Vaginal bleeding during pregnancy

Vaginal bleeding during pregnancy has many causes and ranges in severity from mild (with normal pregnancy outcome) to life-threatening for both infant and mother. The bleeding can vary from scant to excessive, from brown to bright red, and can be painless or painful. The different causes can be divided into vaginal, cervical and uterine factors.

The differential diagnosis is guided by the gestational age of the pregnancy.

Incidence/Prevalence in USA: Common

SIGNS AND SYMPTOMS

Bleeding can vary from scant to excessive

Color of blood varies from brown to bright red

May be painless or painful

CAUSES

Vaginal infection or trauma

Cervicitis

Cervical polyp

Cervical neoplasia

Hyperemia of cervix

Postcoital bleeding

Ectopic pregnancy

Molar pregnancy

Implantation bleeding

Spontaneous abortion

Placenta previa

Placental abruption

Bloody show

Unknown - 50% of first trimester bleeding, no cause ever found

RISK FACTORS

Varies, based on individual causes

DIAGNOSIS

Vaginal or cervical causes can occur throughout the pregnancy

First trimester bleeding - ectopic pregnancy, molar pregnancy, or spontaneous abortion

Second or third trimester bleeding - placenta previa, placental abruptio, or bloody show

LABORATORY

CBC

Quantitative beta human chorionic gonadotropin (HCG) - in early pregnancy bleeding; follow serially every couple of days. Levels fall in spontaneous abortion, are extremely high in molar pregnancy, and rise gradually in ectopic or intrauterine pregnancy. This level usually doubles in 48 hours in normal pregnancy, and failure to double is a concern for ectopic pregnancy.

Blood type and screen - Rh negative patients need Rho(D) immune globulin (RhoGAM). If bleeding profuse, a transfusion may be required.

Coagulation studies (fibrinogen, fibrin split products, platelets) - useful in late pregnancy bleeding and missed abortion

IMAGING

Ultrasound - gestational sac seen at 5-6 weeks, fetal heart tones at 8-9 weeks. Diagnostic of molar pregnancy with 98% accuracy, locates placenta, may show degree of placental separation in abruptio.

Serial ultrasound may be required in early pregnancy to make diagnosis

DIAGNOSTIC PROCEDURES

In first trimester bleeding - pelvic exam, culdocentesis, laparoscopy, laparotomy

In second or third trimester bleeding - locate placenta by ultrasound prior to pelvic exam. If placenta previa, do not perform bimanual or speculum exam unless set up for immediate cesarean delivery.

TREATMENT

APPROPIATE HEALTH CARE

In first trimester bleeding most patients can be managed as outpatient

In late pregnancy bleeding, most patients need inpatient monitoring

GENERAL MEASURES

In late pregnancy bleeding, the amount of bleeding and presence of maternal or fetal compromise indicates whether emergent cesarean section is performed or whether conservative measures are appropriate until greater fetal maturity can be obtained

Threatened abortion: Bedrest and nothing in the vagina. If bleeding is severe, hospitalization and close observation. Type and screen for possible transfusion

SURGICAL MEASURES

If ectopic or molar pregnancy is diagnosed immediate surgical treatment is appropriate

Inevitable or incomplete abortion: D&C (usually suction)

If completeness of abortion is in doubt, then D&C and removal of retained products

ACTIVITY Bedrest, no coitus, no douching

DIET No restrictions

PATIENT EDUCATION

Patient should be instructed to report any increase in the amount and frequency of bleeding and should seek immediate care if experiencing abdominal pain or sudden increased bleeding. She should bring for examination any tissue passed vaginally.

Grief counseling is appropriate if pregnancy loss is inevitable

MEDICATIONS

DRUG(S) OF CHOICE

None

FOLLOWUP

PATIENT MONITORING

Daily to weekly depending on diagnosis and severity of bleeding

POSSIBLE COMPLICATIONS

Anemia

Shock

Fetal or maternal death

Infection

Choriocarcinoma or invasive mole in the case of hydatidiform mole

Premature delivery of infant with associated complications

Coagulopathy

EXPECTED COURSE/PROGNOSIS

Depends on the cause of vaginal bleeding, the severity of bleeding and the rapidity of diagnosis. Maternal mortality is 1 in 826 of ectopic pregnancies.