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Vaginal Bleeding During Pregnancy
Virginia Van Duyne, MD
image BASICS
DESCRIPTION
  • Vaginal bleeding during pregnancy has many causes and ranges in severity from benign with normal pregnancy outcome to life-threatening for both infant and mother.
  • Etiology can be from the vagina, cervix, uterus, fetus, or placenta. The differential diagnosis is guided by the gestational age of the fetus.
EPIDEMIOLOGY
Prevalence
  • In early pregnancy: 7-25% of patients
  • In late pregnancy: 0.3-2% of patients
ETIOLOGY AND PATHOPHYSIOLOGY
  • Many times the cause is unknown.
  • Anytime in pregnancy:
    • Cervicitis (infectious or noninfectious)
    • Vaginal or cervical trauma (including postcoital)
    • Cervical lesion or neoplasia
    • Hyperemia of cervix (increased blood flow from pregnancy)
  • Early pregnancy:
    • For up to 50% of early pregnancy bleeding, no cause is ever found.
    • Ectopic pregnancy: leading cause of 1st-trimester maternal death in the United States. Risk factors: previous ectopic, trauma to fallopian tubes (tubal surgery, infection, tumor), congenital anomaly of tubes, in utero diethylstilbestrol (DES) exposure, current use of IUD, history of infertility, tobacco use
    • Spontaneous abortion: risk factors: advanced maternal age (AMA), alcohol use, tobacco use, anesthetic gas, heavy caffeine use, cocaine use, chronic maternal diseases (poorly controlled diabetes mellitus [DM], celiac disease, autoimmune diseases such as antiphospholipid syndrome), short interconception time (3 to 6 months), current use of IUD, maternal infection (e.g., herpes simplex virus [HSV], gonorrhea, chlamydia, toxoplasmosis, listeriosis, HIV, syphilis, malaria), medications (e.g., retinoids, methotrexate, NSAIDs), multiple previous therapeutic abortions, previous spontaneous abortion, toxins (arsenic, lead, polyurethane), uterine abnormalities (congenital, adhesions, fibroids)
    • Implantation bleeding: benign, about 6 days after fertilization
    • Uterine fibroids
    • Subchorionic bleed: in late 1st trimester
    • Low-lying placenta
    • Gestational trophoblastic disease: hydatidiform mole (most common), choriocarcinoma, or placental-site trophoblastic tumors
  • Late pregnancy:
    • Bloody show of labor (mucus plug)
    • Placenta previa: painless bleeding; occurs in 0.4% deliveries in the United States. Risk factors: previous history of placenta previa, previous uterine surgery (cesarean section, D&C), chronic hypertension, multiparity, multiple gestation, tobacco use, AMA
    • Placental abruption: painful bleeding; occurs in 1-2% deliveries in the United States. Risk factors: previous placental abruption, 1st-trimester bleeding, hypertension, preeclampsia, multiple gestation, tobacco, cocaine or methamphetamine use, unexplained elevated maternal &agr;-fetoprotein, poly- or oligohydramnios, AMA, trauma to abdomen, premature rupture of membranes, thrombophilia, short umbilical cord, male fetus, chorioamnionitis, nutritional deficiency
    • Vasa previa: minimal bleeding with fetal distress; rare (1:2,500 deliveries). Risk factors: in vitro fertilization, multiple gestation, placental abnormalities (low-lying position, bilobate, succenturiate lobe, velamentous insertion of umbilical cord)
    • Placenta accreta, increta, percreta: risk factors: uterine scar (e.g., from cesarean section, endometrial ablation or D&C), current placenta previa, AMA, tobacco use, multiparity, uterine anomalies, uterine fibroids, hypertension
    • Uterine rupture: vaginal bleeding, abnormal fetal heart rate, and disordered or hypertonic uterine contractions with or without pain. Risk factors: previous cesarean section (most common), trauma, use of oxytocin or prostaglandins, multiparity, external cephalic version, placental abruption, shoulder dystocia, placenta percreta, müllerian duct anomalies, history of pelvic radiation
RISK FACTORS
See specific etiologies in earlier discussion.
GENERAL PREVENTION
  • Address modifiable risk factors such as domestic violence and tobacco and drug use.
  • If placenta or vasa previa, nothing per vagina
image DIAGNOSIS
PHYSICAL EXAM
  • Vital signs: When present, signs of hemodynamic instability are first tachycardia and tachypnea, then hypotension and thready pulse.
  • Abdomen: uterine tenderness, fundal height (increasing fundal height may be associated with placental abruption)
  • Speculum: Visualize cervix and identify source of bleeding (from cervical os or from within vagina).
  • Cervix: assess for dilation; required to assess for labor but should not be performed until placenta previa ruled out via ultrasound
  • Fetal monitoring: Doppler heart tones in early pregnancy; external fetal monitoring for gestational age >26 weeks
DIFFERENTIAL DIAGNOSIS
  • Hematuria (UTI, kidney stones)
  • Rectal bleeding
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • CBC
  • Blood type and screen; if significant hemorrhage, type and cross-match
  • Quantitative &bgr;-human chorionic gonadotropin (&bgr;-hCG):
    • Prior to 12 weeks, levels can be followed serially every 2 days with following trends:
      • Doubles or at least 66% rise in 48 hours in normal pregnancy
      • Falls in spontaneous abortion
      • Extremely high in molar pregnancy
      • Rises gradually (<50% in 48 hours) or plateaus in ectopic pregnancy
  • Transvaginal ultrasound should be used to confirm an intrauterine pregnancy (IUP) when the quantitative &bgr;-hCG >2,000 (1)[A].
  • Other lab tests based on clinical scenario:
    • Wet mount, gonorrhea/chlamydia, Pap smear
    • Progesterone level occasionally used to determine viability in threatened abortion (<5 indicates not viable, >25 indicates viability, 5 to 25 is equivocal).
    • Bleeding time, fibrinogen, and fibrin split products: if suspect coagulopathy or abruption
    • Kleihauer-Betke: low sensitivity and specificity for abruption; helpful for dosing Rho(d) immune globulin (RhoGAM)
  • Ultrasound is the preferred imaging modality.
    • Early pregnancy:
      • Gestational sac seen at 5 to 6 weeks; fetal heartbeat observed by 8 to 9 weeks
      • Diagnostic of ectopic with nearly 100% sensitivity when &bgr;-hCG level 1,500 to 2,000 mIU/mL. If no IUP is present and ultrasound does not confirm ectopic pregnancy, serial quantitative &bgr;-hCG values should be followed (2)[C].
    • Late pregnancy:
      • Proceed to rule out placenta previa with ultrasound, labor with serial cervical exams, and abruption with external fetal monitoring.
P.1101

image TREATMENT
MEDICATION
First Line
  • Treat underlying cause of bleeding, if identified.
  • If mother is Rh negative, give RhoGAM to prevent autoimmunization. In late pregnancy, dose according to the amount of estimated fetomaternal hemorrhage.
  • If cause of bleeding is preterm labor, consider betamethasone for fetal lung maturity if <34 weeks' gestation. Tocolytics may be used to prolong pregnancy to allow for course of steroids.
  • If threatened abortion: Consider progesterone (relative risk 0.53) (3)[A].
  • If mother has an inherited bleeding disorder or if bleeding is severe, consider recombinant or donor blood products.
SURGERY/OTHER PROCEDURES
  • Cesarean section may be indicated for recurrent or uncontrolled bleeding with placenta or vasa previa.
  • If ectopic is diagnosed, immediate surgical treatment may be needed. Some early ectopic pregnancies can be treated medically if certain criteria are met (2)[C].
  • Surgical uterine evacuation is necessary for molar pregnancy due to malignant potential (4)[C].
  • Incomplete or inevitable spontaneous abortion: Management is patient centered. In the absence of infection, patient may elect expectant, medical, or surgical management. If expectant management, typically wait 2 weeks for patient to complete abortion; most complete by 9 days. If at 2 weeks abortion is not completed or medical management has failed, surgical intervention (D&C or aspiration) is generally indicated (5)[A]. May send tissue to pathology to confirm.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • In early pregnancy: based on quantity of bleeding, need for surgical treatment for ectopic pregnancy, or presence of infection in case of spontaneous abortion
  • In late pregnancy, if significant bleeding and/or presence of maternal or fetal compromise
  • In late pregnancy with trauma, if ≥2 contractions/10 minutes
Discharge Criteria
  • In late pregnancy, may discharge when bleeding has stopped; labor, previa, and abruption have been ruled out; and fetal heart tracing is normal.
  • After trauma in late pregnancy, may discharge home if normal fetal heart tracing for ≥4 hours with <2 contractions/10 minutes
image ONGOING CARE
Patient Monitoring
  • Patient should be instructed to report any increase in the amount or frequency of bleeding and to seek immediate care if experiencing fever, abdominal pain, or sudden increased bleeding. Patient should save any tissue passed vaginally for examination.
  • Frequency of outpatient follow-up as indicated based on etiology of bleeding
PATIENT EDUCATION
  • American Academy of Family Physicians (AAFP): www.familydoctor.org
  • American College of Obstetricians & Gynecologists (ACOG): www.acog.org
PROGNOSIS
  • Prognosis depends on the etiology of vaginal bleeding, severity of bleeding, and rapidity of diagnosis.
  • Maternal mortality is 31.9 deaths/100,000 ectopic pregnancies.
  • 1/2 of patients with early pregnancy bleeding miscarry. If fetal heart activity (ultrasound) present in 1st-trimester bleed, <10% chance of pregnancy loss.
  • Heavy bleeding in early pregnancy, particularly when accompanied by pain, is associated with higher risk of spontaneous abortion. Spotting and light episodes are not, especially if lasting only 1 to 2 days.
  • Subchorionic hemorrhage has about 2- to 3-fold increased risk of spontaneous abortion. Smaller hemorrhage and presence of viable fetal heart rate confer lower risk of loss. Most resolve spontaneously.
  • Women with early pregnancy bleeding have an increased risk of preterm delivery, premature rupture of membranes, manual removal of placenta, placental abruption, elective cesarean delivery, and term labor induction later in the same pregnancy. These women also have an increased risk of adverse pregnancy outcomes, including hyperbilirubinemia, congenital anomalies, NICU admission, and reduced neonatal birth weight. Finally, there is an increased risk in subsequent pregnancies of recurrence of early pregnancy bleeding.
  • Bed rest has not been shown to affect the outcome of bleeding in early pregnancy but may be indicated for bleeding in late pregnancy with placenta or vasa previa or with maternal hypertension.
REFERENCES
1. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729.
2. Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. 2009;79(11): 985-994.
3. Wahabi HA, Fayed AA, Esmaeil SA, et al. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2011;(12):CD005943.
4. Snell BJ. Assessment and management of bleeding in the first trimester of pregnancy. J Midwifery Womens Health. 2009;54(6):483-491.
5. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;(3):CD003518.
Additional Reading
&NA;
  • Chi C, Kadir RA. Inherited bleeding disorders in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2012;26(1):103-117.
  • Dadkhah F, Kashanian M, Eliasi G. A comparison between the pregnancy outcome in women both with or without threatened abortion. Early Hum Dev. 2010;86(3):193-196.
  • Griebel CP, Halvorsen J, Golemon TB, et al. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243-1250.
  • Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. 2006;194(1):92-94.
  • Hasan R, Baird DD, Herring AH, et al. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. 2009;114(4):860-867.
  • Lykke JA, Dideriksen KL, Lidegaard O, et al. Firsttrimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol. 2010;115(5):935-944.
  • Magann EF, Cummings JE, Niederhauser A, et al. Antepartum bleeding of unknown origin in the second half of pregnancy: a review. Obstet Gynecol Surv. 2005;60(11):741-745.
  • Mercier FJ, Van de Velde M. Major obstetric hemorrhage. Anesthesiol Clin. 2008;26(1):53-66.
  • Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin North Am. 2007; 34(3):403-419.
  • Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005-1016.
  • Publications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430-439.
  • Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician. 2007;75(8): 1199-1206.
  • Walfish M, Neuman A, Wlody D. Maternal haemorrhage. Br J Anaesth. 2009;103(Suppl 1):i47-i56.
  • Wijesiriwardana A, Bhattacharya S, Shetty A, et al. Obstetric outcome in women with threatened miscarriage in the first trimester. Obstet Gynecol. 2006;107(3):557-562.
See Also
&NA;
Abnormal Pap and Cervical Dysplasia; Abortion, Spontaneous (Miscarriage); Abruptio Placentae; Cervical Malignancy; Cervical Polyps; Cervicitis, Ectropion, and True Erosion; Chlamydia Infection (Sexually Transmitted); Ectopic Pregnancy; Placenta Previa; Preterm Labor; Trichomoniasis; Vaginal Malignancy
Codes
&NA;
ICD10
  • O20.9 Hemorrhage in early pregnancy, unspecified
  • O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
  • O20.0 Threatened abortion
Clinical Pearls
&NA;
  • Obtain blood type and screen all women presenting with vaginal bleeding in pregnancy and administer RhoGAM to all Rh-negative patients.
  • For up to 50% of early pregnancy bleeding, no cause is ever found.
  • Always consider ectopic pregnancy in 1st-trimester bleeding.
  • Do not perform digital exam in late pregnancy bleeding until placenta has been located on ultrasound.