Vaginal bleeding in early pregnancy

Vaginal bleeding in early pregnancy is bleeding from the genital tract before 14 weeks of gestation (some definitions use 20 weeks).

It occurs in up to a quarter of pregnancies, and most women continue to a live birth, but it can signal miscarriage, ectopic pregnancy, gestational trophoblastic disease or a local gynaecological cause.

The main clinical point is to establish the location and viability of the pregnancy with ultrasound and serum beta hCG. It is also important to recognise the unstable woman with ruptured ectopic pregnancy or haemorrhage, and to give rhesus immunoglobulin and appropriate follow up.

Clinical relevance. Ectopic pregnancy, heavy miscarriage bleeding and septic abortion cause maternal death. Bleeding is also a major cause of anxiety and emergency attendance.

Physiology. Bleeding may arise from the decidua at implantation, from separation of the chorion from the uterine wall (subchorionic haematoma), from cervical vascularity, or from tissue passage in miscarriage.

Classification. By viability and location: viable intrauterine pregnancy with bleeding (threatened miscarriage), inevitable miscarriage (open cervical os), incomplete miscarriage (retained products), complete miscarriage, missed miscarriage (non viable pregnancy without bleeding or with minimal bleeding), septic miscarriage, ectopic pregnancy, pregnancy of unknown location, and molar pregnancy. By source: uterine, cervical, vaginal, other.

Key distinctions. Light bleeding with a closed os and a viable pregnancy on scan is threatened miscarriage. Heavy bleeding with clots and an open os indicates inevitable or incomplete miscarriage. A positive test with pain and no intrauterine pregnancy suggests ectopic pregnancy. Bleeding with a uterus large for dates, very high hCG and a snowstorm appearance suggests molar pregnancy.

History

• Gestation by last menstrual period, test result and any previous scan.
• Bleeding: onset, amount (pads each hour), colour, clots, passage of tissue, duration, trauma or intercourse.
• Pain: site, onset, severity, shoulder tip pain, cramping, back pain.
• Associated: dizziness, syncope, fever, rigors, offensive discharge, nausea and vomiting, symptoms of pregnancy that have stopped.
• Risk factors: previous ectopic pregnancy, tubal surgery, pelvic inflammatory disease, intrauterine device, assisted conception, smoking, previous miscarriage, age over 35, previous caesarean section.
• Obstetric history: recurrent miscarriage (three or more), cervical surgery, uterine anomalies, molar pregnancy.
• Medical history: bleeding disorders, anticoagulants, thyroid disease, diabetes, lupus, antiphospholipid syndrome, thrombophilia.
• Drugs: anticoagulants, antiplatelet agents, teratogens, herbal abortifacients, misoprostol use.
• Instrumentation: recent induced abortion (unsafe in many settings), uterine instrumentation, trauma.
• Social: safety, violence, support, mental health.

Examination

• Vital signs: pulse over 100 beats/min, systolic blood pressure under 100 mmHg, shock index (pulse divided by systolic pressure) over 0.9, temperature, respiratory rate, oxygen saturation, capillary refill.
• Pallor; abdomen (tenderness, guarding, rebound, uterine size, mass).
• Speculum examination: amount of bleeding, clots, tissue or products in the os, cervical dilatation, cervical lesion (polyp, ectropion, cancer), vaginal injury, foreign body, signs of infection and discharge.
• Remove products from the os with sponge forceps if visible (reduces pain and bleeding, may relieve vagal shock).
• Bimanual examination after ultrasound if possible: uterine size, adnexal mass or tenderness, cervical motion tenderness.
• Point of care ultrasound: free fluid in the pouch of Douglas and Morison pouch, intrauterine sac.

Red flags

• Haemodynamic instability, syncope or shoulder tip pain (ruptured ectopic pregnancy, major haemorrhage).
• Peritonism or rigid abdomen.
• Heavy bleeding (soaking more than 2 pads in 1 hour), clots, or products in the os.
• Fever, rigors or offensive discharge (septic abortion).
• Pregnancy of unknown location with pain.
• Intrauterine device in place.
• Uterus larger than dates, hyperemesis, very high hCG, or early pre eclampsia (molar pregnancy).
• Rhesus negative status.
• Suspected unsafe abortion or genital trauma.
• Anticoagulation or known bleeding disorder.

Special groups. Women with a previous caesarean section: risk of scar pregnancy and placenta accreta spectrum. Women with a previous ectopic pregnancy: higher recurrence. Adolescents: unsafe abortion and sexual violence. Women with a rhesus negative blood group: anti D immunoglobulin. Women on anticoagulants: heavier bleeding, and need haematology advice.

Organised by source and location. Each cause is common unless marked serious or uncommon. Pregnancy related, intrauterine

• Implantation bleeding.
• Threatened miscarriage (viable pregnancy).
• Inevitable, incomplete, complete and missed miscarriage.
• Serious: septic miscarriage.
• Subchorionic haematoma.
• Vanishing twin.
• Serious: gestational trophoblastic disease (complete or partial mole, invasive mole, choriocarcinoma).
• Serious: caesarean scar pregnancy, cervical pregnancy.

Pregnancy related, extrauterine

• Serious: tubal ectopic pregnancy (ampullary, isthmic, fimbrial).
• Serious: interstitial (cornual), ovarian, abdominal and heterotopic pregnancy.
• Pregnancy of unknown location.

Cervical and vaginal

• Cervical ectropion (common in pregnancy), cervical polyp, cervicitis (chlamydia, gonorrhoea, trichomoniasis, herpes).
• Postcoital bleeding.
• Vaginal trauma, foreign body, vaginitis.
• Serious: cervical cancer, vaginal cancer.
• Genital warts, varices.

Systemic and other

• Coagulopathy, thrombocytopenia, anticoagulant therapy.
• Haemorrhoids, urethral or rectal bleeding mistaken for vaginal bleeding.
• Hormonal contraception failure.
• Intrauterine device displacement.
• Menstrual period in early pregnancy (rare in the first weeks).
• Serious: uterine rupture (after previous caesarean section or uterine surgery, rare in the first trimester).
• Haemorrhage from an ovarian cyst rupture or corpus luteum.
• Malaria and viral haemorrhagic infections in endemic regions.

Stepwise reasoning

1. Resuscitate when unstable, and obtain intravenous access and blood tests.
2. Confirm pregnancy, and gestational age by dates.
3. Perform ultrasound (transvaginal first) to determine location, viability and number of foetuses.
4. If no intrauterine pregnancy is visible, use serum beta hCG at 0 and 48 hours and follow the pattern.
5. Decide on expectant, medical or surgical management, and plan follow up.

Immediate tests

• Urine pregnancy test; serum quantitative beta hCG.
• Full blood count, group and save (crossmatch when bleeding is heavy), rhesus status and antibodies.
• Urea, creatinine, electrolytes, C reactive protein, coagulation screen, lactate, liver function tests in heavy bleeding or sepsis.
• Blood cultures and high vaginal swab for suspected sepsis; nucleic acid amplification tests for chlamydia, gonorrhoea, Trichomonas vaginalis and Mycoplasma genitalium.
• Thyroid function if hyperemesis or tachycardia; malaria test in endemic regions.
• Histology of any tissue passed or removed (to confirm products of conception and exclude molar pregnancy).

Ultrasound interpretation

• Viable intrauterine pregnancy: sac with yolk sac and embryo with cardiac activity (visible from about 6 weeks, crown rump length 7 mm or more should show a heartbeat).
• Miscarriage: crown rump length 7 mm or more with no heartbeat, or mean sac diameter 25 mm or more with no embryo. Retained products show thickened echogenic endometrium (over 15 mm with vascularity). Otherwise repeat after 7 to 14 days.
• Ectopic pregnancy: no intrauterine pregnancy, adnexal mass (ring sign, moving separately from the ovary), complex or free fluid, haemoperitoneum.
• Pregnancy of unknown location: positive test with no pregnancy visible. Follow beta hCG.
• A rise of less than about 49 to 63% in 48 hours (depends on starting level), or a fall of less than 50%, suggests an abnormal pregnancy.
• A rise of about 63% or more suggests a viable intrauterine pregnancy, and a fall of 50% or more suggests a failing pregnancy.
• Discriminatory level: an intrauterine sac is usually visible on transvaginal ultrasound once beta hCG exceeds about 1500 to 3500 IU/L.
• Molar pregnancy: heterogeneous mass with vesicular spaces ("snowstorm"), bilateral theca lutein cysts, markedly raised beta hCG.
• Subchorionic haematoma: crescentic collection beside the gestational sac.

Limitations. Ultrasound cannot detect all early ectopic pregnancies, and about half of women with ectopic pregnancy have no risk factors. Urine tests may be falsely negative with a very high hCG. Beta hCG levels vary between assays. Early gestation scans may be uncertain, so a single scan is not diagnostic of miscarriage unless criteria are met.

Immediate steps. Airway, breathing and circulation. Give oxygen if saturation is under 94%. Insert two large bore intravenous cannulae. Send blood for group and crossmatch, full blood count and beta hCG. Give crystalloid in aliquots of 250 to 500 mL, aiming for a systolic pressure of about 90 to 100 mmHg until haemorrhage is controlled. Transfuse blood early for haemorrhagic shock and activate the major haemorrhage process.

Give tranexamic acid 1 g intravenously over 10 minutes for ongoing haemorrhage. Remove products visible in the cervical os. Give oxytocin 10 units intramuscularly or 5 units slowly intravenously for heavy bleeding from incomplete miscarriage after 12 weeks, and call the gynaecology and anaesthetic teams. Keep the patient nil by mouth when surgery is possible.

Analgesia and symptom control. Paracetamol 1 g intravenously or orally every 6 hours, maximum 4 g daily (3 g daily with chronic alcohol use, malnutrition or hepatic impairment; 15 mg/kg each dose under 50 kg). Morphine 2 to 5 mg intravenously every 5 to 10 minutes, titrated to pain, with monitoring of respiratory rate and sedation.

Ibuprofen 400 mg orally every 8 hours once bleeding is controlled and surgery is not planned (avoid in peptic ulcer, renal impairment, heart failure, anticoagulation). Ondansetron 4 mg intravenously or orally every 8 hours for nausea (maximum 16 mg daily; avoid with long QT syndrome).

Threatened miscarriage (viable pregnancy)

• Reassure, advise that no treatment alters the outcome in most women, and arrange follow up. Bed rest does not help.
• Micronised progesterone 400 mg vaginally twice daily from the time of bleeding until 16 weeks may be considered for women with a previous miscarriage and current bleeding (evidence of benefit is limited to this group).
• Give anti D immunoglobulin 250 IU intramuscularly within 72 hours to rhesus negative women when gestation exceeds 12 weeks with bleeding, or when management is surgical. Practice for threatened miscarriage under 12 weeks varies.
• Advise return for heavy bleeding, pain or fever.

Miscarriage (incomplete or missed)

• Expectant management for 7 to 14 days in stable women is first line. Repeat the scan if bleeding persists or does not start.
• Medical management: misoprostol 800 microgram vaginally (or 600 microgram orally), repeated after 24 to 48 hours if needed.
• For missed miscarriage, give mifepristone 200 mg orally followed after 24 to 48 hours by misoprostol 800 microgram vaginally.
• Give analgesia (ibuprofen 400 mg orally every 8 hours and codeine or paracetamol).
• Medical management is contraindicated with suspected ectopic pregnancy, sepsis and severe haemorrhage.
• Advise bleeding for up to 3 weeks. Check a pregnancy test at 3 weeks (negative confirms completion).
• Surgical management (manual vacuum aspiration or electric vacuum aspiration): for heavy bleeding, instability, infection, retained products, failed medical management or patient choice. Give misoprostol 400 microgram vaginally or sublingually 2 to 3 hours before in some settings to soften the cervix.
• Anti D immunoglobulin 250 IU intramuscularly within 72 hours to rhesus negative women after surgical management.
• Antibiotic prophylaxis for surgical evacuation: doxycycline 100 mg orally twice daily for 7 days or azithromycin 1 g orally single dose where infection risk is high.
• Offer contraception and counselling. Investigate after three consecutive losses.

Septic miscarriage. Give broad spectrum intravenous antibiotics within 1 hour: ceftriaxone 2 g intravenously once daily with metronidazole 500 mg intravenously every 8 hours. Add gentamicin 5 mg/kg intravenously once daily (adjusted to kidney function and levels) when severe. Piperacillin with tazobactam 4.5 g intravenously every 6 to 8 hours is an alternative. Evacuate the uterus urgently after the first dose of antibiotics. Intensive care for septic shock.

Ectopic pregnancy

• Ruptured or unstable: immediate resuscitation and surgery (laparoscopic salpingectomy, or laparotomy if unstable).
• Stable, unruptured, no foetal cardiac activity, mass under 35 mm and beta hCG under 5000 IU/L: methotrexate 50 mg/m2 body surface area intramuscularly as a single dose.
• Give a second dose if beta hCG falls by less than 15% between day 4 and day 7 (up to three doses).
• Check full blood count, renal and liver function before. Avoid NSAIDs, folic acid, alcohol, live vaccines and sun exposure.
• Methotrexate is contraindicated in breastfeeding, active infection, severe renal, hepatic or haematological disease, and haemodynamic instability.
• Follow beta hCG weekly until undetectable. Avoid conception for 3 months.
• Expectant management for small ectopic pregnancy with falling beta hCG under about 1000 IU/L, with close follow up.
• Salpingostomy for women with a single remaining tube or contralateral damage who wish future fertility (risk of persistent trophoblast, so follow beta hCG weekly).
• Give anti D immunoglobulin 250 IU intramuscularly within 72 hours to rhesus negative women.

Pregnancy of unknown location. Women who are clinically stable with no signs of rupture can be followed with serum beta hCG at 48 hours and a repeat scan. Do not give methotrexate empirically. Provide written safety netting and a telephone contact. Discharge only when a follow up plan is in place.

Gestational trophoblastic disease. Suction evacuation under ultrasound control with oxytocin infusion after evacuation if bleeding. Anti D immunoglobulin 250 IU intramuscularly within 72 hours to rhesus negative women. Register with a trophoblastic disease service. Follow beta hCG weekly until normal for 3 consecutive weeks, then monthly for 6 months (complete mole) or until normal on two occasions (partial mole).

Avoid pregnancy for 6 to 12 months. Chemotherapy for persistent disease, specialist: methotrexate 50 mg intramuscularly on days 1, 3, 5 and 7 with folinic acid 15 mg orally 24 hours after each methotrexate dose for low risk disease.

Cervical and vaginal causes. Cervical ectropion and polyps rarely need treatment. Treat infection (chlamydia: doxycycline 100 mg orally twice daily for 7 days, avoided in pregnancy: azithromycin 1 g orally as a single dose; gonorrhoea: ceftriaxone 1 g intramuscularly once). Refer for colposcopy for suspicious lesions.

Anticoagulated women and bleeding disorders. Seek haematology advice on dose adjustment, and treat heavy bleeding with tranexamic acid and reversal as indicated.

Special groups. Women with a previous caesarean section: scan early to locate the sac; scar pregnancy needs specialist care. Women with an intrauterine device: ectopic pregnancy risk is high; remove the device if the strings are visible and pregnancy is intrauterine. Rhesus negative women: anti D immunoglobulin 250 IU intramuscularly within 72 hours. Adolescents: confidential care. Women with unsafe abortion: broad spectrum antibiotics, surgical evacuation, tetanus prophylaxis and psychosocial support.

Monitoring. Repeat vital signs hourly while unstable, then every 4 hours. Monitor haemoglobin, bleeding, beta hCG and urine output. For threatened miscarriage, review ultrasound at 7 to 14 days. For medical management, perform a pregnancy test at 3 weeks.

Referral and escalation. Refer the same day to the on call gynaecology team for ectopic pregnancy, heavy bleeding, sepsis, molar pregnancy, and any unstable woman. Refer to the early pregnancy assessment service for threatened miscarriage with pain, pregnancy of unknown location, and recurrent pregnancy loss. Refer to haematology for coagulopathy.

Admission criteria. Haemodynamic instability, suspected or confirmed ectopic pregnancy needing treatment, heavy bleeding, sepsis, severe pain, retained products with infection, molar pregnancy, anticoagulation with bleeding, and unsafe social circumstances.

Discharge and follow up. Discharge only when pregnancy of unknown location has a follow up plan, bleeding is light, pain is controlled and the woman can return within 24 hours. Arrange repeat beta hCG at 48 hours, ultrasound review, and gynaecology follow up. Provide contraception advice after miscarriage, and counselling or bereavement support.

Safety netting. Return the same day for worsening or sudden severe pain, shoulder tip pain, fainting, heavy bleeding (soaking more than 2 pads in 1 hour), passage of large clots, fever, offensive discharge, or feeling unwell.