Vaginal bleeding in pregnancy (greater than 20wks)
Background
- Do NOT perform digital exam in patients who present with vaginal bleeding when >20 weeks pregnant
- Only 20% of miscarriages occur after the first trimester
Clinical Features
- Vaginal bleeding
- Uterine fundus palpable above umbilicus
Normal Vitals in Pregnancy[1]
| Vital | Nonpregnant | 1st Trimester | 2nd Trimester | 3rd Trimester |
| HR | 70 | 78 | 82 | 85 |
| SBP | 115 | 112 | 112 | 114 |
| DBP | 70 | 60 | 63 | 70 |
| Hcrt | 40 | 36 | 33 | 34 |
| WBC | 7.2k | 9.1k | 9.7k | 9.8k |
Estimated Gestational Age by Fundal Height[2]
| Weeks | Fundal Height / Finding |
| 12 | Pubic symphysis |
| 20 | Umbilicus |
| 20-32 | Height (cm) above symphysis = gestational age (weeks) |
| 36 | Xiphoid process |
| >37 | Regression |
| Post delivery | Umbilicus |
Differential Diagnosis
Vaginal Bleeding in Pregnancy (>20wks)
- Emergent delivery
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Preterm labor
- Vaginal trauma
- Placenta accreta
- Intrauterine fetal demise
Evaluation
Workup
- B-hCG (quantitative)
- CBC and BMP
- Coags
- T&S (Rh) vs. T&C
- Consider Pelvic ultrasound
Diagnosis
- Typically a clinical diagnosis combining vaginal bleeding with a positive pregnancy test and ultrasound or physical exam showing >20 weeks
Management
- Consider emergent delivery
- See Differential Diagnosis for other possible etiologies
- Normally, management is deferred to OB/GYN team, considering the possibility of viability at this gestational age
Disposition
- Normally to Labor & Delivery
See Also
Vaginal bleeding (main)
External Links
References
- ↑ Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113:1299-1306.
- ↑ Vasquez V, Desai S. Labor and delivery and their complications. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:2296–2312.