Vaginal Bleeding in Early Pregnancy

• Vaginal bleeding in pregnancy poses diagnostic and management challenges

Bleeding Before 20 Weeks Gestation

• Mrs. H, a 24 y/o G2P1001 at 9 weeks and 3 days EGA, reported to the OB acute care clinic with vaginal bleeding for 8 hours.
• The bleeding is lighter than her menses but heavier than spotting and has mild cramping but denies fevers, sweats, chills, N/V, diarrhea, or illness.
• Last pregnancy was uncomplicated with a vaginal delivery at term.

Etiology of Bleeding in Early Pregnancy

• Implantation Bleeding
• Threatened Early Pregnancy Loss
• Subchorionic Hemorrhage
• Early Pregnancy Loss
• Ectopic Pregnancy
• Other Causes: Polyp, Cervicitis, Cervical or Vaginal Trauma

History of Present Illness Questions

• Date of Last Menstrual Period: Regularity of menses
• Onset of Bleeding: Relation to LMP and activity
• Amount of Bleeding: How often is the pad/tampon being changed, and how saturated is it?
• Associated Symptoms: Symptoms of anemia, Cramping/pain
• Risk Factors for Ectopic Pregnancy: H/o ectopic, H/o pelvic infection (PID, GC/CT), Smoking, Current IUD use, Prior tubal surgery, IVF
• Medical History: Bleeding/clotting disorders
• Surgical History: Abdominal or pelvic surgeries
• OB History: H/o ectopic pregnancy, Pregnancy history
• GYN History: STIs
• Medications: Anticoagulants
• Social History: Smoking

Physical Exam

• Heart Rate and Blood Pressure
• Abdominal Exam: Guarding or Rebound?
• Pelvic Exam visualization of the cervix: open or closed?
• Other factors include active bleeding, amount of blood, clots or tissue, and any cervical or vaginal trauma

Labs

• ABO/Rh
• CBC
• bHCG
• GC/CT*
• Type and Screen/Cross*

Imaging

• Pelvic U/S, depending on possible etiology and amount of bleeding

Narrowing the Differential

• Implantation Bleeding
• Threatened Early Pregnancy Loss
• Subchorionic Hemorrhage
• Early Pregnancy Loss
• Ectopic Pregnancy
• Other Causes: Polyp, Cervicitis, Cervical or Vaginal Trauma

Implantation Bleeding

• A diagnosis of exclusion with a small amount of spotting.
• Symptoms occur approximately 10-14 days after fertilization.
• Related to implantation of the fertilized egg into the decidua.

Threatened Early Pregnancy Loss

• Vaginal bleeding with a closed cervix and fetal cardiac activity present has approximately 93% of pregnancies continuing despite bleeding.
• Management is expectant, and consider RhIG if Rh negative.

Subchorionic Hemorrhage (SCH)

• Bleeding secondary to disruption of decidual vessels at maternal-fetal interface may appear as a lucency or organized clot on Ultrasound.
• Expectant management with increased risk of pregnancy loss compared to those without Subchorionic Hemorrhage.

Early Pregnancy Loss (EPL)

• Loss of fetal cardiac activity or absence of pregnancy progression based on ultrasound that may be complete, incomplete, or missed.
• Vaginal bleeding may not always occur, and the patient is administered RhIG for Rh negative status as well as expectant, medical, or surgical options for management.

Ectopic Pregnancy

• Pregnancy implanting outside the uterus is not viable and may be life-threatening to the patient and must be excluded in any pregnant patient with vaginal bleeding with RhIG for Rh negative patients.
• Management is medical or surgical.

Other Causes of Bleeding

• Polyps of the uterine or cervical variety are generally benign but have management variations.
• Cervicitis causes the cervix to become friable.
• Causative factors should be tested and treated as indicated.
• Cervical or Vaginal Trauma is important to evaluate the source to ensure healing and patient safety.

Management Options During Early Pregnancy

• Implantation bleeding, threatened FPL (fetal pulmonary hypoplasia), and subsequent hemorrhage are expectantly managed and can be very frustrating to patients and physicians.
• No intervention has shown to improve or change outcomes.
• For EPL, the patient should be expectantly managed or receive medication such as misoprostol or mifepristone.
• Surgical options are Vacuum aspiration and D&C.
• Manage ectopic pregnancies medically with Methotrexate or surgically resect the involved area
• Manage polyps expectantly or with resection.
• Treat cervicitis with treatment of causative organism and partner treatment as indicated.
• Treat trauma with expectant management or surgical repair as indicated, though rare.

Back to Mrs. H

• After examining the patient and U/S findings, the diagnosis is subchorionic hematoma.
• Management is expectant and reassurance is made.
• The patient returns two weeks later for her routine OB appointment and her pregnancy is found to be progressing as expected.

Bleeding After 20 Weeks Gestation

• Ms. A is a 25-year-old G2P1 at 32 weeks gestation brought to L&D after noting a sudden gush of bright red blood vaginally.
• She has soaked through her clothes with continuous bleeding and notes mild lower abdominal pain.
• Last sexual intercourse was a week prior.
• Prenatal chart review finds the pregnancy progress unremarkable.
• An ultrasound at 14 weeks confirmed pregnancy, but hasn't had one since

Differential Diagnosis?

• Placental abruption
• Placenta Previa
• Vasa Previa
• Genital lacerations/trauma (e.g. labial, vaginal or cervical)
• Cervical/vaginal benign growth or cancer
• Cervicitis
• Bloody show/labor

History of Present Illness Questions

• Questions Specific to Bleeding include onset, inciting events, how many pads per hour, clots and their size, abdominal pain, and lightheadedness/dizziness?
• Associated Symptoms: Symptoms of anemia, Cramping/pain
• Questions specific to pregnancy include contractions, loss of fluid, and indications of decreased fetal movement?
• Medical History: Bleeding/clotting disorders
• Surgical History: Abdominal or pelvic surgeries
• OB History: H/o ectopic pregnancy, Pregnancy history
• GYN History: STIs
• Medications: Anticoagulants
• Social History: Smoking, drug use

Physical Exam

• Serial vital signs
• Continuous fetal monitoring
• Abdominal exam while supine monitoring patient uterine tone
• Ultrasound to assess placental location
• Pelvic exam in dorsal lithotomy position, using a speculum to visualize cervix, assess bleeding including whether the blood is old or new, activity of bleeding, and quantity.
• Digital exam is performed only if you know the placental location to avoid damage.

Evaluation Ancillary Studies

• Complete blood count
• Basic metabolic panel
• Type and cross
• Kleihauer-Betke (KB) test is used to measure the amount of fetal blood transferred to a mother's bloodstream and help with the calculation of additional vials of Rhogam.
• Coagulation studies may be run along with culture for gonorrhea and chlamydia, urine analysis and culture, as well as imaging with pelvic U/S.

Ms. A Clinical Presentation

• Pale and blood pressure is 98/60, with pulse 130, respirations 30, and temperature 99° F.
• Her abdomen is soft without guarding or rebound to palpation, with a uterus that is nontender but firm.
• Fetal heart tones are in the 140s with moderate variability, with an external monitor revealing uterine irritability but no discrete contractions.
• A steady stream of bright red blood coming from her vagina, with a cervix is visually 1 cm dilated.

Considerations When Narrowing a Diagnosis After 20 Weeks Gestation

• Placental abruption, Placenta Previa, vasa Previa, Genital lacerations/trauma, Cervical/vaginal benign growth or cancer, Cervicitis, Bloody show/labor

Placental Abruption

• Defined as separation of the placenta from its implantation site prior to delivery of the fetus that accounts for 30% of bleeding in the 3rd trimester and complicates 1 in 100 births.
• Symptoms include vaginal bleeding with abdominal pain, concealed hemorrhage, non reassuring fetal heart rate tracing, frequent uterine contractions or uterine hypertonicity, and disseminated intravascular coagulation occurring in 10-20% of severe cases
• Risk factors include hypertension, advanced maternal age, preterm premature rupture of membranes, abdominal trauma, and cocaine/tobacco.

Placenta Previa

• Defined as placental tissue close to or overlies the internal cervical os
• Accounts for 20% of bleeding in the 3rd trimester
• Some previas resolve without intervention at 20 weeks occurs 1 in 20, but at 40 weeks occurs 1 in 200.
• Presents with painless vaginal bleeding
• Risk factors include prior cesarean, myomectomy, increasing number of uterine curettages, advanced maternal age, and tobacco use
• Can be expectantly managed if no bleeding with planned delivery by cesarean between 36-37 weeks.

Vasa Previa

• An unprotected fetal umbilical vessels runs through the amniotic membranes and pass over the internal cervical os and is seen in less than 1% of pregnancies.
• Classic presentation is painless vaginal bleeding with concerning fetal heart rate, resulting in fetal blood loss.
• Risk factors include multiples, velamentous cord, succenturiate placental lobe, and in vitro fertilization.
• Can be expectantly managed if signs of labor/bleeding; planned delivery by cesarean between 36-37 weeks.

Other Causes of Vaginal Bleeding

• Genital lacerations/trauma, Cervical/vaginal benign growth or cancer, Cervicitis, Bloody show/labor

General Management of Pregnant Mothers with Bleeding After 20 Weeks

• All will be admitted for close observation with serial vital signs and 2 large bore IVs with serial labs.
• Apply volume resuscitation, and continuously monitor the fetus.
• Administer Betamethasone and Magnesium Sulfate if applicable and Rhogam if applicable.
• The decision for delivery depends on gestational age, fetal status, and maternal stability.
• Route of delivery depends on fetal status, maternal stability, and cervical dilation with Cesarean delivery required for cases of placenta previa and vasa previa.

Diagnosis of Ms. A

• Based on her presentation of ongoing bleeding after she arrived and filling two pads in the past 30 minutes, her exam reveals her to be pale and her blood pressure is 90/40 and pulse is 140.
• Her uterus is not hypertonic on palpitation and fetal monitoring now shows recurrent late decelerations.
• Labs are as follows hemoglobin 7, platelets 80, fibrinogen 60, PT 60, PTT 65.
• Diagnosis: placental abruption with preparation for an immediate cesarean and administration of blood and FFP.

When to Transfuse During Pregnancy?

• Massive acute blood loss of 30-40% blood volume requiring blood products administered in a 1:1:1 ratio.
• Consider transfusion when the patient has Hemoglobin of less than 7 or less than 10 with severe chronic medical conditions and prolonged PTT/PTT fibrinogen is less than 150.
• Platelets less than 20,000 or less than 50,000 require transfusion as well as Symptomatic anemia.