Vaginal bleeding occurs in 20 to 30% of confirmed pregnancies during the first 20 weeks of gestation; about half of these cases end in spontaneous abortion.
Vaginal bleeding is also associated with other adverse pregnancy outcomes such as the following:
Etiology
Obstetric or nonobstetric disorders may cause vaginal bleeding during early pregnancy (see table Some Causes of Vaginal Bleeding During Early Pregnancy).
The most dangerous cause of vaginal bleeding during early pregnancy is
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Ruptured ectopic pregnancy
A ruptured corpus luteum cyst, although less common, is also possible and potentially dangerous and can cause hemoperitoneum and shock.
The most common cause is
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Spontaneous abortion (threatened, inevitable, incomplete, complete, septic, missed)
Some Causes of Vaginal Bleeding During Early Pregnancy
Cause |
Suggestive Findings |
Diagnostic Approach |
Obstetric disorders |
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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 beta-hCG measurement Complete blood count Blood typing Pelvic ultrasonography |
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Threatened abortion |
Vaginal bleeding with or without crampy abdominal pain Closed cervical os, nontender adnexa Most common during the first 12 weeks of pregnancy |
Evaluation as for ectopic pregnancy |
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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 |
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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 |
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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 |
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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 |
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Missed abortion |
Vaginal bleeding, symptoms of early pregnancy (nausea, fatigue, breast tenderness) that decrease with time Closed cervical os |
Evaluation as for ectopic pregnancy |
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Larger-than-expected uterine size, often elevated blood pressure, severe vomiting, sometimes passage of grapelike tissue |
Evaluation as for ectopic pregnancy |
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Ruptured corpus luteum cyst |
Localized abdominal pain, vaginal bleeding, nausea and vomiting Sudden onset of symptoms Most common during the first 12 weeks of pregnancy |
Evaluation as for ectopic pregnancy |
Nonobstetric disorders |
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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 |
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Only spotting or scant bleeding with vaginal discharge Sometimes dyspareunia, pelvic pain, or both |
Diagnosis of exclusion Evaluation for STDs and vaginitis |
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Only spotting or scant bleeding Sometimes cervical motion tenderness, abdominal pain, or both |
Diagnosis of exclusion Evaluation for STDs and vaginitis |
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Cervical polyps (usually benign) |
Scant bleeding, no pain Polypoid mass protruding from cervix |
Clinical evaluation Obstetric follow-up for further evaluation and removal |
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Beta-hCG = beta subunit of human chorionic gonadotropin; STDs = sexually transmitted diseases. |
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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 following:
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.
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 weeks, 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 weeks, 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
Interpretation of findings
Clinical findings help suggest a cause but are rarely diagnostic (see table Some Causes of Vaginal Bleeding). 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:
Rh testing is done to determine whether Rho(D) immune globulin is needed to prevent maternal sensitization. If bleeding is substantial, testing should also include complete blood count and either type and screen (for abnormal antibodies) or cross-matching. For major hemorrhage or shock, prothrombin time/partial thromboplastin time (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 beta-hCG level helps interpret ultrasound results. Beta-hCG levels of ≥1000 to 2000 mIU/mL are commonly used as the discriminatory level; if the level is above the discriminatory level, a gestational sac may be visible if the pregnancy is intrauterine. However, intrauterine pregnancy is still possible even if it is not seen on transvaginal ultrasonography. No established beta-hCG level can exclude an intrauterine pregnancy. The discriminatory level at the facility where the test is done should be used to guide clinical management. (1). In stable patients, serial ultrasonography can help guide management when beta-hCG levels are near this discriminatory level.
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.
If the patient is stable and clinical suspicion for ectopic pregnancy is low, serial beta-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 dilation and curettage (D & C) or diagnostic laparoscopy should be considered.
Diagnosis reference
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1. Doubilet PM, Benson CB: Further evidence against the reliability of the human chorionic gonadotropin discriminatory level. J Ultrasound Med 30 (12):1637–1642, 2011. doi:10.7863/jum.2011.30.12.1637
Treatment
Treatment of vaginal bleeding during early pregnancy is directed at the underlying disorder:
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Ruptured ectopic pregnancy: Immediate laparoscopy or laparotomy
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Unruptured ectopic pregnancy: Methotrexate or salpingotomy or salpingectomy via laparoscopy or laparotomy
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Threatened abortion: Expectant management for hemodynamically stable patients
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Inevitable, incomplete, or missed abortions: D & C or uterine evacuation
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Septic abortion: IV antibiotics and urgent uterine evacuation if retained products of conception are identified during ultrasonography
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Complete abortion: Obstetric follow-up
Key Points
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If patients have vaginal bleeding during early pregnancy, always be alert for ectopic pregnancy; symptoms can be mild or severe.
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Spontaneous abortion is the most common cause of bleeding during early pregnancy.
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Always do Rh testing for women who present with vaginal bleeding during early pregnancy to determine whether Rho(D) immune globulin is needed.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
immune globulin |
Gammagard S/D |
Methotrexate |
OTREXUP |
