Some Causes of Vaginal Bleeding During Early Pregnancy
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Obstetric disorders | ||
Vaginal bleeding with or without abdominal or pelvic pain (often sudden, localized, and constant, not crampy) Closed cervical os No fetal heart sounds Possible hemodynamic instability if ectopic pregnancy is ruptured Sometimes, a palpable adnexal mass | Quantitative beta-hCG measurement, repeated every 2 days if diagnosis is uncertain Complete blood count Pelvic ultrasonography Sometimes, endometrial sampling Laparoscopy or, if the patient is hemodynamically unstable, laparotomy | |
Threatened abortion | Vaginal bleeding with or without crampy abdominal pain Closed cervical os | Fetal heart rate auscultation Quantitative beta-hCG measurement Complete blood count Pelvic ultrasonography |
Inevitable abortion | Vaginal bleeding with crampy abdominal pain Open cervical os (dilated cervix) | Evaluation as for threatened abortion |
Incomplete abortion | Vaginal bleeding with crampy abdominal pain Open or closed cervical os Products of conception often seen or felt through os | Evaluation as for threatened abortion |
Complete abortion | Mild vaginal bleeding at presentation but usually a history of significant vaginal bleeding immediately preceding visit; sometimes, with mild, crampy abdominal pain Closed cervical os; uterus is nonpregnant size | Evaluation as for threatened abortion |
Usually, history of recent induced or spontaneous abortion (risk is higher if induced abortion is performed without appropriately trained clinicians and equipment or if self-induced) Fever, chills, constant abdominal or pelvic pain Vaginal bleeding and/or purulent vaginal discharge Uterine tenderness Open cervical os | Evaluation as for threatened abortion plus evaluation for STIs and vaginitis | |
Gestational trophoblastic disease (hydatidiform mole) | Vaginal bleeding, with or without crampy abdominal pain Larger-than-expected uterine size, often elevated blood pressure, severe vomiting If more advanced, sometimes passage of grapelike tissue from the vagina | Evaluation as for threatened abortion plus thyroid tests, creatinine, liver tests, chest x-ray |
Ruptured corpus luteum cyst | Localized abdominal pain, vaginal bleeding, sometimes nausea and vomiting Sudden onset of symptoms | Evaluation as for ectopic pregnancy |
Gynecologic or other disorders | ||
Trauma | History or suspicion of physical trauma (eg, motor vehicle accident, laceration of the cervix or vagina due to instrumentation or sexual assault, sometimes a complication of chorionic villus sampling or amniocentesis) | Complete blood count Pelvic ultrasonography (to evaluate fetus) Other imaging studies (to evaluate for injury or internal bleeding) Questions about possible intimate partner violence or sexual assault, if suspected |
Spotting or scant bleeding with vaginal discharge Sometimes, dyspareunia | Evaluation for vaginitis and STIs | |
Mucopurulent cervical discharge Sometimes, scant vaginal bleeding Sometimes, cervical motion tenderness, abdominal pain, or both | Evaluation for STIs and vaginitis | |
Scant vaginal bleeding, no pain Polypoid mass protruding from cervix | Pelvic examination Histology of specimen after biopsy or removal | |
Beta-hCG = | ||
* Evaluation of concerning symptoms in all pregnant patients should include assessment of maternal vital signs, physical examination, and evaluation of fetal status with fetal heart rate monitoring or ultrasonography. | ||