Early Pregnancy Bleeding

Overview

Early pregnancy bleeding is per vaginal bleeding before viability (WHO < 20 weeks gestation date or < 500 g fetal weight)

Approximately 25% of pregnancie s experience bleeding in the first trimester. Most women need to be reassured since 50% of the time the pregnancy will go on uncomplicated. Lower abdominal pain and heavy bleeding are associated with an increased risk of pregnancy loss. The most common cause of early pregnancy bleeding is miscarriage, and the vast majority of these losses are due to chromosomal anomalies. Every patient presenting with early pregnancy bleeding should get their blood grouped (and possibly crossmatched), and a sterile speculum exam.

Important first steps in the management of first-trimester bleeding (or bleeding after secondary amenorrhoea) include IV fluids, physical exam + sterile speculum exam, quantitative B-hCG, Complete Blood Count, and transvaginal ultrasound. hCG normally takes 2-4 weeks to clear after evacuation.

Progesterone level of <6 ng per mL (19.1 nmol per L) reliably excludes a viable pregnancy (with a Negative Predictive Value of 99%)

• Differentials for early pregnancy bleeding
  • Ectopic pregnancy
  • Implantation bleeding
  • Threatened miscarriage (50% will go on to have a normal pregnancy)
  • Miscarriage
    • Inevitable miscarriage
    • Incomplete miscarriage
    • Complete miscarriage
    • Missed miscarriage
  • Molar pregnancy
  • Gynaecological causes:
    • Vulvar, vagina, or cervical trauma
    • Cervical polyp
    • Cervical ectopia
    • Cervical cancer
    • Trichomoniasis
    • Candidiasis
    • Venereal warts
• What are the possible causes of pallor in a patient with early pregnancy bleeding?
  • Vasovagal shock
  • Hypovolemic shock
  • Anemia
  • Septic shock

General Management of Early Pregnancy Bleeding

• Physical examination
  • Bimanual exam: to feel for masses e.g. adnexal mass, cervical motion tenderness,
  • Sterile Speculum exam
    • Check whether the cervical os is dilated or closed
    • Look for clots or products of conception
    • Rule out vulvar, vaginal, or cervical trauma
• Investigations
  • Quantitative B-hCG: compare past and future measurements. Should double every 48 hours. Compared to estimated dates on LMP
    • A normal pregnancy with serum hCG > 1,500IU/L should be able to be confirmed as intrauterine on transvaginal ultrasound
  • CBC: to evaluate blood loss
  • Transvaginal ultrasound: to visualize the fetus
    • Gestational sac visible at 5 weeks
    • Yolk sac and fetal pole visible 5-6 weeks
    • Fetal heart motion (visible at 6-7 weeks LMP): viable fetus
    • Ectopic pregnancy: positive hCG with no evidence of intrauterine pregnancy
  • PT/PTT
  • Blood type and cross-match
  • Rh status: established in any woman presenting with FTB/amenorrhoea
• When is RhoGAM (anti-D) recommended?
  • All Rh-negative women who have undergone a surgical procedure to manage a miscarriage or ectopic pregnancy (to reduce the risk of isoimmunization since these patients are bleeding)
  • The Kleihauer test is not needed to quantify fetomaternal hemorrhage during the first trimester

Complications of Early Pregnancy Bleeding

• What are some of the complications associated with a threatened abortion?
  • Later complications in pregnancy e.g. Abruption placentae
  • First trimester bleeding in subsequent pregnancies
• Complications of early pregnancy bleeding
  • Pregnancy loss (progression to inevitable, incomplete, complete, missed abortion)
  • Heavy bleeding (≥ 1-2 pads per hour for 2 hours)
  • Retained POC
  • Endometritis
  • Septic abortion