Vaginal bleeding in pregnancy (less than 20wks)

Background

• Occurs in 20-40% of 1st trimester pregnancies
• Once IUP is confirmed by ultrasound no utility in obtaining B-hCG
• US
  • Do not use hCG to determine whether ultrasound should be obtained

Abortion Types

Classification	Characteristics	OS	Fetal Tissue Passage	Misc
Threatened	Abdominal pain or bleeding; < 20 weeks gestation	Closed	No	If < 11 weeks (with fetal cardiac activity) 90% progress to term. If between 11 and 20 weeks 50% progress to term
Inevitable	Abdominal pain or bleeding; < 20 weeks gestation	Open	No
Incomplete	Abdominal pain or bleeding; < 20 weeks gestation	Open	Yes, some
Complete	Abdominal pain or bleeding; < 20 weeks gestation	Closed	Yes, complete expulsion of products	Distinguish from ectopic based on decreasing hCG and/or decreased bleeding
Missed	Fetal death at <20 weeks without passage of any fetal tissue for 4 weeks after fetal death	Closed	No
Septic	Infection of the uterus during a miscarriage. Most commonly caused by retained products of conception	Open	No, or may be incomplete	Uterine tenderness and purulent discharge from the OS may be present

Clinical Features

History

• Previous spontaneous abortion
• Extent of bleeding, clots, tissue
  • Often quantified by pads per hour, greater than 1 per hour is concerning
• Presence of cramping
• Light-headedness? Chest pain? Shortness of breath? Palpitations?

Physical

• Uterus able to palpated in abdomen ~ 12 weeks
• Uterus able to visualzed by abdominal ultrasound ~ 10 weeks
• Open os decreases, but does not rule-out, ectopic
• If products of conception obtained send to pathology to rule-out trophoblastic disease
• Can quantify amount of bleeding by number of scopettes of blood on pelvic exam
• Large subchorionic hemorrhage increases chances of a miscarriage

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)

• Ectopic pregnancy
• Subchorionic hematoma
• First Trimester Abortion
  • Complete Abortion
  • Incomplete Abortion
  • Inevitable Abortion
  • Missed Abortion
  • Septic abortion
  • Threatened Abortion
• Gestational trophoblastic disease
  • Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
• Heterotopic pregnancy
• Implantation bleeding
• Molar pregnancy
• Non-pregnancy related bleeding
  • Cervicitis
  • Fibroids
  • Implantation bleeding

Evaluation

Work-Up

• B-hCG (quantitative)
• CBC and BMP
• Coags
• T&S (Rh) vs. T&C
• Urinalysis
• Pelvic ultrasound

Evaluation

• By ultrasound finding:
  • +IUP = threatened abortion
    • Ectopic ruled-out unless on fertility drugs
  • Empty uterus + free fluid/adnexal mass = Ectopic
  • Empty uterus + no free fluid / no mass
    • Beta-HCG:
      • >1,500 = Presumed ectopic
      • <1,500 = Indeterminate: follow serial B-HCG levels in 48hrs (if no peritonitis)
        • Increased >66% = normal IUP
        • Increased <66% = Ectopic

Discrimatory Zone

Values are for IUP visualization, not ectopic visualization

• Pelvic Ultrasound: hCG >1500
• Abd Ultrasound: hCG >3000

Management

1. RhoGAM if Rh Negative
2. Assess need for transfusion (severe anemia or hypotension)
3. Treat specific process:
   • Ectopic
   • Threatened abortion
   • Indeterminate
     • Follow serial B-HCG levels in 48hrs (if no peritonitis)
     • If peritonitis/surgical abdomen, immediate OB/GYN consult for possible ectopic

Disposition

• Admit for:
  • Ectopic
  • Life threatening bleeding
  • Surgical abdomen

See Also

Vaginal bleeding (main)

• Non-pregnant vaginal bleeding
  • Prepubertal vaginal bleeding
• Pregnant
  • Vaginal bleeding in pregnancy (less than 20wks)
  • Vaginal bleeding in pregnancy (greater than 20wks)
  • Postpartum hemorrhage

Videos

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