vaginal bleeding du ing pregnancy (2)

Summary:Décription:Any bleeding during pregnancy should be considered abnormalEtiology varies with gestational ageBleeding may vary from scant brown staining to bright-red, life-threatening hemorrhage associated with shockMay be painless or associated with degrees of pain varying from cramps or back pain to severe abdominal paiFetus may or may not be compromisedIt is very important to remember Rho(D) immune globulin administration for Rhesus-negative women to prevent hemolytic disease of the newborn in subsequent pregnanciesImmediate actionIf there is heavy bleeding, hemodynamic compromise, collapse, or fetal compromise, transfer urgently to the emergency department or delivery suiteSuspected ectopic or molar pregnancy should be referred urgently to an obstetric and gynecology specialistKey pointsHeavy bleeding with hemodynamic compromise requires immediate hospitalization and further evaluation and treatment regardless of gestational ageRho(D) immune globulin should be considered for all Rhesus negative mothers following any episode of vaginal bleeding in pregnancy regardless of gestational agePatients more than 20 weeks gestational age with vaginal bleeding should not be examined vaginally (bimanual or speculum) unless the placental site is known or shown to not be previa. BackgroundCardinal featuresAny bleeding in pregnancy should be regarded as abnormal, although no cause is found in 50% of cases of bleeding in early pregnancySource of bleeding may be vagina, cervix, or uterusPossible causes vary with gestational ageEctopic pregnancy is potentially the most serious cause of first-trimester bleeding, presenting with bleeding and painBleeding may vary from scant, brown staining to bright red, life-threatening hemorrhage associated with shockMay be painless or associated with degrees of pain varying from cramps or back pain to severe abdominal painFetus may or may not be compromisedIt is very important to remember Rho(D) immune globulin administration for Rhesus-negative women to prevent hemolytic disease of the newborn in subsequent pregnancies

Causes

Common causes50% of first-trimester bleeding has no detectable cause80% of third-trimester bleeding is due to preterm labor, local lesions of lower genital tract, or no discoverable cause7% of third-trimester bleeding is due to placenta previa and 13% is caused by significant placental abruptionImplantation bleed occurs at the time of embryo implantation, about the same time as first missed periodSpontaneous abortion may be threatened, complete, incomplete, or inevitableEctopic pregnancy

Bloody show at termCervical lesions: polyps, decidual reaction, neoplasiaCervicitis/vulvovaginitisVaginal or postcoital traumaBlood dyscrasias

Rare causesTrophoblastic disease: molar pregnancy, choriocarcinomaVasa previa: velamentous insertion of cord in lower uterine segment leaving vessels unsupported and prone to tearing. May be rapidly fatal to fetus

Serious causesEctopic pregnancy: most common cause of first trimester maternal deathTrophoblastic disease: although most cases are benign, trophoblastic disease may rapidly progress to invasive mole or frank choriocarcinomaPlacental abruption: hemorrhage may be life-threatening to mother and fetusPlacenta previa: hemorrhage may be life-threatening to mother and fetusVasa previa: fetal death occurs in at least 50-90% of cases

Contributory or predisposing factorsPelvic inflammatory disease and previous ectopic pregnancy predispose to ectopic pregnancyRisk factors for placental abruption include hypertension (found in 40-50% of cases), trauma, polyhydramnios, multiple pregnancy, high parity, smoking, cocaine use, chorioamnionitis, and preterm premature rupture of membranesRisk factors for placenta previa include advancing age, multiparity, African or Asian race, smoking, cocaine use, previous placenta previa, one or more previous cesarean sections or other uterine surgery, and previous suction curettage for spontaneous or induced abortion

Epidemiology

Incidence and prevalenceIncidence

Hydatidiform mole: 0.67/1000 pregnancies in the USChoriocarcinoma: 0.05/1000 pregnanciesVasa previa: 0.3/1000 deliveriesAbruption severe enough to result in death of fetus: 2.4/1000 deliveriesFrequency of any cancer in association with pregnancy: 1/1000 live birthsFrequency of cervical cancer diagnosed in pregnancy: 0.4-0.5/1000 pregnanciesFrequency

10-15% of clinically recognized pregnancies are lostOf married women in the US, 4% experience two fetal losses and 3% experience three or more losses20-25% of patients in the US have vaginal spotting/bleeding in first trimester. Spontaneous abortion occurs in 50% of these1-2% of all pregnancies in the US are ectopic; 108,000 cases of ectopic pregnancy reported in the US in 1992Average reported frequency for placental abruption is about 1/120 deliveries (0.83%)Average reported frequency for placenta previa is <1/200 deliveries (<0.5%)

DemographicsAge

Age is a significant risk factor for trophoblastic disease: women over 40 have a 5.2-fold increased risk compared with mothers aged 21-35 yearsIncreased risk of placenta previa with advancing ageRace

Ectopic pregnancy is more frequent in women of African originRisk of placenta previa is higher in women of African or Asian backgroundGenetics

Spontaneous abortion is more common in pregnancies of abnormal karyotype, e.g. trisomies, triploidy, monosomy, structural chromosomal abnormalities, translocationsMost complete molar pregnancies have 46XX karyotype of paternal derivation

Codes

ICD-9 code180.0 Cervical dysplasia, cancer184.0 Vaginal cancer616.0 Cervicitis616.10 Vulvovaginitis622.7 Cervical polyps630 Hydatidiform mole631 Other abnormal product of conception633 Ectopic pregnancy634 Spontaneous abortion640 Hemorrhage early in pregnancy641 Antepartum hemorrhage, abruptio placentae, and placenta previa

DiagnosisClinical presentation

SymptomsAmount of bleeding reported may be small or largeBlood may be brown or bright redMay be painless, or painful cramps and/or back pain may be reportedReduced or lack of fetal movement, depending on degree of fetal compromiseWeakness, dizziness, fainting

SignsSigns depend on cause of bleeding but may include varying degrees of the following:

Shock with tachycardia and hypotension, orthostatic hypotensionPallor (if bleeding is severe)Tender abdomen, especially with ectopic pregnancyTender uterusBlood in vaginaTender adnexa

Open internal osAbsent fetal heart tones

Associated disordersCocaine abuse is associated with preterm labor and placental abruption in particular.

Differential diagnosisAt any gestational age:

Vaginal lacerations caused by traumaCervicitisVulvovaginitisCervical polypsCervical neoplasiaAt gestational age up to 20 weeks:

Spontaneous abortionEctopic pregnancyHydatidiform moleLow-lying placentaAt gestational age above 20 weeks:

Molar pregnancyPlacenta previaPlacental abruption, marginal separation of placentaVasa previaSpontaneous abortionEctopic pregnancyTrophoblastic diseasePlacental abruptionPlacenta previaLesions of the cervix and vaginaVasa previa

Workup

Diagnostic decisionDiagnosis is based on history and examination and confirmed with appropriate special investigationsStage of gestation needs to be taken into account when considering the etiology of bleeding in pregnancyAim to exclude disorders requiring urgent treatment first: ectopic pregnancy and trophoblastic disease in early pregnancy; placenta previa and placental abruption in later pregnancyFirst trimester bleeding:

Obtain serum hCG level: obtain pelvic ultrasound if hCG >2000 milli-international units/mLPelvic ultrasound: if positive for gestational sac there is no need for further work-up of ectopic; if negative for gestational sac follow serial serum hCG levelsIf initial serum hCG <2000 milli-international units/mL, follow serial quantitative hCG levels (every 48h) until level >2000 milli-international units/mL and then proceed with pelvic ultrasound

Guidelines

Fleischer AC, Andreotti RF, Bohm-Velez M, et al, Expert Panel on Women's Imaging. First trimester bleeding. American College of Radiology (ACR); 2005Thurmond A, Fleischer AC, Andreotti RF, et al, Expert Panel on Women's Imaging. Second and third trimester bleeding. American College of Radiology (ACR); 2005Morin L, Van den Hof MC; Diagnostic Imaging Committee, Society of Obstetricians and Gynaecologists of Canada. Ultrasound evaluation of first trimester pregnancy complications. J Obstet Gynaecol Can 2005;27:581-91ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can 2007;29:261-73SOGC clinical guidelines. Gynecological and Obstetric Management of Women with Inherited Bleeding Disorders. J Obstet Gynaecol Can 2005;27:707-18Royal College of Obstetricians and Gynaecologists (RCOG). The management of gestational trophoblastic neoplasia. London (UK): Royal College of Obstetricians and Gyneacologists (RCOG); 2004 (Guideline; no. 38)The American Academy of Family Physicians has produced the following guidance information:

Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician 2007;75:1199-206Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician 2005;72:1243-50Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915-26Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604Don't miss!

A high percentage of ectopic pregnancies are missed on initial consultation.

Questions to askPresenting condition

When was your last menstrual period? Helps date the pregnancy but often difficult to obtain accurate information. Different etiologies of bleeding are more likely to occur at different gestationsHave you had a positive pregnancy test? Many patients will do a home pregnancy test. An ectopic pregnancy may occasionally present before the first missed period. A negative test excludes, with reasonable accuracy, a complication of pregnancy as the cause of bleeding provided it is not done too early or on dilute urineHave there been any complications in this pregnancy? Previous episodes of bleeding may have been treatedWhat is the bleeding like, when did it start, what has been the duration, volume, color? Try to establish nature of bleedingHave you felt the baby moving? Fetal movements, which are usually felt from about 14-16 weeks, will decrease or stop if fetus is compromisedHave you passed any tissue or clots? Tissue may have been passed with an incomplete spontaneous abortion. Clots may be passed with heavier bleeding. Vesicles may be passed with hydatidiform mole but this is usually a late sign

Is there any relation to intercourse? May indicate postcoital trauma to cervical or vaginal lesions as cause of bleeding. May also provoke bleeding from placenta previaIs there anything of significance in past obstetric history? Ask about number of pregnancies, operative deliveries, prior pelvic surgery, pregnancies or deliveries complicated by placental abruption or placenta previa, elective or spontaneous abortion, previous preterm labor, incompetent cervix, previous ectopic pregnancyIs there anything of significance in the past gynecologic history? Ask about diethylstilbestrol exposure, genital trauma, abnormal Papanicolaou smears, contraceptive method, infertility treatment, gynecologic surgeryAre there any associated symptoms? Bleeding from spontaneous abortion may be associated with crampy pain. Products in the os may cause extreme pain; ectopic pregnancy leads to abdominal or pelvic pain in the majority of cases; typically, bleeding from placenta previa is painless and that due to placental abruption is painful. Weakness, dizziness, and syncope may be associated with hypovolemia and are warning signs of a ruptured ectopic pregnancy; vaginal discharge may be associated with infection; urinary symptoms may be present with infection, which may cause bleeding mistaken for vaginal bleedingContributory or predisposing factors

Are there any risk factors for pelvic inflammatory disease that may predispose to ectopic pregnancy? Prior pelvic inflammatory disease, known current sexually transmitted disease, multiple partners, recent abortionAre there any risk factors for ectopic pregnancy? Prior ectopic pregnancy, use of intrauterine device, infertility, tubal surgeryIs there a previous history of trophoblastic disease? The risk of trophoblastic disease is increased in patients with a previous historyIs there a history of bleeding tendency or easy bruising? May indicate blood dyscrasiaIs the patient taking any anticoagulants or platelet inhibitors? Possible if previous history of thromboembolic disease or pregnancy-induced hypertensionIs there a known history of coagulation disorder? For example, von Willebrand's diseaseIs there evidence of cocaine abuse? An important risk factor for placental abruption and preterm laborDoes the patient smoke? Placental abruption, ectopic pregnancy, and cervical neoplasia are more common in smokersFamily history

Is there a history of diethylstilbestrol exposurein utero? Associated with vaginal malignancy and uterine abnormalitiesIs there a family history of coagulation disorders? May be a family history in some inherited coagulopathies, with women displaying a tendency rather than frank disease (hemophilia A and B); von Willebrand's disease should be considered

ExaminationGeneral examination: to assess for level of distress, color, hydration. Patient with larger volume blood loss may be pale and dehydratedRecord vital signs: including pulse (tachycardia with hypovolemia), blood pressure (may be hypotensive or have orthostatic hypotension with hypovolemia), respirations, temperaturePerform cardiopulmonary examination: to assess fitness for anesthesia. May be chest signs and effusion in choriocarcinomaExamine the skin: ecchymoses or petechiae may be present in women with blood dyscrasiasExamine the abdomen: to assess for distension due to gravid uterus, scars, trauma; palpate for tenderness, guarding, signs of peritoneal irritation that may be present in ectopic pregnancy, masses, organomegaly, inguinal lymph nodesAuscultate: for fetal heart tones

Examine the pelvis: do not perform in suspected placenta previa unless prepared for emergency cesarean delivery and full resuscitation, since examination may provoke torrential hemorrhageExamine external genitals: to assess for vulvar lesions, cystocele, rectocele, urethral pathologyPerform speculum examination: to assess for vaginal wall lesions, cervical lesions, vaginal discharge, blood in vaginal vault or internal os, prolapse, tearsPerform bimanual examination: to assess uterine size, adnexal masses, tenderness, cervical motion tenderness, internal os

Summary of testsUrine pregnancy test is a simple test to confirm the patient is pregnantQuantitative beta-human chorionic gonadotropin (hCG): measurement of hCG in plasma permits accurate quantification to determine whether pregnancy is normal or pathologic. Raised level can be detected before the missed period, at about 6-7 days after ovulation, at the time of implantationHematology studies (complete blood count, blood group and screen, and Rhesus typing, including anti-D immunity): can determine the amount of blood loss and if there is a need for blood transfusionCoagulation studies (platelets, prothrombin time, thrombin time, partial thromboplastin time, disseminated intravascular coagulation panel): can indicate a bleeding diathesisUltrasound: the most useful diagnostic test for vaginal bleeding in pregnancyProgesterone level <5mg/dL suggests a nonviable pregnancy; >25mg/dL suggests a good prognosis. Not a frequently used test, but it may be used by a specialist in cases of doubtInfection screening: cervical cultures/wet mount may be required to diagnose cervicitis; vaginal swabs may culture causative organism in vulvovaginitis but most cases are due to Candida albicansPapanicolaou smear: should be done at initial antenatal visit if no recent result is availableCuldocentesis: may be useful if there is no easy access to other diagnostic facilities in cases where hemoperitoneum is suspected secondary to ruptured ectopic pregnancy; performed by a specialistLaparoscopy and/or laparotomy: may be performed by specialist to diagnose/treat ectopic pregnancyBiopsy of vulvar or vaginal lesions: referral to a gynecologist is preferable, since such lesions may bleed profusely during pregnancyFetal monitoring: may be performed by specialist for gestations >20 weeks to ascertain fetal well being and uterine contractions

Order of testsUrine pregnancy testQuantitative beta-human chorionic gonadotropin (hCG)Hematology studiesCoagulation studiesUltrasoundInfection screeningPapanicolaou smear

TestsBody fluids

Urine pregnancy testQuantitative beta-human chorionic gonadotropin (hCG) levelHematology studiesCoagulation studiesInfection screening

Imaging

Ultrasound

Special tests

Papanicolaou smear

Clinical pearlsBe aware of heterotropic pregnancy (combined intrauterine and ectopic). This is a rare event (incidence 1:30,000).

Consider consultRefer for definitive diagnosis in ectopic pregnancy. May be difficult to make the diagnosis clinically and a high index of suspicion is required to pursue a definitive diagnosisAny woman with bleeding late in the second trimester should be evaluated immediately, preferably in hospitalTreatmentGoalsResuscitate as necessary. Stabilize hemodynamically, secure intravenous line, provides adequate blood and fluid replacementExclude serious causes, and refer as appropriateEnsure fetal health as well as maternalReassure as appropriatePrevent Rhesus isoimmunization and hemolytic disease of newborn due to anti-D antibodies in a subsequent pregnancy

Immediate actionHemodynamic stabilization may be required immediately before patient is transferred to the hospital or specialist centerUrgent transfer to the hospital for all suspected ectopic pregnancies

Therapeutic options

Summary of therapiesChoice of therapy depends on etiology of bleedingIn first trimester, many patients may be managed as outpatients if ectopic pregnancy is excluded. Any woman with bleeding in late second trimester and beyond should be evaluated immediately, preferably in hospitalReassurance may be the only appropriate measure for those with implantation bleeds, threatened spontaneous abortion, or minor bleeding of no apparent causeGeneral advice includes bed rest and no coitus. Does not influence outcome of spontaneous abortion, but may be important for placenta previaHemodynamic stabilization is important. Secure intravenous line and adequate blood and fluid replacement for patients with heavy bleedingExpectant or conservative management may be appropriate for some cases of spontaneous abortion. Complete spontaneous abortion is better managed expectantly since this has a lower complication rate than surgical management. Medical evacuation may be of use in incomplete spontaneous abortion. Emergency dilatation and curettage may be necessary for incomplete spontaneous abortion with heavy bleeding

Rho(D) immune globulin is important for Rhesus-negative women to prevent hemolytic disease of the newborn in subsequent pregnanciesLaparotomy or laparoscopy with salpingectomy or salpingostomy may be required for ectopic pregnancyCesarean section may be required urgently in later pregnancy where life of the mother or fetus is at risk due to heavy bleeding from placenta previa or abruption. Placenta previa mortality has fallen from 25% to <1% in the past 40 years, owing to expectant management and liberal use of cesarean sectionCesarean section is appropriate if pregnancy has reached 37 weeks or lung maturity is documented by amniocentesis at the time of bleeding, in the presence of life-threatening maternal hemorrhage, or beyond 24 weeks for fetal distress, and for patient in labor beyond 34 weeks. Usually performed by a specialistIf bleeding is not life-threatening, patient may be managed expectantly with close monitoring in hospital or, if stable, bed rest at home with easy readmission for further bleeding. Fetus at 32 weeks has 80% chance of achieving 36 weeks in utero and the gains that that confersTrophoblastic disease should be managed in a specialist center and involves suction curettage and monitoring of human chorionic gonadotropin levels with hysterectomy or chemotherapy for more invasive diseaseCervical and vaginal lesions, including benign cervical lesions, should be referred to a specialist for removalGuidelines

ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can 2007;29:261-73SOGC clinical guidelines. Gynecological and Obstetric Management of Women with Inherited Bleeding Disorders. J Obstet Gynaecol Can 2005;27:707-18Royal College of Obstetricians and Gynaecologists (RCOG). The management of gestational trophoblastic neoplasia. London (UK): Royal College of Obstetricians and Gyneacologists (RCOG); 2004 (Guideline; no. 38)ACOG practice bulletin. Prevention of Rh D alloimmunization. Washington, D.C: American College of Obstetricians and Gynecologists (ACOG), 1999 (ACOG practice bulletin; no. 4). Summary from the National Guideline ClearinghouseThe American Academy of Family Physicians has produced the following guidance information:

Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician 2007;75:1199-206Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician 2005;72:1243-50Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915-26Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604

Order of therapiesRho(D) immune globulin

Efficacy of therapiesAdministration of Rho(D) immune globulin reduces the risk of Rhesus alloimmunization to 0.2%Ectopic pregnancy: rate of persistent ectopic pregnancy is about 8% following laparoscopic salpingectomyTrophoblastic disease: suction curettage successfully treats 75-80% of cases of molar pregnancies; 20% go on to require further treatment

Placenta previa: maternal mortality is <1% and perinatal mortality is <10% with the use of ultrasound diagnostic techniques, expectant management, and liberal use of cesarean deliveryPlacental abruption: perinatal mortality is about 0.9/1000 births overall with expectant management and emergency cesarean delivery

Medications and other therapiesMedications

Rho(D) immune globulin

Summary of evidence

EvidenceAdministration of Rho(D) immune globulin to Rhesus-negative women at 24 weeks' and 34 weeks' gestation during the first pregnancy reduces the risk of Rhesus-D alloimunisation from 1.5% to 0.2% [1]Level A

Clinical pearlsMost cases of placental separation are mild and self-resolveVaginal bleeding from abdominal wall trauma warrants in-hospital monitoring

NeverNever omit to perform a pregnancy test in a woman of childbearing age presenting with abdominal pain or abnormal vaginal bleedingNever perform a digital examination on a pregnant woman who presents with bleeding until ultrasound has excluded placenta previa

Management in special circumstancesEctopic pregnancy is potentially fatal without interventionPlacental abruption, placenta previa, and vasa previa are risks for rapid fetal deathCoexisting diseasePatients with blood dyscrasias will need referral to a hematologist and specialist treatment.

Patient satisfaction/lifestyle prioritiesSome patients may prefer expectant or conservative management to surgical interventions where possible.

Patient and caregiver issues

Questions patients askDoes bleeding mean that I will miscarry? 20-25% of pregnant women in the US experience bleeding; of these, half go on to miscarryWill I miscarry again? Risk of recurrence starts to rise after third spontaneous abortionHave I done anything to cause this bleeding? Highly unlikely that any patient action will cause bleedingCould I have done anything to prevent bleeding? Reassure patient that bleeding is beyond her control

Health-seeking behaviorHas the patient previously been to the emergency department? Up to 40% of cases of ectopic pregnancy are misdiagnosed at initial consultation.

FollowDepends on diagnosisPatients with first-trimester bleeding are more likely to deliver preterm and should be followed closely through the remainder of the pregnancyBereavement and genetic counseling is appropriate for all pregnancy lossesTrophoblastic disease requires long-term follow-up, monitoring hCG levels until normal for at least 6 months. Also requires assessment in subsequent pregnanciesEctopic pregnancies that have been treated conservatively or by salpingostomy require follow-up with human chorionic gonadotropin luevels until negative to exclude the possibility of persistent ectopic pregnancyPlan for reviewPatients with early pregnancy bleeding that resolves should be given routine antenatal carePatients undergoing dilatation and curettage should consult soon after for counseling as required and contraceptive advice as appropriateLaparotomy and laparoscopy require routine surgical follow-up

Information for patient or caregiverspontaneous abortion: if managed medically, patient should be advised to report if heavy bleeding occursEctopic pregnancy: if being managed conservatively, patients should report if symptoms suggesting rupture occur, i.e. increased pain, dizziness, syncopePlacenta previa and placental abruption: confer increased risk in subsequent pregnancies

Ask for advice

Question 1Do all suspected ectopic pregnancies need treatment?

Answer 1

Some will spontaneously abort, but ectopic pregnancy is life-threatening and all presumed cases should be treated.

Question 2Does a threatened abortion of a live fetus need Rho(D) immune globulin therapy?

Answer 2

These require no treatment.

Consider consultRefer conditions requiring surgical treatment, e.g. ectopic pregnancy, incomplete spontaneous abortion

Trophoblastic disease should be managed in a specialist centerBleeding complications of later pregnancy may need urgent cesarean section. Placental abruption places mother and fetus in high-risk position that should be managed by an experienced obstetrician with neonatal and maternal resuscitation facilities. Placenta previa may need urgent cesarean deliverySeek perinatal consult for high-risk pregnancyOutcomesPrognosisDepends on cause, severity, and rapidity of diagnosisPatients with bleeding in first and early second trimester are more likely to deliver pretermEctopic pregnancy may persist in current pregnancy, necessitating further intervention, or recur in subsequent pregnancyPreterm labor may occur in subsequent pregnancySpontaneous abortion: 20% risk of spontaneous abortion in subsequent pregnancyPlacenta previa maternal mortality <1% and perinatal mortality <10%Progression of diseaseRecurrence

Trophoblastic disease may rarely recur. There is a 1 in 74 risk of further molar pregnancy in subsequent gestations. 20% of molar pregnancies require further treatment after suction curettage; 3-5% progress to choriocarcinoma. Pregnancy must be avoided until at least 6 months of normal human chorionic gonadotropin levels are recorded after molar pregnancyAbruption may recur in 5-17% and in up to 25% with two prior episodes. The influence that risk factors such as hypertension have on this is not clear

Clinical complicationsVaginal bleeding in pregnancy may lead to:

Shock from large volume blood lossDisseminated intravascular coagulation, especially in placental abruptionAnemiaAnti-D antibodies may result from fetal-maternal hemorrhages in RhD-negative women who are carrying a RhD-positive fetusFetal/maternal deathInfectionPreterm labor and delivery of baby with associated complications

Consider consultWomen in shock from large volume blood loss should be transferred to the hospital as soon as possible

PreventionPrimary prevention

Modifiable risk factorsTobacco

Stop smoking, preferably before conception.

Alcohol and drugs

Stop drugs of abuse, particularly cocaine.

Sexual behavior

Use barrier methods of contraception, particularly at a young age, to prevent spread of sexually transmitted disease and reduce risk of cervical cancer.

Secondary preventionIt is not known how modification of risk factors affects recurrence of conditions causing bleeding in pregnancy (e.g. control of hypertension and risk of recurrent placental abruption).

ScreeningScreening for Chlamydia may be useful for selected patients to prevent pelvic inflammatory disease:

Sexually active women under 25Women with a new sexual partnerWomen with multiple partners in the previous 12 monthsWomen using nonbarrier methods of contraceptionWomen with symptoms of cervical friability, mucopurulent discharge, or intermenstrual bleedingScreening for cervical cancer is cost-effective.

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Spontaneous abortion is fetal loss before 20 weeks' gestation or delivery of a fetus weighing under 500g. Fetal loss before 12th week is termed 'early' and between 12 and 20 weeks' gestation is termed 'late.'

FeaturesVaginal bleeding for >3 days carries 15-20% chance of spontaneous abortionProfuse bleeding with pain has a higher association with spontaneous abortion than painless bleedingUterine size may be smaller than dates in cases of missed abortionCervix may be dilated with fetal tissue passed through the osInevitable if internal os open, threatened if os is closed

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Ectopic pregnancy is defined as pregnancy occurring outside the endometrial lining of the uterus; 96% are tubal but ectopic pregnancy may also be ovarian, cervical, or abdominal.

FeaturesRisk factors include pelvic inflammatory disease, previous ectopic pregnancy, previous tubal surgery, intrauterine device use, and assisted reproductionAbnormal vaginal bleeding or amenorrhea occurs in 75% of patientsAbdominal pain and tendernessAdnexal tendernessPeritoneal signs (acute abdomen)Shoulder pain (referred)

Shock

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Trophoblastic disease includes hydatidiform mole, invasive mole, choriocarcinoma, and placental site trophoblastic tumor. Hydatidiform mole runs benign course in 75-80% of cases; only 3% result in choriocarcinoma. Choriocarcinoma, which is highly malignant and frequently metastatic, may occur after any pregnancy but is most common after hydatidiform mole.

FeaturesGestational trophoblastic disease usually presents with vaginal bleeding and cramps in the first trimester or early in the second trimesterPassage of classic vesicular tissue may occur but is usually a late signUterus is large for dates in about 50% of casesNo signs of normal intrauterine pregnancy, no fetal heart tonesVaginal bleeding is most common presentation in choriocarcinomaUterine perforation and hemorrhage may occur in choriocarcinoma; fatal intra-abdominal bleeding may occurMetastases appear early in choriocarcinoma. Dark hemorrhagic nodules may appear on vagina and vulva; also occur in lung, brain, liver, kidney, bone, and many unusual sites


Placental abruption is separation of the placenta from the uterine wall before delivery of the fetus, initiated by bleeding into the decidua basalis from small arterial vessels that are pathologically altered and prone to rupture. A hematoma forms, causing separation and ultimately destruction of placenta in the affected area. Process may be self-limiting and of no further consequence to the pregnancy, or there may be continued dissection and separation of placenta by blood under pressure continuing into the myometrium and peritoneal surface.

Features80% of cases occur before onset of laborClassic symptoms are vaginal bleeding, abdominal pain, uterine contractions, and uterine tendernessBleeding may be revealed or concealed: 10% of women have concealed bleeding80% of cases have external bleeding. Actual blood loss is often much greater than perceived as only a small portion of that lost from the circulation makes its way through the cervixGrade 1: mild vaginal bleeding, uterine irritability, stable vital signs, normal fetal heart rate, normal coagulation profileGrade II: moderate vaginal bleeding, hypertonic uterine contraction, orthostatic hypotension, fetal compromise, abnormal coagulation statusGrade III: severe bleeding (may be concealed), hypertonic uterine contractions, hypovolemic shock, fetal death, thrombocytopenia, fibrinogen <150mgRisk factors include hypertension (found in 40-50% of cases), trauma, polyhydramnios, multiple pregnancy, high parity, smoking, cocaine use, chorioamnionitis, and preterm premature rupture of membranes

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The placenta encroaches on or overlies the internal os during the third trimester. A low-lying placenta is a possible placenta previa before the third trimester; it is more common in early pregnancy and often resolves without becoming symptomatic.

FeaturesSudden onset of painless bleeding in second or third trimesterAbsence of pain distinguishes placenta previa from placental abruption, although painful labor may initiate bleeding from placenta previaPeak incidence in early third trimesterMay be no obvious precipitating cause, e.g. pelvic examination, intercourse, or onset of laborDigital examination should not be performed unless a cesarean delivery can be performed if requiredRisk factors include advancing age, multiparity, African or Asian race, smoking, cocaine use, previous placenta previa, one or more previous cesarean births, prior suction curettage for spontaneous or induced abortion, and placenta accretaPatients with a history of cesarean section and placenta previa have an incidence of placenta accreta of 16-25% and most will require cesarean hysterectomy


The placenta encroaches on or overlies the internal os during the third trimester. A low-lying placenta is a possible placenta previa before the third trimester; it is more common in early pregnancy and often resolves without becoming symptomatic.

FeaturesSudden onset of painless bleeding in second or third trimesterAbsence of pain distinguishes placenta previa from placental abruption, although painful labor may initiate bleeding from placenta previaPeak incidence in early third trimesterMay be no obvious precipitating cause, e.g. pelvic examination, intercourse, or onset of laborDigital examination should not be performed unless a cesarean delivery can be performed if requiredRisk factors include advancing age, multiparity, African or Asian race, smoking, cocaine use, previous placenta previa, one or more previous cesarean births, prior suction curettage for spontaneous or induced abortion, and placenta accretaPatients with a history of cesarean section and placenta previa have an incidence of placenta accreta of 16-25% and most will require cesarean hysterectomy


Lesions of the cervix and vagina include cervical cancer (the most commonly diagnosed malignancy in pregnancy), benign cervical lesions, cervical polyps, cervicitis (chlamydial or gonococcal), vulvovaginitis due to candidal infection, vaginal lacerations, and vulvovaginal metastases of choriocarcinoma.

FeaturesCervical cancer is an uncommon cause of bleeding in pregnancy; friable exophytic lesion of the cervix is seen on speculum examinationPolyps and lacerations may also be seen on speculum examinationCandidiasis affects 15% of pregnant women and causes itching, burning, dyspareunia, excoriations that may bleed or become secondarily infected, and a thick, white, curd-like dischargeCervicitis may cause mucopurulent discharge and bleeding postcoitally or intermenstrually


Vasa previa is velamentous insertion of the cord in the lower uterine segment, leaving vessels unsupported and prone to tearing. A high index of suspicion is essential for its diagnosis, and immediate delivery is required.

FeaturesRupture of fetal vessel leading to severe fetal compromiseFetal mortality is 50-90%


vaginal bleeding du ing pregnancy (2)

Education