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Vaginal bleeding in early pregnancy is a common problem affecting approximately 25% of all clinically diagnosed pregnancies. Of these about 50% will be due to a failed pregnancy.

Bleeding in early pregnancy is commonly defined as vaginal bleeding during the first trimester, however some definitions extend this to an arbitrary figure of 20 weeks.

Ectopic pregnancy must always be considered in the first instance.

Clinical examination alone is unreliable in the modern assessment of the stable patient with mild early pregnancy bleeding. It is best assessed by ultrasound and quantitative beta HCG levels. 1

Patients with heavy bleeding, circulatory shock or vagal shock will need speculum examination as part of their resuscitative management. 1

The following refers to miscarriage.

A miscarriage is defined as a pregnancy loss occurring before 20 completed weeks gestation or a fetus < 400 grams weight if the gestation is unknown.

See also separate documents on:

  • Bleeding in Early Pregnancy – Threatened Miscarriage
  • Ectopic Pregnancy
  • Anti D

Pathophysiology

The causes of bleeding in early pregnancy include:

  • Ectopic pregnancy.
  • Abortion (miscarriage):
    • Threatened.
    • Failed pregnancy:
    • Incomplete (or inevitable).
    • Complete
    • Septic
  • Trophoblastic disease (or “molar” pregnancy)

4.         Incidental:

            ●          This is due to non pregnancy related pathology, (see non-pregnancy related           vaginal bleeding document).

Clinical Features

The clinical features of a miscarriage (or failed pregnancy) include:

Important points of History:

1.         Pain:

●          Pain is usually more significant than in cases of threatened miscarriage,     particularly in the case of ectopic pregnancy. 

2.         Bleeding:

●          This is usually more severe than in the case of threatened abortion.

●          Estimating the amount of vaginal bleeding is somewhat subjective.

            More objective measures include:

♥          The presence of clots, (suggests a relatively heavy bleed)

♥          Number of pads used.

♥          Bleeding of a degree which is greater than a woman’s normal period carries a worse prognosis

3.         POC:

●          A history of the passage of the “POC” is unreliable in making a definitive statement about the viability of a pregnancy.

Blood clots or decidual cast may be misinterpreted as the POC.

Additionally the correct identification of the POC does not exclude the possibility of a live twin (or of the rare situation of a coexistent ectopic twin pregnancy).      

Important points of Examination:

1.         Check for hemodynamic stability.

●          Hypotension and tachycardia suggests significant blood loss.

●          Hypotension and relative bradycardia may indicate cervical shock.

2.         Abdominal:

            ●          Significant tenderness is suggestive of ectopic pregnancy.

3.         PV examination:

●          When there is significant or recurring blood loss, or if there is significant pain,      then PV examination is warranted in contrast to the situation of uncomplicated        threatened abortion.

PV examination is both diagnostic and therapeutic.

POC may be identified

            POC or clot present within the os can cause bleeding and/or cervical shock

Investigations

Blood tests:

These should include:

1.         FBE

3.         Beta HCG (if clinical uncertainty).

4.         Blood group for the determination of the need for the administration of anti-D and cross   match as clinically indicated.

If sepsis is suspected:

1.         CRP (if sepsis suspected).

2.         Blood cultures

3.         Vaginal swabs for M&C

Ultrasound:

A failed pregnancy is now defined on ultrasound criteria.

Criteria includes:

●          The finding of a crown – rump length (CRL) greater than 6-10 mm

With

●          No cardiac activity

Or

●          A gestational sac equal to or greater than 20-15 mm with no fetal pole (previously termed             a “blighted ovum”).  

A failed pregnancy may then:

●          Remain within the uterus (previously termed a “missed abortion”).

Or

●          May progress to:

            ♥          An incomplete miscarriage

            ♥          A complete miscarriage

Pregnancy of unknown location:

When no pregnancy can be identified on ultrasound, yet the beta HCG is elevated, a pregnancy of unknown location is diagnosed i.e it could be intrauterine but the pregnancy is too early to be seen on ultrasound, or it could be an ectopic, that again is too early to be identified on ultrasound.

Management

Haemodynamically unstable patients:

1.         ABC:

            ●          Give fluid/ blood products as required

2.         Analgesia/ sedation

            ●          Give as clinically indicated.

3.         Os clearance:

●          Blood clot within the os can result in cervical shock, a vagally mediated reaction   that results in bradycardia and hypotension.  

●          Clearing the os resolves the shock.

4.         Ergometrine:

●          If fluid and os clearance fails to correct ongoing bleeding, then ergometrine may   be given if the diagnosis of miscarriage is clear.

●          Give 250 micrograms IM. 

5.         Anti-D:

●          Anti-D is given for all cases of miscarriage, (including cases of incomplete            abortion and curettage.

6.         Antibiotics:

            ●          These are given in the rare case of septic abortion.

7.         Surgical:

●          Emergency surgical evacuation may ultimately be required to control bleeding not             controlled by other means.

Haemodynamically stable patients:

1.         Anti D is given.

2.         Analgesia:

            ●          Simple oral analgesia may be given as required.

Then in the haemodynamically stable patient there are 3 options available:

1.         Expectant (or conservative):

            ●          Success is variable, but some literature quotes a 75% success rate. 2

                        It is usually associated with a slightly prolonged period of bleeding and pain

2.         Medical:

            ●          This may be via prostaglandin E1

3.         Surgical:

            ●          This is by cervical dilation and curettage.

                        The procedure is not an urgent one and is done electively.

The patient’s preference is a particular factor that is taken into consideration.

Disposition:

Whatever option  is undertaken, there should be close follow-up.

Advice is given for patients to return for review if there is ongoing bleeding, pain, or fever and discharge.

Referral for psychological support may be required for some women.


References

FOAMed

Publications

Fellowship Notes

Dr Jessica Hiller LITFL Author

Doctor at Sir Charles Gairdner Hospital in Western Australia. Graduated from Curtin University in 2023 with a Bachelor of Medicine, Bachelor of Surgery. I am passionate about Obstetrics and Gynaecology, with a special interest in rural health care.

Dr Lucy J Yarwood LITFL author

MSc, MBChB University of Manchester. Currently doctoring in sunny Western Australia, aspiring obstetrician and gynaecologist

Physician in training. German translator and lover of medical history.

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