VAGINAL BLEEDING DURING PREGNANCY

VAGINAL BLEEDING DURING PREGNANCY - Kimberle Vore, MD
BASICS
DESCRIPTION
• Vaginal bleeding during pregnancy has many causes and ranges in severity from mild (with normal pregnancy outcome) to life threatening for both infant and mother.
• Bleeding can vary from scant to excessive, from brown to bright red, and can be painless or painful.
• Causes can be divided into vaginal, cervical, and uterine factors. The differential diagnosis is guided by the gestational age of the pregnancy.
• System(s) Affected: Cardiovascular; Reproductive
ALERT
Pregnancy Considerations
A complication of pregnancy
EPIDEMIOLOGY
• Predominant age: Childbearing
• Predominant sex: Female only
Prevalence
In the US: Common
RISK FACTORS
• Cervical or vaginal infections
- Multiple sexual partners
- Previous history of sexually transmitted disease or pelvic inflammatory disease
• Cervical dysplasia: Previous history of abnormal pap
• Placenta previa
- Previous history of previa
- Previous caesarean section
- History of uterine surgery including dilation and curettage (DC)
• Placental abruption
- Previous history of abruption (increases risk by 10%)
- Hypertension
- Preeclampsia
- Multiple gestation
- Smoking
- Cocaine use
Genetics
No known genetic pattern
ETIOLOGY
• Vaginal or cervical causes can occur throughout the pregnancy, and usually are no threat to the pregnancy. They include
- Vaginal infection or trauma
- Cervicitis (infections or noninfections)
- Cervical polyp
- Cervical neoplasia
- Hyperemia of cervix (increased blood flow from pregnancy)
- Postcoital bleeding: Usually cervical source
• Bleeding from above the cervix is a concern because it can be life threatening to mother and/or fetus. In determining the cause it is helpful to separate first-trimester bleeding from later-pregnancy bleeding.
- 1st-trimester bleeding causes include Implantation bleedingbenign; ectopic pregnancy; threatened or spontaneous abortion; molar pregnancy; subchorionic bleed
- 2nd- or 3rd-trimester bleeding causes include: Placenta previa (nonpainful); placenta abruption (painful, contraction usually present); subchorionic bleed
• Many times the cause is unknown. For up to 50% of 1st-trimester bleeding, no cause is ever found.
ASSOCIATED CONDITIONS
Depends on cause of vaginal bleeding

DIAGNOSIS
SIGNS AND SYMPTOMS
• Bleeding can vary from scant to excessive.
• Color of blood varies from brown to bright red.
• May be painless or painful
• Patient reports bleeding from vagina.
TESTS
Lab
• Blood work based on dating of pregnancy, previous tests, and need for further diagnosis
• Blood type and screen. If not known already, needs to be done on all women
• Rh-negative patients who bleed during pregnancy will need Rho(d) immune globulin (RhoGAM), to prevent mother from becoming sensitized if exposed to infant's Rh-positive blood. In 3rd-trimester bleeding, the mother may lose significant amounts of blood and require transfusion.
• Quantitative--human chorionic gonadotropin (Q hCG) can be used in early pregnancy when ultrasound is not able to diagnose cause. Ultrasound should be able to see an intrauterine pregnancy (IUP) when Q hCG >2,000.
• Levels can be followed serially every 2 days. Levels fall in spontaneous abortion, are extremely high in molar pregnancy, and rise gradually in ectopic or intrauterine pregnancy. This level usually doubles in 48 hours in normal pregnancy, and failure to increase by 50% is concerning for ectopic
• Once Q hCG level is >2,000, an ultrasound should be performed to confirm diagnosis. When spontaneous abortion is suspected but there is no definitive diagnosis by either ultrasound or pathology confirmation of products of conception, then following Q hCG weekly until level is 25 is advised to exclude possible undiagnosed ectopic pregnancy. If dropping levels start to rise, reconsider ectopic pregnancy. In molar pregnancy, after surgical evacuation of productions of conception, monthly Q hCG are followed for 1 year to rule out the possibility of choriocarcinoma. During this time the patient should be instructed not to get pregnant.
• Other labs are based on severity of bleeding:
- CBC: May be done to assess severity, when bleeding profuse
- Bleeding time, fibrinogen, fibrin split products: Rarely necessary. Disseminated intravascular coagulation (DIC) reported rarely in missed abortion.
Imaging
• Ultrasound (USN) is the diagnostic test of choice. A gestational sac can be seen at 5-6 weeks, fetal heart tone can be observed by 8-9 weeks. USN is diagnostic of molar pregnancy with 98% accuracy. In later pregnancy USN locates the placenta and may show degree of placental separation in abruption.
• Serial ultrasound may be required in early pregnancy.
Diagnostic Procedures/Surgery
• It is important to evaluate whether bleeding is coming from genital tract or from other nearby structures.
• Association of bleeding with other activities or symptoms may aid in the diagnosis (e.g., following bowel movement, after intercourse, associated with abdominal cramping).
• In 1st-trimester bleeding: Pelvic exam is performed to confirm bleeding from cervical os, and if any adnexal masses. If pregnancy is >8 weeks, USN should be done to confirm IUP. If no IUP and USN not confirmatory for ectopic, then serial Q hCG are followed. If pelvic pain and concern for ectopic pregnancy is high but not confirmed by USN, a laparoscopy or laparotomy may be performed to make a diagnosis.
• In 2nd- or 3rd-trimester bleeding: Locate placenta by ultrasound prior to pelvic exam. If placenta previa, do not perform bimanual or speculum exam unless set up for immediate caesarean delivery.
Pathological Findings
Dependent on cause
DIFFERENTIAL DIAGNOSIS
• Hematuria from urinary tract infection (UTI), kidney stones
• Bleeding hemorrhoids
• Rectal bleeding from lower gastrointestinal bleed: Extremely rare in pregnancy
TREATMENT
GENERAL MEASURES
• Appropriate health care
- In 1st-trimester bleeding, most, patients can be managed as outpatients.
- In late-pregnancy bleeding, most patients need inpatient monitoring.
• In late-pregnancy bleeding, the amount of bleeding and presence of maternal or fetal compromise indicates whether emergent caesarean section is performed or whether conservative measures are appropriate until greater fetal lung maturity can be obtained.
• Threatened abortion: Bed rest and nothing in the vagina. If bleeding is severe, hospitalization and close observation. Type and screen for possible transfusion.
Diet
No restrictions
Activity
Bed rest: no coitus, no douching
MEDICATION (DRUGS)
First Line
Rho(d) immune globulin (Rhogam) if mother Rh-negative and significant bleeding from uterus
Second Line
Tocolytics in suspected premature labor
SURGERY
• If ectopic or molar pregnancy is diagnosed, immediate surgical treatment may be needed in some cases.
• Some early ectopic pregnancies can be treated medically if certain criteria are met.
• Inevitable or incomplete abortion: DC (usually suction).
• If completeness of abortion is in doubt, then DC and removal of retained products
• Caesarean section for placenta previa or placental abruption
FOLLOW-UP
PROGNOSIS
• Depends on the cause of vaginal bleeding, the severity of bleeding, and the rapidity of diagnosis. Maternal mortality is 31.9 per 100,000 of ectopic pregnancies. (4)
• If fetal heart tones present in first trimester bleed, 10% chance of pregnancy loss
COMPLICATIONS
• Anemia
• Shock
• Fetal or maternal death
• Infection
• Choriocarcinoma or invasive mole in the case of hydatidiform mole
• Premature delivery of infant with associated complications
• Coagulopathy (extremely rare)
PATIENT MONITORING
Daily to weekly, depending on diagnosis and severity of bleeding
REFERENCES
1. American College of Emergency Physicians. Clinical policy for the initial approach to patients presenting with a chief complaint of vaginal bleeding. Ann Emerg Med. 1997;29(3):435-458.
2. Suspected ectopic pregnancy. Obstet Gynecol. 2006;107:399-413.
3. Signore CC. Second trimester vaginal bleeding: Correllation of ultrasonographic findings with perinatal outcome. Am J Obstet Gynecol. 1998;179(2):336-340.
4. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. 2006;194:92-94.
MISCELLANEOUS
See also: Abnormal Pap Smear; Abortion, Spontaneous; Abruptio Placentae; Cervical Dysplasia; Cervical Malignancy; Cervical Polyps; Cervicitis; Cervicitis, Ectropion and True Erosion; Chlamydial Sexually Transmitted Diseases; Ectopic Pregnancy; Placenta Previa; Preterm Labor; Trichomoniasis; Vaginal Malignancy; Vulvovaginitis, Bacterial; Vulvovaginitis, Candidal