Vaginal Bleeding During Pregnancy

para>Confirm fetal presentation and placental position prior to cervical exam. ‚

TREATMENT

MEDICATION

First Line

Treat underlying cause of bleeding, if identified.
If mother is Rh negative, give RhoGAM to prevent autoimmunization. In late pregnancy, dose according to the amount of estimated fetomaternal hemorrhage.
If cause of bleeding is preterm labor, consider betamethasone for fetal lung maturity if <34 weeks ' gestation. Tocolytics may be used to prolong pregnancy to allow for course of steroids.
If threatened abortion: Consider progesterone (relative risk 0.53) (3)[A].
If mother has an inherited bleeding disorder or if bleeding is severe, consider recombinant or donor blood products.

SURGERY/OTHER PROCEDURES

Cesarean section may be indicated for recurrent or uncontrolled bleeding with placenta or vasa previa.
If ectopic is diagnosed, immediate surgical treatment may be needed. Some early ectopic pregnancies can be treated medically if certain criteria are met (2)[C].
Surgical uterine evacuation is necessary for molar pregnancy due to malignant potential (4)[C].
Incomplete or inevitable spontaneous abortion: Management is patient centered. In the absence of infection, patient may elect expectant, medical, or surgical management. If expectant management, typically wait 2 weeks for patient to complete abortion; most complete by 9 days. If at 2 weeks abortion is not completed or medical management has failed, surgical intervention (D&C or aspiration) is generally indicated (5)[A]. May send tissue to pathology to confirm.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

In early pregnancy: based on quantity of bleeding, need for surgical treatment for ectopic pregnancy, or presence of infection in case of spontaneous abortion
In late pregnancy, if significant bleeding and/or presence of maternal or fetal compromise
In late pregnancy with trauma, if ≥2 contractions/10 minutes

Discharge Criteria

In late pregnancy, may discharge when bleeding has stopped; labor, previa, and abruption have been ruled out; and fetal heart tracing is normal.
After trauma in late pregnancy, may discharge home if normal fetal heart tracing for ≥4 hours with <2 contractions/10 minutes

ONGOING CARE

Patient Monitoring

Patient should be instructed to report any increase in the amount or frequency of bleeding and to seek immediate care if experiencing fever, abdominal pain, or sudden increased bleeding. Patient should save any tissue passed vaginally for examination.
Frequency of outpatient follow-up as indicated based on etiology of bleeding

PATIENT EDUCATION

American Academy of Family Physicians (AAFP): www.familydoctor.org
American College of Obstetricians & Gynecologists (ACOG): www.acog.org

PROGNOSIS

Prognosis depends on the etiology of vaginal bleeding, severity of bleeding, and rapidity of diagnosis.
Maternal mortality is 31.9 deaths/100,000 ectopic pregnancies.
‚ ½; of patients with early pregnancy bleeding miscarry. If fetal heart activity (ultrasound) present in 1st-trimester bleed, <10% chance of pregnancy loss.
Heavy bleeding in early pregnancy, particularly when accompanied by pain, is associated with higher risk of spontaneous abortion. Spotting and light episodes are not, especially if lasting only 1 to 2 days.
Subchorionic hemorrhage has about 2- to 3-fold increased risk of spontaneous abortion. Smaller hemorrhage and presence of viable fetal heart rate confer lower risk of loss. Most resolve spontaneously.
Women with early pregnancy bleeding have an increased risk of preterm delivery, premature rupture of membranes, manual removal of placenta, placental abruption, elective cesarean delivery, and term labor induction later in the same pregnancy. These women also have an increased risk of adverse pregnancy outcomes, including hyperbilirubinemia, congenital anomalies, NICU admission, and reduced neonatal birth weight. Finally, there is an increased risk in subsequent pregnancies of recurrence of early pregnancy bleeding.
Bed rest has not been shown to affect the outcome of bleeding in early pregnancy but may be indicated for bleeding in late pregnancy with placenta or vasa previa or with maternal hypertension.

REFERENCES

11 Crochet ‚ JR, Bastian ‚ LA, Chireau ‚ MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309(16):1722 " “1729.22 Deutchman ‚ M, Tubay ‚ AT, Turok ‚ D. First trimester bleeding. Am Fam Physician. 2009;79(11):985 " “994.33 Wahabi ‚ HA, Fayed ‚ AA, Esmaeil ‚ SA, et al. Progestogen for treating threatened miscarriage. Cochrane Database Syst Rev. 2011;(12):CD005943.44 Snell ‚ BJ. Assessment and management of bleeding in the first trimester of pregnancy. J Midwifery Womens Health. 2009;54(6):483 " “491.55 Nanda ‚ K, Lopez ‚ LM, Grimes ‚ DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;(3):CD003518.

ADDITIONAL READING

Chi ‚ C, Kadir ‚ RA. Inherited bleeding disorders in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2012;26(1):103 " “117.
Dadkhah ‚ F, Kashanian ‚ M, Eliasi ‚ G. A comparison between the pregnancy outcome in women both with or without threatened abortion. Early Hum Dev. 2010;86(3):193 " “196.
Griebel ‚ CP, Halvorsen ‚ J, Golemon ‚ TB, et al. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243 " “1250.
Grimes ‚ DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. 2006;194(1):92 " “94.
Hasan ‚ R, Baird ‚ DD, Herring ‚ AH, et al. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. 2009;114(4):860 " “867.
Lykke ‚ JA, Dideriksen ‚ KL, Lidegaard ‚ O, et al. First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol. 2010;115(5):935 " “944.
Magann ‚ EF, Cummings ‚ JE, Niederhauser ‚ A, et al. Antepartum bleeding of unknown origin in the second half of pregnancy: a review. Obstet Gynecol Surv. 2005;60(11):741 " “745.
Mercier ‚ FJ, Van de Velde ‚ M. Major obstetric hemorrhage. Anesthesiol Clin. 2008;26(1):53 " “66.
Mukul ‚ LV, Teal ‚ SB. Current management of ectopic pregnancy. Obstet Gynecol Clin North Am. 2007;34(3):403 " “419.
Oyelese ‚ Y, Ananth ‚ CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005 " “1016.
Publications Committee, Society for Maternal-Fetal Medicine, Belfort ‚ MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430 " “439.
Sakornbut ‚ E, Leeman ‚ L, Fontaine ‚ P. Late pregnancy bleeding. Am Fam Physician. 2007;75(8):1199 " “1206.
Walfish ‚ M, Neuman ‚ A, Wlody ‚ D. Maternal haemorrhage. Br J Anaesth. 2009;103(Suppl 1):i47 " “i56.
Wijesiriwardana ‚ A, Bhattacharya ‚ S, Shetty ‚ A, et al. Obstetric outcome in women with threatened miscarriage in the first trimester. Obstet Gynecol. 2006;107(3):557 " “562.

CODES

ICD10

O20.9 Hemorrhage in early pregnancy, unspecified
O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
O20.0 Threatened abortion
O26.859 Spotting complicating pregnancy, unspecified trimester
O46.8X2 Other antepartum hemorrhage, second trimester
O46.8X9 Other antepartum hemorrhage, unspecified trimester
O26.853 Spotting complicating pregnancy, third trimester
O46.92 Antepartum hemorrhage, unspecified, second trimester
O46.8X1 Other antepartum hemorrhage, first trimester
O44.11 Placenta previa with hemorrhage, first trimester
O20.8 Other hemorrhage in early pregnancy
O44.12 Placenta previa with hemorrhage, second trimester
O44.13 Placenta previa with hemorrhage, third trimester
O46.91 Antepartum hemorrhage, unspecified, first trimester
O44.10 Placenta previa with hemorrhage, unspecified trimester
O46.93 Antepartum hemorrhage, unspecified, third trimester
O26.852 Spotting complicating pregnancy, second trimester
O26.851 Spotting complicating pregnancy, first trimester
O46.8X3 Other antepartum hemorrhage, third trimester

ICD9

640.93 Unspecified hemorrhage in early pregnancy, antepartum condition or complication
641.93 Unspecified antepartum hemorrhage, antepartum condition or complication
640.00 Threatened abortion, unspecified as to episode of care or not applicable
649.53 Spotting complicating pregnancy, antepartum condition or complication
641.83 Other antepartum hemorrhage, antepartum condition or complication
641.13 Hemorrhage from placenta previa, antepartum condition or complication
663.53 Vasa previa complicating labor and delivery, antepartum condition or complication

SNOMED

106004004 Hemorrhagic complication of pregnancy (disorder)
34842007 Antepartum hemorrhage (disorder)
54048003 Threatened abortion (disorder)
284075002 Spotting per vagina in pregnancy (finding)
38010008 Intrapartum hemorrhage (disorder)
75836008 Ante AND/OR intrapartum hemorrhage associated with trauma (disorder)
198903000 Placenta previa with hemorrhage
26840006 Ante AND/OR intrapartum hemorrhage associated with leiomyoma (disorder)
25825004 hemorrhage in early pregnancy (disorder)

CLINICAL PEARLS

Obtain blood type and screen all women presenting with vaginal bleeding in pregnancy and administer RhoGAM to all Rh-negative patients.
For up to 50% of early pregnancy bleeding, no cause is ever found.
Always consider ectopic pregnancy in 1st-trimester bleeding.
Do not perform digital exam in late pregnancy bleeding until placenta has been located on ultrasound.

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