Vaginal bleeding in early pregnancy

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

This article have been viewed 1621 times

Chapter 39 VAGINAL BLEEDING IN EARLY PREGNANCY

Vaginal bleeding in early pregnancy is common. The main differential diagnosis is threatened abortion, spontaneous abortion, ectopic pregnancy, and molar pregnancy.

Vaginal bleeding during early pregnancy is presumptively called a threatened abortion unless another cause is found. A threatened abortion occurs in 25% of all pregnancies and represents bleeding in the first trimester without passage of tissue. Half of all threatened abortions progress to a spontaneous abortion. However, only 4% to 10% of pregnancies with fetal cardiac activity and vaginal bleeding progress to a spontaneous abortion. Other related terms include inevitable abortion (rupture of membranes and/or cervical dilation during early pregnancy so that pregnancy loss is inevitable), incomplete abortion (only partial expulsion of products of conception occur), and missed abortion (retention of a failed pregnancy).

Ectopic pregnancy occurs in nearly 2% of pregnancies. Because life-threatening bleeding can occur, it is an important diagnosis to make. Risk factors include a history of salpingitis, previous ectopic pregnancy, and advanced maternal age.

Hydatidiform moles are caused by abnormal growth of the placental trophoblastic tissue. With a complete mole, a fetus does not develop. With a partial mole, an abnormal fetus develops. Hydatidiform moles can become malignant and develop into choriocarcinoma.

When a pregnant patient has vaginal bleeding in early pregnancy, a complete history and physical examination are important to determine the cause. The important elements are outlined as follows.

Medications Linked to Bleeding in Pregnancy

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Key Historical Features

✓ Associated symptoms

• Fever, chills, or night sweats, which may indicate infection

• Dizziness, which may indicate a large amount of blood loss

✓ History of trauma

✓ Obstetric and gynecologic history

• Nature and amount of bleeding and passage of any tissue or clots

• Menstrual history

• Previous pregnancies and any complications, including prior spontaneous abortion

• Previous ultrasound examinations during this pregnancy and whether a viable intrauterine pregnancy was documented

• Associated pelvic or abdominal pain, which may indicate ectopic pregnancy

• Sexual history

• History of any gynecologic surgery or procedures, especially recent procedures, including induced abortions

• History of any sexually transmitted diseases or pelvic inflammatory disease

✓ Medical history, especially history of bleeding disorders

✓ Surgical history

✓ Family history

Key Physical Findings

✓ Vital signs, including orthostatic assessments

✓ Evidence of a bleeding disorder, such as bruising

✓ Gynecologic/obstetric examination

• Perineum and vulvar examination for any lesions or trauma

• Speculum examination to evaluate for any bleeding or cervical lesions and to determine whether the cervical os is open or closed

• Bimanual examination to evaluate the size and consistency of the uterus and whether there is any uterine tenderness; in addition, evaluation for adnexal tenderness or masses (patients with a molar pregnancy often have a discrepancy between the uterine size and dates; patients with an ectopic pregnancy may have cervical motion tenderness or pelvic tenderness)

✓ Abdominal examination for tenderness, rebound, or guarding (the presence of peritoneal signs is suspect for ectopic pregnancy)

✓ Rectal examination to note the presence of any hemorrhoids

Suggested Work-Up

The key to evaluating vaginal bleeding in early pregnancy is to initially rule out ectopic pregnancy, especially if the patient is experiencing abdominal pain.

Urine pregnancy test	To confirm pregnancy
Transvaginal ultrasonography	To determine whether there is a viable intrauterine pregnancy and to evaluate for an adnexal mass or free fluid in the cul-de-sac (a molar pregnancy has a “snowstorm” appearance on ultrasonography)
Blood type and screen	To determine the patient’s Rh status, because anti–D immune globulin should be given if the patient is Rh negative

Additional Work-Up

Quantitative β–human chorionic gonadotropin (β-hCG) measurement	Useful if an intrauterine pregnancy is not seen on ultrasound examination, in order to determine the risk of an ectopic pregnancy
	Serial β-hCG measurements are useful for determining a patient’s risk of spontaneous abortion
	A gestational sac should be seen on transvaginal ultrasonogram if the β-hCG measurement is 2000 IU/L or higher; if a gestational sac is not seen, an ectopic pregnancy should be suspected
	β-hCG measurements should double over 48 hours in a viable pregnancy
Complete blood cell count	To determine whether the patient is anemic; also useful if the patient is febrile, to determine the white blood cell count
Wet-mount preparation and potassium hydroxide (KOH) microscopy of vaginal discharge	To evaluate for vaginitis
Cervical culture for Neisseria gonorrhea and Chlamydia trachomatis	If patient is at risk for a sexually transmitted disease
Pap smear	If cervical dysplasia is suspected

FURTHER READING

Beckmann CRB, Ling FW, Smith RP, et al, editors. Obstetrics and Gynecology, 5th, Philadelphia: Lippincott Williams & Wilkins, 2006.

Chamberlain G. Vaginal bleeding in early pregnancy—II. BMJ. 1991;302:1195-1197.

Coppola PT, Coppola M. Vaginal bleeding in the first 20 weeks of pregnancy. Emerg Med Clin North Am. 2003;21:667-677.

Della-Giustina D, Denny M. Ectopic pregnancy. Emerg Med Clin North Am. 2003;21:565-584.

Farquhar CM. Ectopic pregnancy. Lancet. 2005;366:583-591.

Griebel CP, Halvorsen J, Golemon TB, et al. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-1250.

McKennett M, Fullerton JT. Vaginal bleeding in pregnancy. Am Fam Physician. 1995;51:639-646.

Related

Instant Work-ups A Clinical Guide to Obstetric and Gynecologic C