Bleeding in pregnancy

First trimester vaginal bleeding

• Major causes
  • Ectopic prenancy
  • Early pregnancy loss
  • Implantation (day 7-14)
  • Early pregnancy loss – Threatened abortion, inevitable/incomplete, complete
  • Cervical, vaginal or uterine pathology (e.g. Polyps, inflammation/infection, fibroids, ectropion, cancer
  • PID/ cervicitis
  • gestational trophoblastic disease
  • trauma
• Investigations
  • Serial BhCG – 48-72 hours – should approx. 70% – > double 48 hours
  • Maternal blood group and anitbody status
  • Transvaginal USS – gestational sac visible from 4+3 (from last period)
  • Safety net
  • review

• Common, 20-40% of owmen

Bleeding in second half of pregnancy (antepartum bleeding)

• Less common
• Causes
  • Bloody show associated with labor (> 20 weeks) or cervical insufficiency
  • Early pregnancy loss (< 20 weeks)
  • Placenta previa
  • Abruptio placentae
  • Uterine rupture
  • Vasa previa
  • Cervical, vagina, uterine pathology
  • Painful – uterine rupture, placentral abruption
  • Non painful – placenta previa, vasa previa
• Ensure haemodynamically stable
• USS initally – Do not do physical exam of the cervix until placenta previa excluded – can cause severe haemorrhage
• Anti-D if negative!
• Consider fetal fibronective if between 26-34 weeks – negative result is highly accurate will not labour in next week

Third term

• Bloody show/ early labour

EPL irrespective of pregnancy location or management option. 

1. Rh D immunoglobulin
   1. If Rh D negative with no preformed anti-D antibodies, recommend a dose of Rh D immunoglobulin to prevent Rh D alloimmunisation
   2. If Rh D immunoglobulin is indicated
      1. Administer as soon as possible and within 72 hours of pregnancy loss
      2. Can be administered up to 10 days after pregnancy loss but efficacy may be lower
      3. If gestation is 12 weeks or less the recommended dose is 250 international units (IU)
      4. If gestation more than 12 weeks the recommended dose is 625 IU
2. Return to normal menstrual cycle
   1. Resumption of normal menstrual cycle indicates resolution of EPL
   2. complications and completion of management
   3. Ongoing, irregular bleeding requires follow-up—consider:
      1. Beta human chorionic gonadotropin (β-hCG) to exclude GTD
      2. Retained products
      3. Infection
3. Ongoing and follow-up care
   1. If GTD, register with Queensland Trophoblast Centre (QTC)
4. Advice after EPL
   1. When to seek emergency assistance:
      1. If experiencing strong pain unrelieved by paracetamol
      2. Shoulder tip or diaphragmatic pain
      3. Soaking of more than one pad within 60 minutes
      4. Fainting
      5. Elevated temperature
   2. Timing and nature of follow-up investigations and appointments,
      1. including contact details of relevant care providers
      2. Resumption of sexual activity
      3. Contraception
      4. Recommendations for conception interval (if any)
      5. Future pregnancy planning
      6. Resumption of menstruation/expected bleeding
      7. Accessing psychological support
         1. In the first month following EPL, studies consistently demonstrate an association between EPL and the proportion of women who experience:
            1. Anxiety (18–32%)
            2. Moderate depression (8–20%)
            3. Post-traumatic stress disorder (PTSD) (25–39%)
            4. Pathological grief (characterised by despair, deep feelings of worthlessness and hopelessness, and difficulty resuming normal interactions and activities of daily life) can develop

Determining viability and location of pregnancy 

• Normal β-hCG
  • Serum β-hCG first becomes positive at 9 days post conception
  • β-hCG greater than 5 IU/L confirms pregnancy
  • For a potentially viable intrauterine pregnancy (IUP) up to 6–7 weeks gestation o Mean doubling time for β-hCG is 1.4–2.1 days
  • 85% show serial β-hCG rise of at least 66% every 48 hours
  • 15% show serial β-hCG rise between 53–66% every 48 hours
  • The slowest recorded rise over 48 hours is 53%
• Ultrasound scan
  • TVS by an experienced sonographer is the gold standard in first trimester 
  • If TVS unavailable, recognise that TAS may be less accurate 
  • An IUP is usually visible on TVS when mean sac diameter (MSD) is greater than or equal to 3 mm
  • USS may be less reliable if fibroids, diffuse adenomyosis, early multiple pregnancy present
• Serial β-hCG
  • Serial β-hCG is recommended in stable circumstances
  • Repeat β-hCG 48 hours (up to 72 hours) after initial level 
  • A single β-hCG value: o Does not differentiate between a viable and nonviable pregnancy
  • Cannot be used to exclude IUP Discriminatory zone 
  • The discriminatory zone is the serum β-hCG level above which a gestational sac should be visible on TVS or TAS if an IUP is present
  • A single β-hCG value is not considered discriminatory
  • No consensus on β-hCG level that defines the discriminatory zone with TVS
  • 1000 IU/L to 3500 IU/L in international guidelines (TVS)
  • Much higher β-hCG levels if TAS only is used