Bleeding during First and Second Trimesters of Pregnancy
Essentials
There is no treatment for bleeding during the first trimester.
If first trimester miscarriage is suspected, the patient should be referred to specialized care if
bleeding or pain affects the patient's general condition
an infection is suspected
Rhesus prophylaxis is needed and it cannot be organized through the primary care antenatal clinic (from week 8 of pregnancy onwards).
If bleeding starts during the second trimester of pregnancy, the patient should be readily referred to a gynaecology outpatient clinic either as an emergency case or an urgent case.
Bleeding after 22nd week of pregnancy: usually refer the patient to an obstetric clinic as emergency. If the bleeding is only scant and there is no pain, and depending on local policies, the visit to a specialist may also take place on the following day. Do not hesitate to consult the hospital.
Principles
Slight, transient and painless bleeding ("wiping bleeding") is common and harmless.
It is often caused by doing sport, gynaecological examination or sexual intercourse.
The bleeding ceases usually within 1-2 days.
Follow-up suffices as treatment.
If the bleeding is prolonged, the patient should be referred to a gynaecology outpatient clinic for an assessment within 1-7 days until the week 22 of pregnancy.
More substantial or prolonged bleeding before the week 8 of pregnancy.
Bleeding that resembles or exceeds that of menstruation suggests miscarriage.
If the patient is painless (with or without pain medication) and their general condition is not impaired, follow-up and performing a home pregnancy test 4 weeks after the bleeding started suffice as treatment. If the new test is positive, a referral to a gynaecology outpatient clinic should be made to exclude residual products of conception.
If the patient has pain, ectopic pregnancy must be excluded.
Depending on the patient's general condition, refer her as an emergency case or urgent case to a gynaecology outpatient clinic.
More substantial or prolonged bleeding after the week 8 of pregnancy.
If the bleeding is profuse and/or the patient has pain, refer the patient to a gynaecological outpatient clinic immediately as an emergency case or as an urgent (within 1-7 days) case for an assessment.
An Rh-negative patient with bleeding (after week 8 of pregnancy) needs Rh-prophylaxis within 3 days after the bleeding begun.
A patient in poor general condition or with fever should always be referred as an emergency case to a hospital.
Check local policies concerning referral of these patients, i.e. when and to which clinic to refer different patients (this guideline is based on the medical assessment of urgency).
From the 22nd week of pregnancy onwards, a pregnant patient with bleeding should always be referred as an emergency patient to an obstetric clinic.
A patient with no pain and very slight bleeding may be able to wait until the following day. Do not hesitate to consult the clinic.
Causes of bleeding
Doing sport, gynaecological examination and sexual intercourse are common causes of transient (lasting 1-2 days) bleeding.
Placenta previa or placental detachment (particularly during the second half of pregnancy)
Vaginal or cervical damage
Trophoblastic disease (rare)
Causes of miscarriage
Common causes
Foetal or chromosomal abnormalities
An intrauterine gestational sac but no foetus (anembryonic pregnancy i.e. blighted ovum)
Immunological rejection
Rare causes
Uterine and cervical abnormalities
Endocrinological imbalance, diabetes and hyperthyroidism, impaired function of the corpus luteum
Viral infections, listeriosis, toxoplasmosis
Physical examination
General condition
A patient in good general condition is treated at home. Bleeding heavier than menstruation is not dangerous if it does not affect the patient's general condition.
If you suspect a febrile infection or the patient has bled profusely, do not hesitate to refer the patient to a gynaecological emergency department.
Check body temperature, blood pressure, pulse, basic blood count with platelet count, CRP and in early pregnancy also plasma total hCG. In the case of scant bleeding, perform urinary tests (urinalysis, bacterial culture).
Gynaecological status
Uterus: Does the size correlate with the duration of pregnancy? Tenderness? Contractions? Is the cervix dilated (during 2nd trimester)? Is there bleeding, and is it profuse?
Foetus: Can you see the foetus or is it already expelled? If the cervix is not dilated, can you hear heart sounds (after the 12th week of pregnancy) or can you observe the heart function with ultrasound or palpate movements (after weeks 16 -18 of pregnancy)?
Threat of miscarriage (abortus imminens)
Minimal vaginal bleeding. The patient is in good general condition and has no pain. The size of the uterus is increased and the cervix is not dilated. Heart function of foetus can be observed by ultrasonography and in 2nd trimester also by doppler.
Perform (or repeat) ultrasound after 1-2 weeks, if bleeding continues. Refer the patient to specialized care, as necessary.
Investigate for chlamydia or gonorrhoea if necessary (part of the examination routine in many maternal care centres).
Rest may be beneficial, and at least physical exertion should be avoided. Sick leave may be necessary.
Advise the patient to avoid sexual intercourse during the bleeding since it could act as a local stimulus.
The woman may be asymptomatic and notice that symptoms of pregnancy have reduced.
It may take several weeks before the bleeding starts.
Prolonged slight bleeding or slight brownish and watery discharge
Vaginal ultrasonography reveals lifeless foetus with crown-rump length of > 7 mm.
If missed abortion is detected within primary health care before the bleeding has started, the patient should be refferred to a gynaecology outpatient clinic (urgency 1-7 days) for medical evacuation (or rarely abrasion) of the uterus.
Medical evacuation is usually performed at home. The treatment is carried out at a hospital ward if the foetus matches over 10-12 pregnancy weeks or if the mother's illness or life situation necessitates it.
The patient is usually given mifepristone at the outpatient department and she takes at home misoprostol (prostaglandin) usually 800 µg vaginally Medical Treatment for Early Fetal Death (Less Than 24 Weeks). If the bleeding is more profuse, misoprostol may also be taken orally. Misoprostol administration may be repeated after 3 days if needed.
After medical evacuation, a sufficient follow-up is a home pregnancy test 4 weeks after the treatment or the time when more substantial bleeding started. If the test is positive, the patient should be in contact with the unit responsible for the treatment.
If the pregnancy has lasted for more than 8 weeks, remember to check the patient's blood group. If it is Rh-negative, urgently arrange anti-D-protection either within the primary care antenatal clinic or by referring the patient to specialized care.
Bleeding is equally or more profuse than in mensturation. There are cramps in the lower abdomen while the uterus contracts. Blood clots may come out.
If the patient is in good condition, she can be followed-up at home. Profuse bleeding subsides within a few hours or days.
If the duration of pregnancy is over 8+0 weeks, remember to check the patient's blood group. If it is Rh-negative, urgently arrange anti-D-protection either within the primary care antenatal clinic or by referring the patient to specialized care
If an ultrasonography is performed and a complete miscarriage is found (external orifice of the uterus is open and the uterus is totally empty or emptying) and the possibility of extrauterine pregnancy has been excluded, no further procedures are needed.
If required, the miscarriage is confirmed and extrauterine pregnancy excluded by detecting a rapidly declining hCG concentration. The practice is agreed locally.
Miscarriage is incomplete when not all pregnancy tissue has been expelled from the uterine cavity. In case of slight bleeding the patient may be referred to hospital on the following day for medical evacuation.
Caused by microbes passing from the vagina to the uterus and is usually the result of incompletely induced abortion in unsterile conditions. Profuse bleeding and pain often occur, possibly with symptoms of toxic shock. The most common causative organisms are E. coli and Streptococcus faecalis.
Make an emergency referral to hospital. The patient may need treatment for sepsis.
References
Schreiber CA, Creinin MD, Atrio J ym. Mifepristone pretreatment for the medical management of early pregnancy loss. N Engl J Med 2018;378(23):2161-2170. [PubMed]
Coomarasamy A, Harb HM, Devall AJ ym. Progesterone to prevent miscarriage in women with early pregnancy bleeding: the PRISM RCT. Health Technol Assess 2020;24(33):1-70. [PubMed]
Coomarasamy A, Williams H, Truchanowicz E ym. A Randomized Trial of Progesterone in Women with Recurrent Miscarriages. N Engl J Med 2015;373(22):2141-8. [PubMed]