal Bleeding in Early
Pregnancy
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ECTOPIC
PREGNANCY
• Pregnancy which is
outside the uterine
cavity
– Can be in the tube, ovary,
abdomen or other
locations
– If it ruptures, can lead to
hemorrhage and death
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Pregnancy
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Ectopic Pregnancy:
Clinical Diagnosis
• Symptoms:
– Pain: 90-100% of patients
– Amenorrhea/abnormal menses:
75-95%
– Irregular bleeding: 50-80%
– Pregnancy symptoms: 10-25%
Weckstein 1987.
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Pregnancy
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Ectopic pregnancy:
Clinical Diagnosis (cont’d)
• Signs:
– Afebrile
– Abdominal tenderness: 80-95%
– Rebound tenderness: 45%
– Palpable mass: 50% (often opposite side)
– Normal sized uterus: 71%
• Use combination testing to increase
sensitivity and specificity
Vaginal Bleeding in Early
Pregnancy
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Signs and Symptoms of
Unruptured Ectopic Pregnancy
• Symptoms of early pregnancy
– Irregular spotting or bleeding
– Nausea
– Swelling of breasts
– Bluish discoloration of vagina and cervix
– Softening of cervix
– Slight uterine enlargement
– Increased urinary frequency
• Abdominal and pelvic pain
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Pregnancy
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Signs and Symptoms of
Ruptured Ectopic Pregnancy
• Collapse and weakness
• Fast, weak pulse (≥110/minute)
• Hypotension
• Hypovolemia
• Acute abdominal and pelvic pain
• Abdominal distension
• Rebound tenderness
• Pallor
Vaginal Bleeding in Early
Pregnancy
Ruptured ectopic pregnancy
seen through a laparoscope
Source: Vicken Sepillan, MD
Dept. of OB/GYN, Univ. of Texas
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Differential Diagnosis for Ectopic
Pregnancy
• Threatened abortion
• Acute or chronic PID
• Ovarian cysts
(torsion or rupture)
• Acute appendicitis
• Remember: A ruptured ectopic pregnancy could
be life-threatening!
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Pregnancy
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Treatment of Ectopic Pregnancy
• Surgical-Salpingectomy (removal of
the pregnancy or tube)
• Also treated medically, although not
available in developing countries
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Pregnancy
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Molar pregnancy
• Symptoms and signs:
– Heavy bleeding
– Dilated cervix
– Uterus larger than dates
– Uterus softer than
normal
– Partial expulsion of
products of conception
which resemble grapes
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Pregnancy
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Molar pregnancy contd.
Gross and histology
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Pregnancy
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Molar Pregnancy contd.
• If diagnosis of molar pregnancy is certain,
evacuate the uterus:
– Use vacuum aspiration
• Risk of perforation using a metal curette is high
• Have three syringes cocked and ready for use as
uterine contents are copious and must be evacuated
rapidly
– Infuse oxytocin 20 units in 1 L IV (NS or RL)
at 60 drops/minute to prevent hemorrhage once
evacuation is under way
Vaginal Bleeding in Early
Pregnancy
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Molar pregnancy contd.
• Subsequent management
– Use contraception for at least one year
– Follow up every 8 weeks for at least one year to
monitor for trophoblastic disease or
choriocarcinoma
Vaginal Bleeding in Early
Pregnancy
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Summary
• Vaginal bleeding in early pregnancy could be
caused by:
– Threatened abortion
– Incomplete abortion
– Complete abortion
– Ectopic pregnancy
– Molar pregnancy
• Diagnosis can often be made clinically, saving
time and expense
• Treatment should be directed at the aetiology
Vaginal Bleeding in Early
Pregnancy
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References
• Ganges F. Bleeding in Early Pregnancy, a presentation in Accra,
•
•
•
•
Ghana, Basic Maternal and Newborn Care Technical Update.
April, 2006.
Jongen V. 1996. Ectopic pregnancy and culdo-abdominocentesis.
Int J Gynecol Obstet 55: 75-76.
Musnick RA. 1982. Clinical test for placenta in 300 consecutive
menstrual aspirations. Obstet Gynecol 60:738-741.
Weckstein LN. 1987. Clinical diagnosis of ectopic pregnancy.
Clin Obstet and Gynecol 30(1):236-244.
WHO. Managing Complications in Pregnancy and Childbirth.
WHO. Geneva. 2000
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Pregnancy
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