Vaginal Bleeding in Pregnancy, Emergency Medicine

Basics

Description

- 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

- 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

- Vital signs: - Tachycardia - Hypotension - Orthostatic changes - Signs of hemodynamic instability may be absent due to pregnancy-related physiologic increase in blood volume

- 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

- 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

- Qualitative beta-human chorionic gonadotropin ( ˇ ²-hCG) - Quantitative ˇ ²-hCG: - Imperfect correlation with US findings - Detectable 9 " “11 days following ovulation

- US: - Essential diagnostic modality: - Confirms intrauterine pregnancy (IUP) - Detects gestational sac at 5 wk (usually with ˇ ²-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

- DIC: - Associated with late pregnancy bleeding - Especially with placental abruption - Treated with blood products

Major cause of maternal/fetal morbidity and mortality
Early pregnancy hemorrhage ( ≤20 wk):Occurs in 30% of all pregnancies50% lead to spontaneous abortion
Late pregnancy hemorrhage (>20 wk):Occurs in 3 " “5% of all pregnancies
Risk factors:Advanced maternal ageSubstance abusePelvic inflammatory disease (PID)Previous cesarean sectionPrevious termination of pregnancyPrevious dilation and curettage (D&C)Previous ectopic pregnancyIncreased parityMultiple gestationPreeclampsiaHypertensionTraumaUse of assisted reproductive technology
Genetics:50 " “60% of miscarriages due to chromosomal abnormalities

Etiology

Vaginal
Cervical
Uterine
Uterine " “placental interface
Hematologic dysfunction

Diagnosis

Signs and Symptoms

History

Intensity and duration of bleeding:Amount (clots, number of pads)Color (dark or bright red)Painful or painlessWatery, blood-tinged mucusLife-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:TachycardiaHypotensionOrthostatic changesSigns 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 wkAuscultated with hand-held Doppler past 10 wk gestationNormal fetal heart rate: 120 " “160 beats/min
Abdominal exam:Uterine size:12 wk: Palpable in abdomen20 wk: Palpable at umbilicusPeritoneal signsFirm or tender uterus in late pregnancy suggests abruption
Pelvic exam " ”only in early pregnancy:Evaluate source and intensity of bleedingDetermine patency of cervical os (use finger and only in first trimester):Threatened abortion: os closedInevitable abortion: os openIncomplete abortion: os open or closedComplete abortion: os closedEmbryonic demise (missed abortion): os closedProducts of conception (POC) may be noted in incomplete or completed abortion:POC in the cervical os can result in profuse bleedingEvaluate uterine size, tendernessEvaluate for uterine fibroids or adnexal massesLate pregnancy: Do not perform pelvic exam unless in controlled OR setting:Severe hemorrhage may ensuePlacenta 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 ( ˇ ²-hCG)
Quantitative ˇ ²-hCG:Imperfect correlation with US findingsDetectable 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 ˇ ²-hCG ≥1,000 " “2,000 IU), yolk sac at 6 wk, and cardiac activity at 5 " “6 wk of gestationEssentially rules out ectopic pregnancy by showing IUP (except in women at high risk for heterotopic pregnancy)Proves ectopic pregnancy by showing fetal pole outside uterusSuggests ectopic pregnancy by detecting free fluid in cul-de-sac or adnexal massDetects retained POCDemonstrates "snowstorm " ¯ appearance within uterus with gestational trophoblastic disease

Diagnostic Procedures/Surgery

Culdocentesis:Limited useIdentifies 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 patientsDefinitive diagnosis and treatment of ectopic pregnancy

Differential Diagnosis

Early pregnancy (<20 wk):Implantation bleedingThreatened abortionComplete, incomplete, inevitable, embryonic demise (missed abortion), and septic abortionEctopic pregnancyHeterotopic pregnancyGestational trophoblastic disease (molar pregnancy)Subchorionic hemorrhageAnembryonic gestation (blighted ovum)Infection (e.g., cervicitis)TraumaCervical 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 previaCervical/vaginal trauma or pathologyUterine rupture (uncommon)Infection (e.g., cervicitis)TraumaCervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)Bleeding disorders

Treatment

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/laparotomyStable: Perform US:If confirmatory or suggestive of ectopic pregnancy, obtain OB/GYN consultation for surgery or methotrexate therapyIf inconclusive, obtain OB/GYN consultation and arrange for repeat ˇ ²-hCG testing in 2 days
Threatened abortion:Emergent OB/GYN consultation for heavy/uncontrolled bleedingArrange OB/GYN follow-up for minimal bleeding
Inevitable/incomplete/missed (embryonic demise) abortion:POC in the cervical os can result in profuse bleedingIf POC cannot be removed with gentle traction, obtain emergent OB/GYN consultationArrange OB/GYN follow-up if bleeding minimal
Complete abortion:Emergent OB/GYN consultation for heavy/uncontrolled bleedingArrange OB/GYN follow-up if bleeding minimal
Septic abortion:Initiate broad-spectrum antibiotic therapyEmergent OB/GYN consultation for D&C
Late pregnancy vaginal bleeding:Hemodynamic stabilization:Fluid resuscitationPositioning of patient onto left side or displacement of uterus laterally to relieve compression by IVCDIC:Associated with late pregnancy bleedingEspecially with placental abruptionTreated with blood productsImmediate obstetric consultation and rapid transfer to obstetric unit

Medication

First Line

Anti-Rh0 (D) immune globulin: <12 wk " “50 ˇ ¼g IM; >12 wk " “300 ˇ ¼g IM
Methotrexate:Variable dosing regimensOnly recommended for hemodynamically stable women with unruptured ectopic pregnancy with low ˇ ²-hCG
Antibiotics for septic abortion:Multiple acceptable antibiotic regimensMust provide polymicrobial coverage

Second Line

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

Follow-Up

Disposition

Admission Criteria

Early pregnancy vaginal bleeding with:Unstable vital signs or significant bleedingRuptured ectopic pregnancyIncomplete 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 intercourseSeek 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 ˇ ²-hCG testing and repeat exams in 2 days

Pearls and Pitfalls

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

Additional Reading

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 ˇ ²-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2012;58:12 " “20.

Codes

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
633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
641.10 Hemorrhage from placenta previa, unspecified as to episode of care or not applicable
641.20 Premature separation of placenta, 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
O00.9 Ectopic pregnancy, unspecified
O44.10 Placenta previa with hemorrhage, unspecified trimester
O45.90 Premature separation of placenta, unsp, unsp trimester

SNOMED

34842007 Antepartum hemorrhage (disorder)
25825004 hemorrhage in early pregnancy (disorder)
17369002 Miscarriage (disorder)
34801009 Ectopic pregnancy (disorder)
198903000 Placenta previa with hemorrhage
415105001 placental abruption (disorder)