PV bleeding in early pregnancy

Early pregnancy:

- Before reach viable gestational age ( < 22 weeks)

Causes of early pregnancy bleeding:

1. Miscarriages – most common cause (threatened, missed, inevitable, incomplete, complete)

2. Ectopic pregnancy
3. Gestational trophoblastic disease
4. Cervical causes (malignant/non-malignant causes: cervical Ca, polyps, cervical ectropion)

Relevant history:

1. Bleeding – duration, amount, passage of vesicles/product of conception/clots/ associated

with coitus
 Minimal bleeding: threatened miscarriage
 Heavier bleeding – incomplete, inevitable miscarriage
 Passage of vesicles – molar pregnancy
 Brownish – missed miscarriage
2. Pain – duration, site, severity, shoulder tip pain
 Bleeding equal to or heavier than a menstrual period and bleeding accompanied by
pain are associated with an increased risk of early pregnancy loss
 Progressing pain – inevitable miscarriage as related to uterine contraction and
cervical dilatation to expel POC
 Less intense pain – threatened miscarriage
 Shoulder tip pain – associated with ruptured ectopic pregnancy (diaphragm irritation
due to hemoperitoneum in ruptured ectopic pregnancy)
3. Menstrual cycle – LMP, regularity
4. Contraception – IUCD, progesterone contraceptive
5. Past obstetric history – previous miscarriage or ectopic pregnancy
6. Risk factors:
 Previous tubal surgery
 Previous pelvic infection especially history of sub-fertility
 IVF
 Progesterone only pills (Higher levels of progesterone cause ciliary dysfunction and
subsequently may be a possible cause of ectopic pregnancy)
 IUCD

Physical examination:

1. Vital signs – for hemodynamic instability

2. Per-abdomen
3. Per-speculum examination
 Non-obstetric cause of bleeding: vaginitis, cervicitis, cervical polyps
 Product of conception visible – incomplete abortion
Investigations

(A) Radiological intervention

Transvaginal/transabdominal ultrasound
– TRO ectopic pregnancy, intrauterine pregnancy (viable/non-viable), no visualised
intrauterine pregnancy (PUL/complete abortion)

USG features:
a) Viable IU pregnancy (FH+): suggestive threatened miscarriage with good prognosis
b) Empty gestational sac: Empty gestational sac >25mm, likely to be non-viable, if sac
has no double lining (decidual lining), possible ectopic pregnancy
c) Fetal pole with absent heart beat: missed miscarriage
d) Empty uterus: consider complete miscarriage/early pregnancy (< 5 weeks)/ectopic
pregnancy

(B) Blood investigation

Beta HCG level to reveal the size of pregnancy if in doubt of pregnancy location via USG
a) 0 hour and 48 hours BHCG
o If reading greater than 1500 IU/L after 48H with empty uterus, ectopic is
suspected
o Slower rate of increase suggests early pregnancy loss/ectopic

Full blood count (FBC) - baseline Hb to assess for anemia

Rh factor – if Rh is not known, Rhogam indicated within 72 hours for all Rh-ve patients with
abdominal trauma, ectopic pregnancy and those undergo surgical intervention.

Management

Treat accordingly for suspected diagnosis (miscarriages, molar pregnancy, ectopic pregnancy
or local cervical cause.