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Vaginal Bleeding During Pregnancy

BASICS

DESCRIPTION

Vaginal bleeding during pregnancy has many causes and ranges from benign to life-threatening.
Etiology may involve the vagina, cervix, uterus, fetus, or placenta. The differential diagnosis depends on gestational age.

EPIDEMIOLOGY

Prevalence
- Early pregnancy: 7–25%
- Late pregnancy: 0.3–2%

ETIOLOGY AND PATHOPHYSIOLOGY

Anytime in pregnancy:
- Cervicitis (infectious or noninfectious)
- Vaginitis (infectious or noninfectious)
- Vaginal or cervical trauma (including postcoital)
- Cervical lesions (polyps, warts, neoplasia)
- Cervical hyperemia

Early pregnancy:
- Cause unknown in up to 50%
- Ectopic pregnancy: leading cause of 1st-trimester maternal death
- Risk factors: prior ectopic, tubal trauma, DES exposure, IUD, infertility, tobacco
- Spontaneous abortion:
- Risk factors: AMA, tobacco, infections (HSV, gonorrhea, listeria), uterine anomalies
- Implantation bleeding, vanishing twin, subchorionic bleeding, low-lying placenta, gestational trophoblastic disease

Late pregnancy:
- Bloody show, placenta previa (painless), placental abruption (painful), vasa previa, placenta accreta spectrum, uterine rupture

DIAGNOSIS

HISTORY

  • Quality of dating, timing, amount, obstetric history
  • Early pregnancy: nausea/vomiting, suprapubic pain
  • Late pregnancy: contractions, abdominal pain, fetal movements

PHYSICAL EXAM

  • Vitals: check for hypotension, thready pulse
  • Abdomen: uterine tenderness, fundal height
  • Speculum: localize source of bleeding
  • Fetal monitoring: Doppler or EFM depending on gestational age

DIFFERENTIAL DIAGNOSIS

  • Hematuria
  • Rectal bleeding

DIAGNOSTIC TESTS & INTERPRETATION

Initial labs

  • CBC, Blood type and screen
  • Quantitative Ξ²-hCG:
  • Normal pregnancy: doubles or rises β‰₯66% in 48 hrs
  • Spontaneous abortion: fall
  • Ectopic: plateau or slow rise
  • Molar: very high Ξ²-hCG
  • Progesterone level:
  • \<5: nonviable
  • >25: viable
  • 5–25: equivocal
  • Other: Wet mount, STI screen, INR/PT/PTT, Kleihauer-Betke

Ultrasound

  • Early pregnancy:
  • Gestational sac at 5–6 wks, heartbeat by 8–9 wks
  • Ectopic diagnosis: Ξ²-hCG > 1500–2000 with no IUP
  • Late pregnancy:
  • Rule out placenta previa, abruption, and labor

ALERT: Confirm fetal position and placenta location before any cervical exam

TREATMENT

MEDICATIONS

  • Treat underlying cause
  • RhoGAM if Rh-negative
  • Betamethasone if \<36 wks + preterm labor
  • Progesterone for threatened abortion (RR 0.53)
  • Blood products if inherited bleeding disorder or severe hemorrhage

SURGERY / PROCEDURES

  • Cesarean for placenta/vasa previa bleeding
  • Ectopic: may need surgery
  • Molar pregnancy: uterine evacuation
  • Incomplete abortion: expectant, medical, or surgical (D&C or aspiration)

ADMISSION & NURSING CONSIDERATIONS

  • Early pregnancy: consider for surgical treatment, infection
  • Late pregnancy: consider for trauma, preterm labor, fetal monitoring
  • Discharge if stable, previa/abruption/labor ruled out

ONGOING CARE

FOLLOW-UP

  • Report fever, dizziness, increased bleeding, abdominal pain
  • Save passed tissue
  • Follow-up depends on underlying cause

PATIENT EDUCATION

  • AAFP: https://www.familydoctor.org
  • ACOG: https://www.acog.org

PROGNOSIS

  • Depends on cause, bleeding severity, diagnosis speed
  • Ectopic mortality: 31.9/100,000
  • With fetal heart activity: \<10% risk of miscarriage
  • Subchorionic bleeding: ↑ risk of abortion (2–3x); small bleeds fare better
  • Risks in current pregnancy: preterm labor, abruption, cesarean, fetal issues
  • Recurrence of bleeding more likely in future pregnancies

CLINICAL PEARLS

  • Always obtain blood type/screen and give RhoGAM if Rh-negative
  • Ectopic must be excluded in any early pregnancy bleeding
  • Avoid digital exam until placenta previa ruled out

CODES

ICD-10
- O20.9: Hemorrhage in early pregnancy, unspecified
- O46.90: Antepartum hemorrhage, unspecified
- O20.0: Threatened abortion

REFERENCES

  1. Crochet JR et al. JAMA. 2013;309(16):1722–1729.
  2. Deutchman M et al. Am Fam Physician. 2009;79(11):985–994.
  3. Wahabi HA et al. Cochrane Database Syst Rev. 2011;(12):CD005943.
  4. Snell BJ. Womens Health. 2009;54(6):483–491.
  5. Nanda K et al. Cochrane Database Syst Rev. 2012;(3):CD003518.

Additional Reading: Al-Ma'ani W, Chi C, Prine LW, etc.

See Also:
- Abnormal Pap
- Abruptio Placentae
- Cervical Malignancy
- Placenta Previa
- Preterm Labor