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
- +IUP = threatened abortion
Discrimatory Zone[1]
Values are for IUP visualization, not ectopic visualization
- Pelvic Ultrasound: hCG >1500
- Abd Ultrasound: hCG >3000[2]
Management
- RhoGAM if Rh Negative
- ACOG Clinical practice guideline recommends forgoing routine Rh testing and RhIg administration at less than 12 weeks of gestation[3]
- Assess need for transfusion (severe anemia or hypotension)
- Treat specific process:
- Ectopic
- Threatened abortion
- Indeterminate
Disposition
- Admit for:
- Ectopic
- Life threatening bleeding
- Surgical abdomen
See Also
Vaginal bleeding (main)
- Non-pregnant vaginal bleeding
- Pregnant
Videos
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References
- ↑ Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med. 1995;40:525–8
- ↑ Wag, R. et al. Use of a !-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography. Annals of Emergency Medicine. 58(1)12-20. PDF
- ↑ (2024). ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation. Obstetrics & Gynecology, 144 (6), e140-e143. doi: 10.1097/AOG.0000000000005733.