Bleeding per vagina at any time during pregnancy must be regarded as abnormal and is associated with an increased likelihood of pregnancy complications.

Hemorrhage

• Common in U.S. and occurs in women of childbearing age.
• 15% to 25% of patients have vaginal spotting/bleeding in the first trimester.
• Miscarriage and threatened abortion are the most common causes of bleeding in the first trimester.
• Early vaginal bleeding increases the risk of miscarriage (50%) and preterm birth. Some studies have also noted an increased risk of small-for-gestational-age fetal measurements, low birth weight, and possible intrauterine fetal demise.
• Ectopic pregnancy is the leading cause of maternal mortality in the first trimester. 1% to 2% of all pregnancies are ectopic (with a possibility of cesarean scar pregnancy in those with prior cesarean sections).
• Placental abruptions are noted in 1 in 150 pregnancies with an increased recurrence rate in subsequent pregnancies (6% to 17% after one episode, up to 25% after two episodes).
• The increased cesarean rate over the past few decades has been associated with an increased diagnosis of placental implantation disorders-an important cause of vaginal bleeding in pregnancy.

• Bleeding: Ranges from scant to life-threatening with hemodynamic instability
• Color: Brown to bright red
• Can be painless or painful (cramps, back pain, severe abdominal pain)
• Fetal compromise: Ranges from none to fetal demise

• Any gestational age:
  1. Cervical lesions: Polyps, decidual reaction, neoplasia
  2. Vaginal or cervical trauma
  3. Cervicitis/vulvovaginitis
  4. Postcoital trauma
  5. Bleeding dyscrasias
• Gestation <20 wk:
  1. Implantation bleeding
  2. Spontaneous abortion
  3. Presence of intrauterine device
  4. Ectopic pregnancy (including cesarean scar and cervical or abdominal pregnancy)
  5. Molar pregnancy (incidence is 1 in 1000 pregnancies)
  6. Low-lying placenta/placenta previa
  7. hCG-secreting tumors, including gestational trophoblastic neoplasia or gestational choriocarcinoma (incidence is 1 in 1500 to 20,000 pregnancies)
• Gestation >20 wk:
  1. Molar pregnancy
  2. Placental disorders (low-lying placenta, placenta previa, placenta accreta spectrum)
  3. Placental abruption
  4. Vasa previa
  5. Marginal separation of the placenta
  6. Preterm labor
  7. Bloody show at term
  8. Uterine rupture
  9. Postpartum hemorrhage related to retroplacental myomas
  10. Rare etiologies such as uterine artery aneurysm/pseudoaneurysm or uterine arteriovenous malformations (AVMs). AVMs may be diagnosed following persistent vaginal bleeding after delivery or other uterine procedures

• Gestation <20 wk:
  1. Pelvic examination with vaginal/cervical cultures if appropriate
  2. Ultrasound to verify viable intrauterine pregnancy when β-hCG levels achieve threshold values (≥1500 mIU/ml for transvaginal sonography, although this varies by institution). If viable intrauterine pregnancy, evaluate pregnancy and uterine cavity including placenta and placental location
  3. Laparoscopy (if indicated)
  4. Laparotomy (rarely required)
• Gestation >20 wk:
  1. Before pelvic examination, ultrasound for placental location, placental cord insertion, and placental evaluation
  2. Digital exam is contraindicated in cases of placenta previa or low-lying placenta
  3. If viable fetus, evaluation of fetal well-being as appropriate based on gestational age
  4. If suspected preterm labor, evaluate as clinically appropriate

• Urine pregnancy test: If positive, get quantitative serum beta human chorionic gonadotropin (β-hCG). The following are typical although not entirely exclusive patterns:
  1. Normal pregnancy: β-hCG doubles approximately every 48 hr (should at least increase ≥66%)
  2. Spontaneous abortion: β-hCG level will fall
  3. Ectopic pregnancy: β-hCG level will rise inappropriately (<66% in 48 hr)
  4. Molar pregnancy: β-hCG level is higher than expected for gestational age (may be substantially higher)
• CBC
• Blood type and screen (Rh-negative patients need RhoGAM)
• Coagulation profile (particularly if moderate to heavy bleeding)
• Cervical/vaginal cultures, wet mount
• Pap smear for cervical malignancy; caution with biopsy as cervical biopsy sites in pregnancy can bleed extensively

Ultrasound findings:

• 5 to 6 wk: Should see the gestational sac (transvaginally); β-hCG >1500 mIU/ml (varies by institution) is the discriminatory level for visualization of a singleton gestation
• 6 to 7 wk: Should see fetal cardiac activity
• Molar pregnancy: Characteristic cluster of placental cysts

Additionally, evaluate for:

• Evidence of subchorionic/submembranous hemorrhage or placenta accreta spectrum
• Location of placenta and placental cord insertion (particularly if >20 wk)
• Degree of placental separation: Difficult to assess

• Pelvic rest: No coitus, douching, or tampons
• Counseling: Genetic, bereavement (if indicated)
• For viable fetuses, ultrasound assessment of fetal growth and assessment of fetal well-being via external fetal monitoring as clinically appropriate
• Bed rest is not recommended: Recent studies show limited to no benefit of bed rest and possible increased medical and psychologic risk to patients on activity restriction

• Hemodynamic stabilization with intravenous fluid administration and transfusion of blood products as clinically indicated
• Emergency dilation and curettage, laparoscopy, laparotomy, or cesarean delivery as necessary

• If patient is unstable and needs emergency OB/GYN management and/or surgery
• If patient has suspected ectopic or molar pregnancy, as immediate surgical treatment or medical intervention is likely indicated
• Perinatal consultation for high-risk pregnancies (placental implantation disorders, cesarean scar or abdominal pregnancy, placental abruption, vasa previa)
• Gynecologic oncology consultation if cervical carcinoma or hCG-secreting tumor is suspected

Abruptio Placentae (Related Key Topic)

Cervical Insufficiency (Related Key Topic)

Ectopic Pregnancy (Related Key Topic)

Molar Pregnancy (Related Key Topic)

Placenta Previa (Related Key Topic)

Sheehan Syndrome (Related Key Topic)

Spontaneous Abortion (Related Key Topic)