Vaginal Bleeding During Early Pregnancy: A Merck Manual of Patient Symptoms podcast

Vaginal bleeding occurs in 20 to 30% of confirmed pregnancies during the first 20 wk of gestation; about half of these cases end in spontaneous abortion. Vaginal bleeding is also associated with other adverse pregnancy outcomes such as low birth weight, preterm birth, stillbirth, and perinatal death.

Etiology

Obstetric or nonobstetric disorders may cause vaginal bleeding during early pregnancy (see Table 2: Symptoms During Pregnancy: Some Causes of Vaginal Bleeding During Early Pregnancy).

The most dangerous cause is

• Ruptured ectopic pregnancy

The most common cause is

• Spontaneous abortion (threatened, inevitable, incomplete, complete, septic, missed)

Table 2
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Some Causes of Vaginal Bleeding During Early Pregnancy Cause Suggestive Findings Diagnostic Approach Obstetric disorders Ectopic pregnancy Vaginal bleeding, abdominal pain (often sudden, localized, and constant, not crampy), or both Closed cervical os Sometimes a palpable, tender adnexal mass Possible hemodynamic instability if ectopic pregnancy is ruptured Quantitative β-hCG measurement CBC Blood typing Pelvic ultrasonography Threatened abortion Vaginal bleeding with or without crampy abdominal pain Closed cervical os, nontender adnexa Most common during the first 12 wk of pregnancy Evaluation as for ectopic pregnancy Inevitable abortion Crampy abdominal pain, vaginal bleeding Open cervical os (dilated cervix) Products of conception often seen or felt through os Evaluation as for ectopic pregnancy Incomplete abortion Vaginal bleeding, abdominal pain Open or closed cervical os Products of conception often seen or felt through os Evaluation as for ectopic pregnancy Complete abortion Mild vaginal bleeding at presentation but usually a history of significant vaginal bleeding immediately preceding visit; some abdominal pain Closed cervical os, small and contracted uterus Evaluation as for ectopic pregnancy Septic abortion Fever, chills, continuous abdominal pain, vaginal bleeding, purulent vaginal discharge Usually, apparent history of recent induced abortion or instrumentation of the uterus (often illegal or self-induced) Open cervical os Evaluation as for ectopic pregnancy plus cervical cultures Missed abortion Vaginal bleeding, symptoms of early pregnancy (nausea, fatigue, breast tenderness) that decrease with time Closed cervical os Evaluation as for ectopic pregnancy Gestational trophoblastic disease Larger-than-expected uterine size, often elevated BP, severe vomiting, sometimes passage of grapelike tissue Evaluation as for ectopic pregnancy Ruptured corpus luteum cyst Localized abdominal pain, vaginal bleeding Most common during the first 12 wk of pregnancy Evaluation as for ectopic pregnancy Nonobstetric disorders Trauma Apparent from history (eg, laceration of the cervix or vagina due to instrumentation or abuse, sometimes a complication of chorionic villus sampling or amniocentesis) Clinical evaluation Questions about possible domestic violence if appropriate Vaginitis Only spotting or scant bleeding with vaginal discharge Sometimes dyspareunia, pelvic pain, or both Diagnosis of exclusion Cervical cultures Cervicitis Only spotting or scant bleeding Sometimes cervical motion tenderness, abdominal pain, or both Diagnosis of exclusion Cervical cultures Cervical polyps (usually benign) Scant bleeding, no pain Polypoid mass protruding from cervix Clinical evaluation Obstetric follow-up for further evaluation and removal β-hCG = β subunit of human chorionic gonadotropin. Some Causes of Vaginal Bleeding During Early Pregnancy Cause Suggestive Findings Diagnostic Approach Obstetric disorders Ectopic pregnancy Vaginal bleeding, abdominal pain (often sudden, localized, and constant, not crampy), or both Closed cervical os Sometimes a palpable, tender adnexal mass Possible hemodynamic instability if ectopic pregnancy is ruptured Quantitative β-hCG measurement CBC Blood typing Pelvic ultrasonography Threatened abortion Vaginal bleeding with or without crampy abdominal pain Closed cervical os, nontender adnexa Most common during the first 12 wk of pregnancy Evaluation as for ectopic pregnancy Inevitable abortion Crampy abdominal pain, vaginal bleeding Open cervical os (dilated cervix) Products of conception often seen or felt through os Evaluation as for ectopic pregnancy Incomplete abortion Vaginal bleeding, abdominal pain Open or closed cervical os Products of conception often seen or felt through os Evaluation as for ectopic pregnancy Complete abortion Mild vaginal bleeding at presentation but usually a history of significant vaginal bleeding immediately preceding visit; some abdominal pain Closed cervical os, small and contracted uterus Evaluation as for ectopic pregnancy Septic abortion Fever, chills, continuous abdominal pain, vaginal bleeding, purulent vaginal discharge Usually, apparent history of recent induced abortion or instrumentation of the uterus (often illegal or self-induced) Open cervical os Evaluation as for ectopic pregnancy plus cervical cultures Missed abortion Vaginal bleeding, symptoms of early pregnancy (nausea, fatigue, breast tenderness) that decrease with time Closed cervical os Evaluation as for ectopic pregnancy Gestational trophoblastic disease Larger-than-expected uterine size, often elevated BP, severe vomiting, sometimes passage of grapelike tissue Evaluation as for ectopic pregnancy Ruptured corpus luteum cyst Localized abdominal pain, vaginal bleeding Most common during the first 12 wk of pregnancy Evaluation as for ectopic pregnancy Nonobstetric disorders Trauma Apparent from history (eg, laceration of the cervix or vagina due to instrumentation or abuse, sometimes a complication of chorionic villus sampling or amniocentesis) Clinical evaluation Questions about possible domestic violence if appropriate Vaginitis Only spotting or scant bleeding with vaginal discharge Sometimes dyspareunia, pelvic pain, or both Diagnosis of exclusion Cervical cultures Cervicitis Only spotting or scant bleeding Sometimes cervical motion tenderness, abdominal pain, or both Diagnosis of exclusion Cervical cultures Cervical polyps (usually benign) Scant bleeding, no pain Polypoid mass protruding from cervix Clinical evaluation Obstetric follow-up for further evaluation and removal β-hCG = β subunit of human chorionic gonadotropin.

Evaluation

A pregnant woman with vaginal bleeding must be evaluated promptly.

Ectopic pregnancy or other causes of copious vaginal bleeding (eg, inevitable abortion, ruptured hemorrhagic corpus luteum cyst) can lead to hemorrhagic shock. IV access should be established early during evaluation in case such complications occur.

History: History of present illness should include the patient's gravidity (number of confirmed pregnancies), parity (number of deliveries after 20 wk), and number of abortions (spontaneous or induced); description and amount of bleeding, including how many pads were soaked and whether clots or tissue were passed; and presence or absence of pain. If pain is present, onset, location, duration, and character should be determined.

Review of symptoms should note fever, chills, abdominal or pelvic pain, vaginal discharge, and neurologic symptoms such as dizziness, light-headedness, syncope, or near syncope.

Past medical history should include risk factors for ectopic pregnancy and spontaneous abortion (see Symptoms During Pregnancy: History).

Physical examination: Physical examination includes review of vital signs for fever and signs of hypovolemia (tachycardia, hypotension).

Evaluation focuses on abdominal and pelvic examinations. The abdomen is palpated for tenderness, peritoneal signs (rebound, rigidity, guarding), and uterine size. Fetal heart sounds should be checked with a Doppler ultrasound probe.

Pelvic examination includes inspection of external genitals, speculum examination, and bimanual examination. Blood or products of conception in the vaginal vault, if present, are removed; products of conception are sent to a laboratory for confirmation. The cervix should be inspected for discharge, dilation, lesions, polyps, and tissue in the os. If the pregnancy is < 14 wk, the cervical os may be gently probed (but no more than fingertip depth) using ringed forceps to determine the integrity of the internal cervical os. If the pregnancy is ≥ 14 wk, the cervix should not be probed because the vascular placenta may tear, especially if it covers the internal os (placenta previa). Bimanual examination should check for cervical motion tenderness, adnexal masses or tenderness, and uterine size.

Red flags: The following findings are of particular concern:

• Hemodynamic instability (hypotension, tachycardia, or both)
• Orthostatic changes in pulse or BP
• Syncope or near-syncope
• Peritoneal signs (rebound, rigidity, guarding)
• Fever, chills, and mucopurulent vaginal discharge

Interpretation of findings: Clinical findings help suggest a cause but are rarely diagnostic (see Table 2: Symptoms During Pregnancy: Some Causes of Vaginal Bleeding During Early Pregnancy). However, a dilated cervix plus passage of fetal tissue and crampy abdominal pain strongly suggests spontaneous abortion, and septic abortion is usually apparent from the circumstances and signs of severe infection (fever, toxic appearance, purulent or bloody discharge). Even if these classic manifestations are not present, threatened or missed abortion is possible, and the most serious cause—ruptured ectopic pregnancy—must be excluded. Although the classic description of ectopic pregnancy includes severe pain, peritoneal signs, and a tender adnexal mass, ectopic pregnancy can manifest in many ways and should always be considered, even when bleeding appears scant and pain appears minimal.

Testing: A self-diagnosed pregnancy is verified with a urine test. For women with a documented pregnancy, several tests are done:

• Quantitative β-hCG level
• Blood typing and Rh testing
• Usually ultrasonography

Rh testing is done to determine whether Rh₀(D) immune globulin is needed to prevent maternal sensitization. If bleeding is substantial, testing should also include CBC and either type and screen (for abnormal antibodies) or cross-matching. For major hemorrhage or shock, PT/PTT is also determined.

Transvaginal pelvic ultrasonography is done to confirm an intrauterine pregnancy unless products of conception have been obtained intact (indicating completed abortion). If patients are in shock or bleeding is substantial, ultrasonography should be done at the bedside. The quantitative β-hCG level helps interpret ultrasound results. If the level is ≥ 1500 mIU/mL and ultrasonography does not confirm an intrauterine pregnancy (a live or dead fetus), ectopic pregnancy is likely. If the level is < 1500 mIU/mL and no intrauterine pregnancy is seen, intrauterine pregnancy is still possible.

If the patient is stable and clinical suspicion for ectopic pregnancy is low, serial β-hCG levels may be done on an outpatient basis. Normally, the level doubles every 1.4 to 2.1 days up to 41 days gestation; in ectopic pregnancy (and in abortions), levels may be lower than expected by dates and usually do not double as rapidly. If clinical suspicion for ectopic pregnancy is moderate or high (eg, because of substantial blood loss, adnexal tenderness, or both), diagnostic uterine evacuation or D & C and possibly diagnostic laparoscopy should be done.

Ultrasonography can also help identify a ruptured corpus luteum cyst and gestational trophoblastic disease. It can show products of conception in the uterus, which are present in patients with incomplete, septic, or missed abortion.

Treatment

Treatment is directed at the underlying disorder:

• Ruptured ectopic pregnancy: Immediate laparoscopy or laparotomy
• Unruptured ectopic pregnancy: MethotrexateSome Trade Names
  RHEUMATREX
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  or salpingotomy or salpingectomy via laparoscopy or laparotomy
• Threatened abortion: Expectant management for hemodynamically stable patients
• Inevitable, incomplete, or missed abortions: D & C or uterine evacuation
• Septic abortion: IV antibiotics and urgent uterine evacuation if retained products of conception are identified during ultrasonography
• Complete abortion: Obstetric follow-up

Key Points

• Clinicians should always be alert for ectopic pregnancy; symptoms can be mild or severe.
• Spontaneous abortion is the most common cause of bleeding during early pregnancy.
• Rh testing is required for all women who present with vaginal bleeding during early pregnancy to determine whether Rh₀(D) immune globulin is needed.

Last full review/revision August 2009 by R. Phillips Heine, MD; Geeta K. Swamy, MD

Content last modified February 2012