Vaginal Bleeding During Early Pregnancy

History of present illness should include the following:

• Estimated due date (and whether this is based on last menstrual period or ultrasonography)

• Any risk factors for obstetric complications and prior testing or complications during the current pregnancy

• Description and amount of bleeding, including how many pads were soaked and whether clots or tissue were passed

• Presence or absence of pain

The patient should be asked questions to determine whether it is certain that the source of the bleeding is vaginal. Urinary or gastrointestinal tract bleeding can sometimes be mistaken for vaginal bleeding.

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 gravidity (number of confirmed pregnancies), parity (number of term and preterm deliveries), number of abortions (spontaneous or induced), and risk factors for ectopic pregnancy and spontaneous abortion.

Evaluation of patients during pregnancy should include routine prenatal evaluation to assess maternal and fetal status, including

• Assessment of maternal vital signs

• Abdominal examination for fundal height

• Sometimes, pelvic examination

• Evaluation of fetal status with fetal heart rate auscultation

• Sometimes pelvic ultrasonography (depending on symptoms and gestational age)

Physical examination directed at evaluating vaginal bleeding 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 gestational tissue in the os.

Bimanual examination should check for cervical motion tenderness, adnexal masses or tenderness, and uterine size.

The following findings are of particular concern:

• Hemodynamic instability (hypotension, tachycardia, or both)

• Orthostatic changes in pulse or blood pressure

• Syncope or near-syncope

• Peritoneal signs (rebound, rigidity, guarding)

• Fever, chills, and mucopurulent vaginal discharge

Clinical findings help suggest a cause but are rarely diagnostic (see table Some Causes of Vaginal Bleeding). However, a dilated cervix plus passage of apparent 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.

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

• Quantitative beta-hCG level

• Blood typing and Rh testing

• Usually ultrasonography

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), fibrinogen level, and fibrin split products are also determined.

Transvaginal pelvic ultrasonography is done to confirm an intrauterine pregnancy. If products of conception have been obtained intact, transvaginal pelvic ultrasonography is also suggested to confirm completed abortion and absence of retained products of conception. 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, but there is not absolute correlation between a certain hCG level and gestational age, due to variability and sometimes multiple gestation.

In addition, 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 zone is the level of beta-hCG above which a transvaginal ultrasound should be able to visualize a gestational sac with a yolk sac, a finding that confirms an intrauterine pregnancy. Levels of ≥ 1000 to 2000 mIU/mL are commonly used as the discriminatory zone; however, some studies show that a gestational sac may not be visualized until the hCG is ≥ 3510 IU/L (1). The discriminatory level at the facility where the test is done should be used to guide clinical management (2). In stable patients, serial ultrasonography can help guide management when beta-hCG levels are near this discriminatory zone.

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.

1. 1. Connolly A, Ryan DH, Stuebe AM, Wolfe HM: Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol 121(1):65-70, 2013. doi:10.1097/aog.0b013e318278f421

2. 2. Doubilet PM, Benson CB: J Ultrasound Med 30 (12):1637–1642, 2011. doi:10.7863/jum.2011.30.12.1637