DESCRIPTION

• Major cause of maternal/fetal morbidity and mortality
• Early pregnancy hemorrhage (≤20 wk):
  • Occurs in 30% of all pregnancies
  • 50% lead to spontaneous abortion
• Late pregnancy hemorrhage (> 20 wk):
  • Occurs in 3–5% of all pregnancies
• Risk factors:
  • Advanced maternal age
  • Substance abuse
  • Pelvic inflammatory disease (PID)
  • Previous cesarean section
  • Previous termination of pregnancy
  • Previous dilation and curettage (D&C)
  • Previous ectopic pregnancy
  • Increased parity
  • Multiple gestation
  • Preeclampsia
  • Hypertension
  • Trauma
  • Use of assisted reproductive technology
• Genetics:
  • 50–60% of miscarriages due to chromosomal abnormalities

ETIOLOGY

• Vaginal
• Cervical
• Uterine
• Uterine–placental interface
• Hematologic dysfunction

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• Intensity and duration of bleeding:
  • Amount (clots, number of pads)
  • Color (dark or bright red)
  • Painful or painless
  • Watery, blood-tinged mucus
  • Life-threatening conditions may present with only minimal bleeding
• Last normal menstrual period
• Passage of tissue
• Estimated duration of gestation
• Gravidity/parity
• Fever
• Last intercourse
• Intrauterine device use
• Previous obstetric–gynecologic complications
• Syncope or near-syncope
• Previous obstetric–gynecologic complications
• Spontaneous abortion: Classically crampy, diffuse pelvic pain
• Ectopic pregnancy: Classically sharp pelvic pain with lateralization
• Placenta previa: Classically painless bright red hemorrhage
• Placental abruption: Classically painful dark red hemorrhage

Physical Exam

• Vital signs:
  • Tachycardia
  • Hypotension
  • Orthostatic changes
  • Signs of hemodynamic instability may be absent due to pregnancy-related physiologic increase in blood volume
• Fetal heart tones:
  • Fetal cardiac activity seen on transvaginal US at 6.5 wk
  • Auscultated with hand-held Doppler past 10 wk gestation
  • Normal fetal heart rate: 120–160 beats/min
• Abdominal exam:
  • Uterine size:
    • 12 wk: Palpable in abdomen
    • 20 wk: Palpable at umbilicus
  • Peritoneal signs
  • Firm or tender uterus in late pregnancy suggests abruption
• Pelvic exam—only in early pregnancy:
  • Evaluate source and intensity of bleeding
  • Determine patency of cervical os (use finger and only in first trimester):
    • Threatened abortion: os closed
    • Inevitable abortion: os open
    • Incomplete abortion: os open or closed
    • Complete abortion: os closed
    • Embryonic demise (missed abortion): os closed
  • Products of conception (POC) may be noted in incomplete or completed abortion:
    • POC in the cervical os can result in profuse bleeding
  • Evaluate uterine size, tenderness
  • Evaluate for uterine fibroids or adnexal masses
  • Late pregnancy: Do not perform pelvic exam unless in controlled OR setting:
    • Severe hemorrhage may ensue
    • Placenta previa or vasa previa must be ruled out by US prior to pelvic exam

ESSENTIAL WORKUP

• CBC
• Type and screen
• Quantitative HCG in early pregnancy
• Urinalysis
• US:
  • Transvaginal US provides more information than transabdominal US in early pregnancy

DIAGNOSIS TESTS & INTERPRETATION

Lab

• CBC:
  • Dilutional "anemia" is a normal physiologic change in pregnancy:
    • Blood volume expands by 45%
• Qualitative beta-human chorionic gonadotropin (β-hCG)
• Quantitative β-hCG:
  • Imperfect correlation with US findings
  • Detectable 9–11 days following ovulation
• Blood typing and Rh typing:
  • Cross-match if significant bleeding
• Disseminated intravascular coagulation (DIC) panel in embryonic demise, placental abruption
• Blood cultures with septic abortion
• Suspected POC to lab for identification of chorionic villi

Imaging

• US:
  • Essential diagnostic modality:
    • Confirms intrauterine pregnancy (IUP)
    • Detects gestational sac at 5 wk (usually with β-hCG ≥1,000–2,000 IU), yolk sac at 6 wk, and cardiac activity at 5–6 wk of gestation
    • Essentially rules out ectopic pregnancy by showing IUP (except in women at high risk for heterotopic pregnancy)
    • Proves ectopic pregnancy by showing fetal pole outside uterus
    • Suggests ectopic pregnancy by detecting free fluid in cul-de-sac or adnexal mass
    • Detects retained POC
    • Demonstrates "snowstorm" appearance within uterus with gestational trophoblastic disease

Diagnostic Procedures/Surgery

• Culdocentesis:
  • Limited use
  • Identifies free fluid in cul-de-sac
• D&C or vacuum aspiration:
  • Indicated if suspected incomplete or septic abortion, embryonic demise, gestational trophoblastic disease, or anembryonic gestation to evacuate retained POC
• Laparoscopy/laparotomy:
  • Indicated for unstable patients
  • Definitive diagnosis and treatment of ectopic pregnancy

DIFFERENTIAL DIAGNOSIS

• Early pregnancy (< 20 wk):
  • Implantation bleeding
  • Threatened abortion
  • Complete, incomplete, inevitable, embryonic demise (missed abortion), and septic abortion
  • Ectopic pregnancy
  • Heterotopic pregnancy
  • Gestational trophoblastic disease (molar pregnancy)
  • Subchorionic hemorrhage
  • Anembryonic gestation (blighted ovum)
  • Infection (e.g., cervicitis)
  • Trauma
  • Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
  • Bleeding disorders
• Late pregnancy (> 20 wk):
  • Placental abruption (30%)
  • Placenta previa (20%)
  • Bloody show (associated with cervical insufficiency or labor)
  • Vasa previa
  • Cervical/vaginal trauma or pathology
  • Uterine rupture (uncommon)
  • Infection (e.g., cervicitis)
  • Trauma
  • Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
  • Bleeding disorders

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Unstable vital signs warrant aggressive resuscitation
• In late pregnancy, position patient on left side to decrease uterine compression of inferior vena cava (IVC)
• Consider preferential transport of a woman with late pregnancy to a facility with obstetric capabilities

INITIAL STABILIZATION/THERAPY

• Airway management
• Oxygen
• Pulse oximetry
• Cardiac monitor
• 2 large-bore IV lines
• Blood transfusion as indicated
• Continuous fetal monitoring in later pregnancy

ED TREATMENT/PROCEDURES

• All women with early pregnancy vaginal bleeding must be evaluated for ectopic pregnancy (preferably by transvaginal US)
• Administer Anti-Rh₀ (D) immune globulin if patient is Rh-negative
• Suspected ectopic pregnancy:
  • Unstable: Consider bedside US with emergent OB/GYN consultation for laparoscopy/laparotomy
  • Stable: Perform US:
    • If confirmatory or suggestive of ectopic pregnancy, obtain OB/GYN consultation for surgery or methotrexate therapy
    • If inconclusive, obtain OB/GYN consultation and arrange for repeat β-hCG testing in 2 days
• Threatened abortion:
  • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
  • Arrange OB/GYN follow-up for minimal bleeding
• Inevitable/incomplete/missed (embryonic demise) abortion:
  • POC in the cervical os can result in profuse bleeding
  • If POC cannot be removed with gentle traction, obtain emergent OB/GYN consultation
  • Arrange OB/GYN follow-up if bleeding minimal
• Complete abortion:
  • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
  • Arrange OB/GYN follow-up if bleeding minimal
• Septic abortion:
  • Initiate broad-spectrum antibiotic therapy
  • Emergent OB/GYN consultation for D&C
• Late pregnancy vaginal bleeding:
  • Hemodynamic stabilization:
    • Fluid resuscitation
    • Positioning of patient onto left side or displacement of uterus laterally to relieve compression by IVC
  • DIC:
    • Associated with late pregnancy bleeding
    • Especially with placental abruption
    • Treated with blood products
  • Immediate obstetric consultation and rapid transfer to obstetric unit

MEDICATION

First Line

• Anti-Rh₀ (D) immune globulin: < 12 wk–50 µg IM; > 12 wk–300 µg IM
• Methotrexate:
  • Variable dosing regimens
  • Only recommended for hemodynamically stable women with unruptured ectopic pregnancy with low β-hCG
• Antibiotics for septic abortion:
  • Multiple acceptable antibiotic regimens
  • Must provide polymicrobial coverage

Second Line

Misoprostol has been used in completed abortion to facilitate uterine evacuation in completed miscarriage

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Early pregnancy vaginal bleeding with:
  • Unstable vital signs or significant bleeding
  • Ruptured ectopic pregnancy
  • Incomplete abortion (open os)
  • Septic abortion
• All patients with late pregnancy vaginal bleeding need to be admitted to a labor and delivery unit

Discharge Criteria

• Stable patients with threatened abortion complete abortion, embryonic demise, or anembryonic gestation
• Asymptomatic, hemodynamically stable patient with small, unruptured ectopic (or suspected ectopic) pregnancy after OB/GYN consultation
• Controlled bleeding from vaginal/cervical source

Issues for Referral

• Patients with embryonic demise, anembryonic gestation, or gestational trophoblastic disease need to be referred for uterine evacuation if D&C not performed in ED
• Women with threatened, inevitable, complete, or missed (embryonic demise) abortion should have OB/GYN follow-up within 24–48 hr

FOLLOW-UP RECOMMENDATIONS

• Discharge instructions:
  • No strenuous activity, tampon use, douching, or intercourse
  • Seek medical advice for increased pain, bleeding, fever, or passage of tissue
• All pregnant women with vaginal bleeding during pregnancy who are discharged from the ED require follow-up care
• Women with threatened abortions, known or suspected ectopic pregnancy require repeat β-hCG testing and repeat exams in 2 days

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• Failure to check Rh status in pregnant women with vaginal bleeding
• Failure to give Anti-Rh₀ (D) immune globulin in Rh-negative women with vaginal bleeding
• Placenta previa or vasa previa must be ruled out by US prior to pelvic exam in late pregnancy

ICD9

• 634.90 Spontaneous abortion, without mention of complication, unspecified
• 640.90 Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not applicable
• 641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable

ICD10

• O03.9 Complete or unspecified spontaneous abortion without complication
• O20.9 Hemorrhage in early pregnancy, unspecified
• O46.90 Antepartum hemorrhage, unspecified, unspecified trimester

[Outline]

• ICD9
• ICD10

• Hahn SA, Lavonas EJ, Mace SE, et al. Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2012;60:381–390.
• Huancahuari N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30:837–847.
• Jurkovic D, Wilkinson H. Diagnosis and management of ectopic pregnancy. BMJ. 2011;342:d3397.
• Meguerdichian D. Complications in late pregnancy. Emerg Med Clin North Am. 2012;30:919–936.
• Wang R, Reynolds TA, West HH, et al. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2012;58:12–20.

See Also (Topic, Algorithm, Electronic Media Element)

• Abortion, Spontaneous
• Ectopic Pregnancy
• Hydatidiform Mole
• Placental Abruption
• Placenta Previa
• Postpartum Hemorrhage

Paul Ishimine