Approach to a patient with early

pregnancy bleeding
DR. SAMAR AL-SHWAIKH
Introduction

 Early pregnancy bleeding is the bleeding before 20 weeks of gestation.

 Vaginal bleeding is common in the first trimester (up to 13+6 weeks [ie, 13 weeks plus 6
days of gestation]), occurring in 20 to 40 percent of pregnancies.
Causes

 Ectopic pregnancy
 Miscarriage (threatened, inevitable, incomplete, complete)
 Molar pregnancy
 Implantation of the pregnancy: diagnosis of exclusion
 Cervical, vaginal, or uterine pathology (vaginitis, trauma, tumor, warts,
polyps, fibroids) and Ectropion.
 Bleeding related to early pregnancy loss or threatened abortion is the most
common non-traumatic cause of first-trimester bleeding (prevalence: 15 to 20
percent of pregnancies). Although bleeding may be heavy, almost all patients
remain hemodynamically stable; only an approximate 1 percent of expectantly
managed patients require blood transfusion
 Ectopic pregnancy is much less common (prevalence: 2 percent of pregnancies)
but is the most serious etiology of first-trimester bleeding
Copyrights apply
History .1
Analysis of chief complaint

 Onset, course, duration

 Characters of blood:
 amount ( clots & tampons), blood soaking through her clothes.
 Color
 odor
 passage of tissue or vesicles.

 Timing: any preceeding event ( intercourse, PV).

Associated symptoms

 Abdominal pain: central in abortion, worse on one side in ectopic.

 Back pain.
 Disappearance of early pregnancy symptoms: abortion
 Shoulder pain and dyspareunia: may be present in ectopic.
 Exaggerated early pregnancy symptoms: in molar pregnancy.
 HTN symptoms: in molar pregnancy
 Hyperthyroidism symptoms: in molar pregnancy
 Urinary symptoms.
 Vaginal discharge and itching.
 Fever.
Risk factors

 Ectopic pregnancy: previous ectopic pregnancy, tubal pathology and

surgery, IUD, infertility, smoking, IVF, PID.

 Miscarriage: advancing age, previous spontaneous abortion, increasing

gravidity, smoking, alcohol, cocaine, trauma (CVS and amniocentesis),
uterine structural anomalies, medical conditions (thyroid disease,
thrombophilia, SLE, APA).

 Molar pregnancy: prior molar pregnancy, extremes of maternal age

Other questions

 Complications: anemia” headache, dyspnea, fatigue, palpitation”.

 Genital trauma.
 History of cervical polyp.
 Other sites of bleeding ( per rectum, hematuria )
 History of the current pregnancy
 Previous obstetric history ( previous abortion, consecutive early pregnancy
losses)
 Gynecological history
 Past medical and surgical history (Chronic diseases , Previous surgeries, Drug
history”anticoagulants”.)
Physical examination .2
General examination

 General appearance: the patient may be in pain, pale and in shock

 Vital signs should be examined:

 BP: hypotension in shock.
 Pulse: tachycardia in shock
 RR: increased in shock
 Abdominal Examination
An abdominal examination should be performed before the internal examination

 Gentle percussion is preferable to deep palpation since it causes less pain and guarding
 Midline pain is more consistent with miscarriage.
 Lateral pain is more consistent with ectopic pregnancy.
 The entire abdomen will be tense and tender with guarding and rebound in ruptured
ectopic.
 Determine uterine size: The uterus remains a pelvic organ until approximately 12 weeks of
gestation
 > gestational age in molar pregnancy, multiple gestation, or uterine pathology.
 If the pregnancy is at or beyond 10 to 12 weeks of gestation, a handheld Doppler
ultrasound device can be used to check the fetal heartbeat
Speculum examination

 After the abdominal examination, the patient is placed in the lithotomy position
 Inspection of external genitalia to assess the volume and source of bleeding
 Lesions: vaginal laceration, vaginal neoplasm, vaginal warts, vaginal discharge, polyps,
ectropion, friable cervix, cervical neoplasm.
 Open or closed cervix:
  to distinguish between a threatened and a true early pregnancy loss.
  Direct visualization of the gestational sac in a dilated internal cervical os is generally sufficient
to conclude that early pregnancy loss is inevitable
Investigations .3
Investigations

 Pregnancy test
 CBC (Hemoglobin/hematocrit)
 coagulation studies
Transvaginal ultrasonography

 Transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early

pregnancy.
 It is most useful in bleeding patients with a positive pregnancy test in whom an
intrauterine pregnancy has not been previously confirmed by imaging studies. In these
patients, ultrasound examination is performed to determine whether the pregnancy is
intrauterine or extrauterine (ectopic) and, if intrauterine, whether the pregnancy is
viable (fetal cardiac activity present) or nonviable
 Rarely, ultrasound examination reveals unusual causes of vaginal bleeding, such as
gestational trophoblastic disease or loss of one fetus from a multiple gestation
Other imaging tests

1. transabdominal ultrasound 
2. Magnetic resonance imaging (MRI):  for further evaluation of limited and
nondiagnostic ultrasound, an unusual ectopic pregnancy, gestational trophoblastic
disease, and differentiating causes of severe pelvic pain and adnexal masses.
3. Computed tomography (CT) may be useful in pregnant patients with trauma or acute
nongynecologic pain, for staging of malignancy
 It is not the preferred modality since it involves use of ionizing radiation, but it can be
performed safely(last choice)
Serum quantitative B-hCG

 Done if ultrasonography is nondiagnostic.

 Other investigations are guided by hCG discriminatory zone.
 The discriminatory zone is the serum hCG level above which a gestational sac should
be visualized by TVUS if an IUP is present.
 The discriminatory zone varies somewhat by laboratory and institution; some
institutions set the discriminatory zone at 2000 and others use 3510 milli-international
units/mL.
 for transabdominal ultrasound, the discriminatory zone is higher: approximately 6500
milli-international units/mL.
Management .4
Ectopic pregnancy
Abortion

 threatened abortion: managed expectantly , 90 to 96 percent of pregnancies with

both fetal cardiac activity and vaginal bleeding at 7 to 11 weeks of gestation are not
lost.
 Incomplete, inevitable, or missed abortion can be managed surgically, with
medication, or expectantly if the patient is stable.

 Incomplete, inevitable, or missed abortion managed with emergency D&C if the

patient is unstable.

 Complete abortion is treated expectantly.

Molar pregnancy

 Surgical uterine evacuation is the mainstay of management for

hydatidiform mole, either complete or partial mole.

 Hysterectomy is an option in women who have completed childbearing.

Other managements

 Vaginitis, trauma, tumor, warts, polyps, fibroids: Management of bleeding related to

these conditions depends upon the specific condition
 Ectropion: Therapy is unnecessary.
 Physiologic or implantation bleeding: No intervention is indicated.