Vaginal Bleeding During Pregnancy

What is Vaginal Bleeding During Pregnancy

Vaginal bleeding during pregnancy is common, particularly in the first trimester, and may arise from disruption of blood vessels in the decidua or from cervical, vaginal, or uterine pathology

Vaginal Bleeding During First Trimester of Pregnancy

A small amount of bleeding from the vagina (spotting) is relatively common during early pregnancy. It usually stops on its own. Various things may cause bleeding or spotting during early pregnancy.

Some bleeding may be related to the pregnancy, and some may not. In many cases, the bleeding is normal and is not a problem. However, bleeding can also be a sign of something serious. Be sure to tell your health care provider about any vaginal bleeding right away.

Here are the most common causes of vaginal bleeding during the first trimester

  • Infection or inflammation of the cervix.
  • Growths (polyps) on the cervix.
  • Miscarriage or threatened miscarriage.
  • Pregnancy tissue developing outside of the uterus (ectopic pregnancy).
  • A mass of tissue developing in the uterus due to an egg being fertilized incorrectly (molar pregnancy).

Follow these instructions at home:

Activity

  • Follow instructions from your health care provider about limiting your activity. Ask what activities are safe for you.
  • If needed, make plans for someone to help with your regular activities.
  • Do not have sex or orgasms until your health care provider says that this is safe.

General instructions

  • Take over-the-counter and prescription medicines only as told by your health care provider.
  • Pay attention to any changes in your symptoms.
  • Do not use tampons or douche.
  • Write down how many pads you use each day, how often you change pads, and how soaked (saturated) they are.
  • If you pass any tissue from your vagina, save the tissue so you can show it to your health care provider.
  • Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

  • You have vaginal bleeding during any part of your pregnancy.
  • You have cramps or labor pains.
  • You have a fever.

Get help right away if:

  • You have severe cramps in your back or abdomen.
  • You pass large clots or a large amount of tissue from your vagina.
  • Your bleeding increases.
  • You feel light-headed or weak, or you faint.
  • You have chills.
  • You are leaking fluid or have a gush of fluid from your vagina.

Summary

  • A small amount of bleeding (spotting) from the vagina is relatively common during early pregnancy.
  • Various things may cause bleeding or spotting in early pregnancy.
  • Be sure to tell your health care provider about any vaginal bleeding right away.

Vaginal Bleeding During Second Trimester of Pregnancy

A small amount of bleeding (spotting) from the vagina is common during pregnancy. Sometimes the bleeding is normal and is not a sign of problems, and sometimes it is a sign of something serious. Tell your doctor about any bleeding from your vagina right away.

Follow these instructions at home:

Activity

  • Follow your doctor’s instructions about how active you can be.
  • If needed, make plans for someone to help with your normal activities.
  • Do not exercise or do activities that take a lot of effort until your doctor says that this is safe.
  • Do not lift anything that is heavier than 10 lb (4.5 kg) until your doctor says that this is safe.
  • Do not have sex or orgasms until your doctor says that this is safe.

Medicines

  • Take over-the-counter and prescription medicines only as told by your doctor.
  • Do not take aspirin. It can cause bleeding.

General instructions

  • Watch your condition for any changes.
  • Write down:
    • The number of pads you use each day.
    • How often you change pads.
    • How soaked (saturated) your pads are.
  • Do not use tampons.
  • Do not douche.
  • If you pass any tissue from your vagina, save it to show to your doctor.
  • Keep all follow-up visits as told by your doctor. This is important.

Contact a doctor if:

  • You have vaginal bleeding at any time during pregnancy.
  • You have cramps.
  • You have a fever that does not get better with medicine.

Get help right away if:

  • You have very bad cramps in your back or belly (abdomen).
  • You have contractions.
  • You have chills.
  • You pass large clots or a lot of tissue from your vagina.
  • Your bleeding gets worse.
  • You feel light-headed.
  • You feel weak.
  • You pass out (faint).
  • You are leaking fluid from your vagina.
  • You have a gush of fluid from your vagina.

Summary

  • Sometimes vaginal bleeding during pregnancy is normal and is not a problem. Sometimes it may be a sign of something serious.
  • Tell your doctor about any bleeding from your vagina right away.
  • Follow your doctor’s instructions about how active you can be. You may need someone to help you with your normal activities.

Vaginal Bleeding During Third Trimester

A small amount of bleeding (spotting) from the vagina is common during pregnancy. Sometimes the bleeding is normal and is not a problem, and sometimes it is a sign of something serious. Tell your doctor about any bleeding from your vagina right away.

Follow these instructions at home:

Activity

  • Follow your doctor’s instructions about how active you can be. Your doctor may recommend that you:
    • Stay in bed and only get up to use the bathroom.
    • Continue light activity.
  • If needed, make plans for someone to help you with your normal activities.
  • Ask your doctor if it is safe for you to drive.
  • Do not lift anything that is heavier than 10 lb (4.5 kg) until your doctor says that this is safe.
  • Do not have sex or orgasms until your doctor says that this is safe.

Medicines

  • Take over-the-counter and prescription medicines only as told by your doctor.
  • Do not take aspirin. It can cause bleeding.

General instructions

  • Watch your condition for any changes.
  • Write down:
    • The number of pads you use each day.
    • How often you change pads.
    • How soaked (saturated) your pads are.
  • Do not use tampons.
  • Do not douche.
  • If you pass any tissue from your vagina, save the tissue to show your doctor.
  • Keep all follow-up visits as told by your doctor. This is important.

Contact a doctor if:

  • You have vaginal bleeding at any time during pregnancy.
  • You have cramps.
  • You have a fever.

Get help right away if:

  • You have very bad cramps.
  • You have very bad pain in your back or belly (abdomen).
  • You have a gush of fluid from your vagina.
  • You pass large clots or a lot of tissue from your vagina.
  • Your bleeding gets worse.
  • You feel light-headed or weak.
  • You pass out (faint).
  • Your baby is moving less than usual, or not moving at all.

Summary

  • Tell your doctor about any bleeding from your vagina right away.
  • Follow instructions from your doctor about how active you can be. You may need someone to help you with your normal activities.

Detailed Information

Synopsis

Key Points

  • Vaginal bleeding during pregnancy is common, particularly in the first trimester, and may arise from disruption of blood vessels in the decidua or from cervical, vaginal, or uterine pathology
  • First trimester bleeding is experienced in 20% to 40% of pregnancies; 1 causes include threatened or actual miscarriage, ectopic pregnancy, and hydatidiform mole
  • Bleeding is less common in the second and third trimesters
    • Causes of bleeding before 20 weeks of gestation are similar to those associated with first trimester bleeding
    • Causes of bleeding after 20 weeks of gestation include placental abruption, placenta previa, uterine rupture, and vasa previa
  • Evaluation of patients with vaginal bleeding in pregnancy consists of patient history, comprehensive physical examination, laboratory tests, and transvaginal ultrasonography
    • Diagnosis of bleeding in the first trimester is primarily based on quantitative serum β-hCG testing and transvaginal ultrasonography
    • Diagnosis of bleeding in the second and third trimesters is based on transvaginal and transabdominal ultrasonography; however, this should not delay definitive management if placental abruption or vasa previa is suspected
  • If patient has severe bleeding and is hemodynamically unstable, initiate immediate IV fluid resuscitation and/or blood transfusion and prepare for emergency surgery/delivery
  • If patient is hemodynamically stable and has no evidence of fetal compromise, manage according to underlying cause
  • Give all Rh-negative women with vaginal bleeding anti-D Rh prophylaxis, unless bleeding is clearly non–pregnancy-related 2

Pitfalls

  • All women with early pregnancy bleeding and abdominal pain should be assumed to have an ectopic pregnancy until it is excluded by β-hCG measurement and transvaginal ultrasonography

Terminology

Clinical Clarification

  • Vaginal bleeding during pregnancy is common, particularly in the first trimester, and may arise from disruption of blood vessels in the decidua or from cervical, vaginal, or uterine pathology

Classification

  • First trimester bleeding (less than 14 weeks of gestation) 1 3
    • Most common; experienced in 20% to 40% of pregnancies 1
    • Causes include miscarriage, ectopic pregnancy, implantation bleeding, sexually transmitted infections, and cervical ectropion
  • Second and third trimester bleeding (from 14 weeks to delivery) 4
    • Less common
    • Before 20 weeks of gestation
      • Causes are the same as those associated with first trimester bleeding (eg, miscarriage, ectopic pregnancy, implantation bleeding, sexually transmitted infections, cervical ectropion)
    • Beyond 20 weeks of gestation (antepartum bleeding)
      • Causes include placental abruption, placenta previa, uterine rupture, and vasa previa

Diagnosis

Clinical Presentation

History

  • Accurately date pregnancy on the basis of menstrual history, first or early second trimester dating ultrasonogram, and use of relevant assisted reproductive technology
  • Characterize nature and severity of vaginal bleeding (eg, intermittent or constant, heavy or light)
    • Determine whether onset of bleeding is spontaneous or is associated with precipitating factors (eg, sexual intercourse, vaginal examination, abdominal trauma)
    • Record visual estimate of blood loss (eg, number of pads soaked)
    • Heavy bleeding with passage of clots or tissue suggests miscarriage or placental separation
  • Inquire about associated symptoms
    • Pelvic pain
      • Unilateral, severe, and persistent pelvic pain may suggest ruptured ectopic pregnancy
      • Cramping pain may suggest miscarriage
    • Pregnancy symptoms such as nausea, breast tenderness, or weight gain
    • Lightheadedness and/or syncope
    • Symptoms of impending labor in late pregnancy, including:
      • Recurrent pain, including any kind of labor pain or contractions
      • Nonrecurrent pain, including pulling, traction, pressure, and back pain
      • Watery or bloody discharge
    • Vaginal discharge
  • Obtain sexual history, contraceptive use, and reproductive history, including:
    • Risk for sexually transmitted diseases
    • Previous ectopic pregnancy or miscarriage
    • Current use of intrauterine device (increased risk for ectopic pregnancy)
    • Use of assisted reproduction to achieve current pregnancy
    • History of tubal surgery, endometriosis, pelvic inflammatory disease, or uterine anomaly
  • Obtain menstrual history, including:
    • Amount, frequency, and regularity of bleeding
    • Presence of postcoital or intermenstrual bleeding
  • Inquire about symptoms suggestive of a coagulation disorder (eg, bleeding gums, easy bruising) 5

Physical examination

  • Evaluate vital signs
    • Hypotension, tachycardia, or orthostatic hypotension may be signs of impending shock associated with significant blood loss
    • Pallor may be present with significant blood loss
  • Palpate abdomen for tenderness or signs of peritoneal irritation
  • Estimate size and consistency of uterus and compare with estimated gestational age
    • After the first trimester, determine symphysis-fundus height to estimate fetal growth
      • Body habitus may affect accuracy of measurement
  • Evaluate for fetal heartbeat with handheld Doppler, usually detectable after 10 to 12 weeks of gestation 3
  • Perform a pelvic examination (bimanual and speculum)
    • Use a sterile speculum if rupture of membranes is suspected; avoid digital examination of cervix after 20 weeks of gestation until placenta previa has been excluded by ultrasonogram 4
    • Inspect vulva, vagina, cervix, anus, and urethra 3
      • A non–pregnancy-related source of bleeding may be found (eg, cervical ectropion, polyps)
      • Visible tissue may be present in vagina; this can be removed by gentle traction with forceps and sent for pathologic examination
      • Presence of open cervical os indicates inevitable miscarriage
      • Presence of products of conception in the endocervical canal indicates incomplete miscarriage
    • Assess size and shape of uterus and adnexa
      • Adnexal tenderness and a palpable adnexal mass may be present in ectopic pregnancy
      • Uterine size larger than expected for gestational age may suggest gestational trophoblastic disease, multiple gestation, or uterine fibroids
      • Cervical motion tenderness is highly suggestive of ectopic pregnancy
    • Determine degree of dilation or effacement of cervix (providing placenta previa has been excluded)

Causes and Risk Factors

Causes

  • Pregnancy-related causes of abnormal bleeding 6
    • In first trimester, causes include threatened miscarriage, spontaneous pregnancy loss, ectopic pregnancy, and gestational trophoblastic disease
    • In second and third trimesters, causes include placenta previa, vasa previa, and placental abruption

Risk factors and/or associations

Other risk factors/associations
  • Risk factors for conditions associated with vaginal bleeding in early pregnancy
    • Spontaneous abortion 3
      • Endocrine (eg, progesterone deficiency, thyroid disease, uncontrolled diabetes)
      • Genetic aneuploidy accounts for about one-half of spontaneous abortions 3
      • Immunologic (eg, antiphospholipid syndrome, lupus)
      • Prior or current infection with HSV or syphilis, Toxoplasma gondii, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Listeria monocytogenes, or Mycoplasma genitalium
      • Occupational chemical exposure or radiation exposure in utero
    • Ectopic pregnancy 7
      • Current intrauterine device
      • History of ectopic pregnancy or infertility
      • History of in utero exposure to diethylstilbestrol
      • History of genital infection, such as chlamydia, gonorrhea, or pelvic inflammatory disease
      • History of tubal surgery, including tubal ligation or reanastomosis of the tubes after tubal ligation
      • In vitro fertilization
    • Hydatidiform mole 8
      • Prior molar pregnancy
      • Spontaneous abortion
  • Risk factors for conditions associated with vaginal bleeding in late pregnancy 4
    • Placenta previa
      • Multiparity
      • Multiple gestations
      • Previous cesarean delivery
      • Tobacco use
      • Prior uterine curettage
    • Placental abruption
      • Chronic hypertension
      • Multiparity
      • Preeclampsia
      • Previous abortion
      • Short umbilical cord
      • Sudden decompression of an overdistended uterus due to rupture of membranes with polyhydramnios
      • Thrombophilias
      • Tobacco, cocaine, or methamphetamine use
      • Trauma: blunt abdominal or sudden deceleration
      • Unexplained elevated maternal serum alpha fetoprotein level
      • Uterine fibroids
    • Vasa previa
      • In vitro fertilization
      • Low lying and second trimester placenta previa
      • Marginal cord insertion
      • Multiple gestation
      • Succenturiate placentas (eg, bilobed, trilobed)
    • Invasive placentation (placenta accreta, increta, and percreta) 9
      • Prior cesarean deliveries
      • Concomitant placenta previa
      • History of placenta accreta
      • Uterine surgery (eg, myomectomy)
      • Assisted reproductive therapies

Diagnostic Procedures

Primary diagnostic tools

  • Diagnosis of vaginal bleeding in pregnancy is based on patient history, comprehensive physical examination, laboratory tests, and imaging studies; approach varies according to gestational age
    • Evaluation of patients with first trimester bleeding includes quantitative serum β-hCG testing and transvaginal ultrasonography 3
      • These tests may be repeated if initial findings are nondiagnostic
    • All women with early pregnancy bleeding and abdominal pain should be assumed to have an ectopic pregnancy until it is excluded by β-hCG measurement and transvaginal ultrasonography
    • Evaluate patients with second and third trimester bleeding based on transabdominal or transvaginal ultrasonography; do not delay definitive management if placental abruption or vasa previa is suspected 4
    • RBC antibody screen for all patients with pregnancy-related bleeding
    • Base additional tests on clinical findings; these may include:
      • CBC or hematocrit, coagulation studies, and blood type (with Rh factor) and crossmatch in patients with heavy bleeding or hemodynamic instability 3 4
      • Testing for Chlamydia trachomatis and Neisseria gonorrhoeae, especially if there is evidence of cervicitis 3
      • Cervical cytology or biopsy if cervical pathology is suspected as source of bleeding 10
      • Sampling of blood from vaginal vault for fetal hemoglobin if vasa previa is suspected; should not delay delivery in presence of fetal compromise 4
      • Pathologic examination of expelled products of conception
      • Electronic fetal heart rate monitoring using external heart rate monitors or a scalp electrode (if delivery is imminent and placenta previa has been excluded) in late pregnancy vaginal bleeding

Laboratory

  • Qualitative β-hCG
    • Urine
      • Indicated to confirm or exclude pregnancy in women of reproductive age presenting with vaginal bleeding
  • Quantitative β-hCG
    • Measure serum levels in all patients with vaginal bleeding in the first trimester of pregnancy
    • Is used diagnostically to determine if discriminatory threshold has been reached and to identify a normal versus abnormal rate of rise
    • Discriminatory threshold 11
      • In a normal pregnancy, gestational sac is expected to be visible via transvaginal ultrasonography at serum β-hCG level of 1000 to 2000 milliunits/mL 11
      • Threshold will usually be higher than 2000 milliunits/mL with multiple gestation (but rate of rise is the same)
      • Precise discriminatory threshold level varies by institution
    • Rate of rise
      • In a stable patient, serial quantitative measurements to assess rate of rise may be necessary if there is a positive pregnancy test result (ie, positive qualitative test) but gestational sac is not visualized with ultrasonography
      • In a normal pregnancy, β-hCG levels increase by 80% every 48 hours, on average 3
        • β-hCG values increase by at least 50% in 48 hours in approximately 99% of viable intrauterine pregnancies
      • A slower rate of β-hCG level increase may indicate an abnormal pregnancy, which could be a failed intrauterine pregnancy or an ectopic pregnancy
    • Unexpectedly high serum β-hCG levels require consideration of gestational trophoblastic disease 12
      • Hydatidiform moles are typically associated with hCG levels markedly higher than those seen in a normal pregnancy
      • If gestational trophoblastic disease is suspected, hCG assay is required to establish diagnosis; detects all forms of hCG (eg, β-hCG, core hCG, C-terminal hCG, β-core hCG, hyperglycosylated hCG)
  • CBC
    • Indicated to evaluate for anemia and thrombocytopenia
  • Coagulation panel
    • Indicated to exclude coagulation disorder 5
  • Blood type and antibody screen
    • Type with crossmatch is indicated for patients with large-volume blood loss
  • Rh antigen status
    • Indicated for all women with pregnancy-related bleeding
    • Indicates whether administration of Rh immunoglobulin is required (ie, Rh negative)
  • Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhoeae 13
    • Indicated for detecting Chlamydia trachomatis and Neisseria gonorrhoeae, especially in patients with risk factors for sexually transmitted infection
    • Samples from vagina, cervix, or urine can be tested
    • Positive results indicate presence of organism
  • Apt test for fetal hemoglobin 4
    • Indicated in patients with late pregnancy vaginal bleeding if vasa previa is suspected; however, do not delay delivery to confirm presence of fetal blood in patients with severe bleeding or signs of fetal compromise
    • Point of care test for presence of fetal hemoglobin which, unlike maternal hemoglobin, is resistant to denaturation by alkaline agents
      • Positive result indicates that blood originated from fetus and could be due to vasa previa
      • Negative result indicates that blood is of maternal origin

Imaging

  • Transvaginal ultrasonography 11
    • Preferred study for evaluating patients with vaginal bleeding in early pregnancy 11
      • May be performed in conjunction with transabdominal ultrasonography to assess for free fluid or abnormalities beyond field of view of vaginal probe 11
    • Allows detailed assessment of uterus, endometrium, myometrium, cervix, fallopian tubes, and ovaries and confirms the presence of live intrauterine pregnancy
    • Ultrasonographic findings correlated with β-hCG levels and clinical findings can differentiate causes of first trimester bleeding such as ectopic pregnancy, failed pregnancy, and gestational trophoblastic disease
      • Gestational sac can be seen as early as 4.5 to 5 weeks 11
      • In a normal pregnancy, the gestational sac is expected to be visible via transvaginal ultrasonography at the 1000- to 2000-milliunits/mL level 11
      • A yolk sac should be visible when gestational sac diameter is larger than 8 mm; embryo usually is seen by the time the gestational sac diameter reaches 16 mm (around 6 weeks) 11 14
      • The following findings are suggestive of a failed pregnancy or fetal demise: 11
        • Absence of a yolk sac in a gestational sac larger than 8 mm
        • Absence of an embryo in a gestational sac larger than 16 mm
        • Absence of fetal cardiac activity in an embryo measuring 7 mm or more in crown-rump length
          • Absence of fetal cardiac activity in embryos of any length is of concern and must be reevaluated
      • The following findings may be seen in ectopic pregnancy: 14 15
        • Extrauterine gestational sac, fetal pole, or fetal heart activity definitively establishes diagnosis
        • Moderate or large amount of fluid in the cul-de-sac without intrauterine pregnancy or adnexal mass—may be cystic or complex, but a complex mass is more suggestive—suggests a high probability of ectopic pregnancy
        • No intrauterine or extrauterine pregnancy seen with a quantitative pregnancy test result higher than the discriminatory level; if it is an indeterminate scan, reevaluate
      • A molar pregnancy in the first trimester may look like an endometrial mass with a mixture of solid and cystic components 11
      • Subchorionic hemorrhage is a common finding in patients with first trimester bleeding; it may be associated with subsequent miscarriage in some cases 3
    • In second and third trimesters, ultrasonographic findings may support diagnosis of gestational trophoblastic disease, spontaneous abortion, cervical insufficiency, or placenta previa
      • Hydatidiform mole has characteristic sonographic appearance in the second trimester; distended endometrial cavity has a snowstorm pattern, appearing full of numerous small cystic spaces, and there is no evidence of a fetus
      • Complete placenta previa is diagnosed when placenta covers os; marginal placenta previa is diagnosed when distance between internal cervical opening and placental edge is smaller than 20 mm on transvaginal ultrasonography 16
      • Ultrasonographic findings suggestive of cervical insufficiency include short cervical length, dilated internal os, and prolapsing fetal membranes
      • Vasa previa may be detected on color Doppler ultrasonography if suspected 17
    • Ultrasonography may not be reliable in diagnosing placental abruption and should not delay definitive management in acute cases; however, serial ultrasonograms may be appropriate to monitor fetal growth in cases of chronic abruption 4
    • Contraindicated in second and third trimesters if there is an open cervix with bulging amniotic sac at or below the external os; relatively contraindicated in presence of ruptured membranes
  • Transabdominal ultrasonography 18
    • Preferred initial study for evaluating patients with vaginal bleeding in second and third trimesters
      • After excluding placenta previa, may be performed in conjunction with transvaginal ultrasonography to assess cervical length and internal os
    • Allows detailed assessment of uterus, endometrium, myometrium, fallopian tubes, and ovaries and confirms the presence of live intrauterine pregnancy; cervix may not be fully visualized
    • Ultrasonographic findings may support diagnosis of potentially serious causes of bleeding in late pregnancy (eg, placenta previa, vasa previa, placental abruption)
      • Complete placenta previa: diagnosed when placenta covers os 16
      • Marginal placenta previa: diagnosed when distance between internal cervical opening and placental edge is shorter than 20 mm 19
      • Vasa previa may be detected; however, if internal cervical os is not clearly visualized, transvaginal ultrasonography with color Doppler may be needed for diagnosis 18
      • Placental abruption: placenta may appear thickened with rounded bulging and a heterogeneous echotexture; periplacental hematoma may or may not be visible 18
    • Ultrasonography is not reliable in diagnosing placental abruption and should not delay definitive management in acute cases; however, serial ultrasonography may be appropriate to monitor fetal growth in cases of chronic abruption

Functional testing

  • Fetal heart rate monitoring
    • External monitors use Doppler technology; internal monitors read R-R intervals through an electrode placed on the fetal scalp
    • Fetal heart rate tracing provides information that reflects acid-base status of fetus
      • Category I tracings are normal; no specific action required
        • Defined by:
          • Baseline heart rate: 110 to 160 beats per minute 20
          • Moderate beat to beat variability
          • Accelerations of heart rate with fetal movement; may be present or absent
          • Early decelerations of heart rate with uterine contractions; may be present or absent
          • Absence of late decelerations
      • Category II tracings do not predict abnormal fetal acid-base status, but they may indicate need for ancillary tests to ensure fetal well-being (eg, acoustic stimulation, expected fetal heart rate acceleration). Features of category II tracings include the following:
        • Bradycardia (not accompanied by absent baseline variability): fewer than 110 beats per minute 21
        • Tachycardia: more than 160 beats per minute 22
        • Marked, minimal, or absent baseline variability with no recurrent decelerations
        • Absence of induced acceleration with fetal stimulation
        • Periodic or episodic decelerations
        • Recurrent variable decelerations accompanied by minimal or moderate baseline variability
        • Prolonged deceleration for more than 2 minutes but less than 10 minutes 22
        • Recurrent late decelerations with moderate baseline variability
        • Variable decelerations with other characteristics (eg, slow return to baseline, overshoots)
    • Category III tracings
      • Abnormal fetal acid-base status requiring expeditious response (eg, intrauterine resuscitation, assisted delivery) is indicated by the following features:
        • Baseline variability is absent and any of the following are present:
          • Recurrent late decelerations
          • Recurrent variable decelerations
          • Bradycardia
        • Sinusoidal pattern

Procedures

Cervical cytology (Papanicolaou test)
General explanation
  • Cells from the ectocervix, transformation zone, and endocervical canal are analyzed for potential premalignant and malignant transformation either by conventional cervical cytology or liquid-based cytology
Indication
  • Routine screening
  • Suspicion of, or need to exclude, cervical neoplasia
Contraindications
  • No absolute contraindications
Interpretation of results
  • Epithelial cell abnormalities are evaluated using the 2015 Bethesda System for Reporting Cervical Cytology, which categorizes abnormalities into the following categories: 23
    • Squamous cell abnormalities
      • Atypical squamous cells of undetermined significance
      • Atypical squamous cells; cannot exclude high-grade squamous intraepithelial lesion
      • Low-grade squamous intraepithelial lesion
      • High-grade squamous intraepithelial lesion
      • Squamous cell carcinoma
    • Glandular cell abnormalities
      • Atypical glandular cells
      • Atypical glandular cells; favor neoplasia
      • Adenocarcinoma in situ
      • Adenocarcinoma
Cervical biopsy
General explanation
  • Small tissue sample is surgically removed from lesion for histopathologic examination
  • Sample is obtained via colposcopy when involving cervix
Indication
  • Atypical or large cervical lesions or growths; uncertain diagnosis
  • Cervical lesions or growths that are changing or enlarging over observation period
  • Precancerous cervical lesion detected on cervical cytology
Contraindications
  • No absolute contraindications
Interpretation of results
  • Histopathologic findings indicate whether lesion is benign (with characteristic features of leiomyoma, polyp, or cyst), premalignant, or malignant
  • Premalignant histologic findings are graded as follows:
    • Cervical intraepithelial neoplasia grade 1: mild dysplasia
    • Cervical intraepithelial neoplasia grade 2: moderate dysplasia
    • Cervical intraepithelial neoplasia grade 3: severe dysplasia
  • Invasive malignancies may be squamous cell carcinoma or adenocarcinoma

Other diagnostic tools

Differential Diagnosis

Most common

  • Threatened miscarriage
    • Vaginal bleeding occurring before 20 weeks of gestation, with closed cervix and viable fetus (with cardiac activity)
    • In most cases pregnancy proceeds normally, but some patients subsequently miscarry
    • Diagnosis is based on history, physical examination, and serial serum β-hCG levels and transvaginal ultrasonography findings that demonstrate viable pregnancy
  • Spontaneous abortion/miscarriage (Related: )Miscarriage and recurrent pregnancy loss
    • Pregnancy loss occurring before 20 weeks of gestation
    • Presents with profuse vaginal bleeding and painful uterine cramping
    • Products of conception may have passed or may be seen in cervical os or vagina during physical examination
    • Complete abortion: when all products of conception have passed
    • Incomplete abortion: when some, but not all, products of conception have passed
    • Inevitable abortion: bleeding in presence of dilated cervix (but products of conception have not yet passed); may be associated with ascending infection of endometrium, parametrium, and adnexa (septic abortion)
    • Missed abortion: fetal demise that occurs without immediate expulsion
    • Diagnosis is based on history, physical examination, absence of fetal heartbeat, β-hCG level lower than expected for gestational age, and transvaginal ultrasonography findings (eg, empty gestation sac, no fetal cardiac activity) 24
  • 3Ectopic pregnancy
    • Occurs when fertilized ovum implants outside uterine cavity
    • May present with vaginal bleeding and/or pelvic or abdominal pain, or with unexplained syncope or shock; may be asymptomatic until rupture occurs
      • May have history of previous ectopic pregnancy, pelvic inflammatory disease, tubal sterilization, or tubal surgeries, or may currently use an intrauterine device
    • Diagnosis is based on history, physical examination, β-hCG measurement, and transvaginal ultrasonography
      • Serum hCG titer above the discriminatory level and absence of an intrauterine gestational sac on ultrasonography are presumed to indicate ectopic pregnancy until proven otherwise
  • Gestational trophoblastic disease 3
    • Gestational trophoblastic disease is characterized by benign or malignant placental proliferation, usually in absence of a fetus 3
    • Hydatidiform mole
    • May present with vaginal bleeding, usually during first trimester of pregnancy
    • Diagnosis is suggested by total serum hCG levels higher than 80,000 milliunits/mL and characteristic ultrasonographic appearance; however, histopathologic evaluation of evacuated tissue is required for definitive diagnosis
  • Bloody show associated with labor or cervical insufficiency 4
    • Cervical dilation during labor is often accompanied by passage of small amount of blood or blood-tinged mucus
    • Onset of spontaneous normal labor is characterized by 3 to 5 uterine contractions every 10 minutes (Related: Normal labor)
    • Occasionally labor is substantially premature, so gestational age does not rule it out
    • May be preceded by recurrent abdominal pain or contractions, constant pressure or back pain, watery vaginal discharge, and gastrointestinal symptoms
    • Diagnosis is based on history, physical examination, and observation
      • In cases of heavy bloody show, if diagnosis is uncertain, ultrasonography to check placental location may be indicated
  • Placenta previa 4
    • Defined as placental implantation that overlies or is within 2 cm of the internal cervical os
    • Common incidental finding on routine second trimester ultrasonography; it resolves by term in most cases
    • Symptomatic placenta previa usually manifests as painless vaginal bleeding in the late second or third trimester; bleeding is often postcoital 4
    • Vaginal bleeding is typically not severe enough to result in hemodynamic instability or fetal compromise providing cervical digital examination is not performed
    • Diagnosis is based on history, physical examination, and ultrasonographic findings demonstrating placenta overlying or within 2 cm of the os
  • Placental abruption (Related: ) 4Abruptio placentae
    • Defined as separation of placenta from uterine wall before delivery; in 50% of cases, it occurs before 36 weeks of gestation 4
    • Placental abruption typically manifests as painful vaginal bleeding, uterine tenderness, or back pain with evidence of fetal distress 4
      • Bleeding may be completely or partially concealed; it may be bright, dark, or intermixed with amniotic fluid
    • May occur in context of preterm or term labor or with intrauterine fetal death
    • Diagnosis is based on history and physical examination in conjunction with fetal heart rate monitoring or other tests of fetal well-being 4
    • May be difficult to diagnose on ultrasonography; this should not delay definitive management
  • Sexually transmitted infection/pelvic inflammatory disease during pregnancy (Related: )Pelvic inflammatory disease
    • Infection is most commonly chlamydial or gonococcal (Related: Gonorrhea)
    • May present with vaginal spotting in conjunction with lower abdominal pain; cervicitis or adnexal and cervical motion tenderness may be present on physical examination
    • Differentiating features include presence of fever and mucopurulent cervicovaginal discharge
    • Diagnosis is based on history, physical examination, β-hCG level, and ultrasonographic findings demonstrating viable pregnancy and presence of infecting organisms on recommended tests for relevant organisms (eg, nucleic acid amplification tests 13 for Chlamydia and Neisseria)
  • Vasa previa 17
    • Velamentous insertion of umbilical cord into membranes in lower uterine segment
    • Rare but associated with high fetal mortality rate
    • Presents as severe vaginal bleeding (fetal blood) at time of spontaneous rupture of membranes or amniotomy
    • Diagnosis is based on history and physical examination in conjunction with fetal heart rate monitoring (sinusoidal pattern suggests fetal anemia) or other tests of fetal well-being; confirmed by presence of fetal blood on Apt test, but this should not delay delivery

Treatment

Goals

  • Hemodynamic stabilization, if necessary
  • Identification of cause and timely and appropriate intervention as possible to support fetus

Disposition

Admission criteria

Manage most hemodynamically stable patients who are bleeding before 20 weeks of gestation in an outpatient setting

Admit patients who have significant bleeding after 20 weeks of gestation for initial assessment to determine cause and to determine need for operative delivery

Admit hemodynamically unstable patients with an ectopic pregnancy for immediate surgery

Rapid operative delivery is indicated for patients with severe bleeding and fetal compromise in late pregnancy

Criteria for ICU admission
  • Hemodynamic instability after urgent surgical intervention/delivery

Recommendations for specialist referral

  • Refer to obstetrician/gynecologist for evaluation and management

Treatment Options

If patient has severe bleeding and is hemodynamically unstable, initiate immediate IV fluid resuscitation and/or blood transfusion and prepare for emergency surgery/delivery

  • O-negative, uncrossmatched blood is indicated for initial therapy; fresh frozen plasma, platelets, and fibrinogen replacement may be indicated in patients with coagulopathy 9
  • Specific intervention depends on underlying cause; for example:
    • Salpingostomy or salpingectomy via laparoscopy or laparotomy for tubal ectopic pregnancy (Related: Ectopic pregnancy)
    • Cesarean delivery for placental abruption or placenta previa (Related: Abruptio placentae)

Urgent operative delivery is indicated in late pregnancy if there is evidence of persisting fetal compromise that does not resolve with adequate maternal resuscitation 4

Hemodynamically stable patients with no evidence of fetal compromise are managed according to underlying cause; for example:

  • Clinically stable patients with unruptured tubal ectopic pregnancy can be managed medically or surgically; surgical treatment is preferred for pregnancies in nontubal locations
  • Patients with confirmed miscarriage can be managed expectantly in most cases (Related: Miscarriage and recurrent pregnancy loss)24
    • Consider medical management options in patients without infection, hemorrhage, severe anemia, or coagulation disorders who wish to expedite complete expulsion of uterine contents without undergoing surgery 24
    • Urgent surgical evacuation of uterus is indicated in patients with hemorrhage, hemodynamic instability, or evidence of infection; also consider in those with comorbidities such as coagulation disorders or anemia 24
  • Patients with vaginal bleeding and a confirmed intrauterine pregnancy with a fetal heartbeat (threatened miscarriage) should be counseled and should continue routine prenatal care, with reassessment if bleeding persists or worsens
    • There is no role for bed rest, and pelvic rest or progesterone therapy has not been shown to improve pregnancy outcomes 25 26
  • Patients with non–pregnancy-related causes of bleeding should be treated as appropriate (eg, antibiotic therapy for sexually transmitted infections) 3
  • Patients with molar pregnancy should undergo suction evacuation and curettage soon after diagnosis (Related: Hydatidiform mole)27

Administer anti-D Rh prophylaxis to all Rh-negative women who have vaginal bleeding unless bleeding is clearly non–pregnancy-related; dosing varies according to gestation and indication 2

Nondrug and supportive care

  • Procedures

Monitoring

  • Follow-up depends on underlying cause of bleeding and specific approach to management taken 3
  • May also include serial measurements of β-hCG, transvaginal ultrasonography, and fetal monitoring

Complications and Prognosis

Complications

  • Vaginal bleeding may result in risks to the woman and fetus, depending on etiology 4
    • Maternal complications include:
      • Severe hemorrhage and shock
      • Disseminated intravascular coagulation
      • Operative delivery
      • Pregnancy loss (Related: Miscarriage and recurrent pregnancy loss)
    • Fetal complications (after 20 weeks of gestation) include:
      • Uteroplacental insufficiency resulting in intrauterine growth restriction (Related: Intrauterine growth restriction)
      • Premature birth and related complications
      • Perinatal death

Prognosis

  • Prognosis depends on cause of vaginal bleeding and timeliness of specific intervention if necessary
  • Approximately half of patients who experience vaginal bleeding in the first trimester of pregnancy will subsequently miscarry 3
You cannot copy content of this page