Vaginal Bleed During Pregnancy


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First Trimester Bleed
Spec: Cervical OS US findings Exam Finding Diagnosis Mgt
Closed Viable No passage of POC Threatened Observe
Closed no embryo or fetus   Missed D&C (Sched.)
Closed POC all gone Complete passage of POCs Completed Observe

Open Gest. sac intact no passage of POC Inevitable D&C (Emerg)
Open POC some left POC in OS or vaginal vault Incomplete D&C (Emerg)

Cervical OR Vaginal lesion

Ectopic
 
Molar
 

1. Implantation Bleeding

  • Do Nothing

2. Abortion

Inevitable Abortion
  • DILATED internal cervical os, +/- ROM
  • Vaginal bleeding & cramping without passage of POC.
  • US: (+) POC
  • Mgt:
    • Emergency Suction D&C.
    • Prostaglandin suppositories are an alternative

Incomplete.

  • DILATED internal cervical os
  • Cramping & Vaginal bleeding w/ some POC passed vaginally. Visible tissue in vagina or endocervical canal. 
  • US: Retained intrauterine fetal tissue
  • Mgt: Emergency suction D&C, Control bleeding.

Threatened.

  • CLOSED cervix.
  • No POC expelled, Membranes intact. (+) abdominal pain.
  • Fetus still VIABLE
  • US: Normal
  • Mgt:
    • Observe, Avoid heavy activity, Pelvic rest x 24-48 hr w/ gradual resumption of activity,
    • Abstinence from coitus & douching.

Complete

  • CLOSED cervix.
  • All products of conception (POC) expelled.
  • US: normal endometrial strip w/o intrauterine debris.
  • Mgt:
    • D&C if ↑ likelihood that abortion was incomplete.

Missed.

  • CLOSED cervix
  • Symptoms are absence of bleeding or cramping
  • US: No fetal cardiac activity. Fetal tissue is retained.
  • Mgt:
    • Conservative observation OR schedule suction dilation & curettage.
    • Prostaglandin suppositories are an alternative.
    • DIC is a serious but rare complication whose risk ↑ with ↑ GA.
 

3. Ectopic Pregnancy

  • CLOSED internal cervical os
  • If unruptured -- amenorrhea, vaginal bleeding, & unilateral lower-abd. pelvic pain.
  • Enlarged uterus.
  • US: Absence of intrauterine gestational sac when quantitative serum HCG is > 1,500
  • Mgt:
    • Methotrexate or Laparoscopy.

[Read Ectopic Pregnancy]

 

4. Neoplasia

  • ?

5. Hydatiform Mole

  • Early pregnancy bleeding w/ hyperemesis &/or new onset of hyperthyroidism.
  • Vaginal bleeding w/ possible vaginal "grape-like" vesicles.
  • Labs: HCG >100,000 (abnormally high)
  • Mgt:
    • Suction D&C
 

6. Cervix

  • ?
 


 

Third Trimester Bleed
  Abruption Pla. Previa Vasa
Previa
Ut.
Rupture
Pain YES NO NO YES
Patho Premature
seperation
Lower Seg.
Implantation
Unprotected
fetal Vessels
Complete Wall
laceration
Dx Clinical US Clinical Clinical
Risk Factors Cocaine, HTN, Blunt trauma Twins, Prev. placenta previa Access lobe Volamentous Classical CS Myomectomy
Tx Varies by gestational age & maternal/fetal status Crash CS Laparotomy
 

1. Premature Labor

Regular uterine contractions + concurrent cervical change at < 37 weeks’ gestation
  • The 1° cause of neonatal morbidity and mortality.
  • Risk factors include:
    • Multiple gestation,
    • Infection
    • PROM
    • Trauma
    • Uterine anomalies
    • Previous preterm labor or delivery
    • Polyhydramnios
    • Placental abruption
    • Poor maternal nutrition, &
    • Low SES.
    • Most patients have no identifiable risk factors.

HISTORY/PE

  • Patients may have Menstrual-like cramps or Contractions, onset of Low back pain, Pelvic pressure, and New Vaginal DSischarge or Bleeding.

DIFFERENTIAL DIAGNOSIS
The differential should include premature labor, preterm rupture of membranes, preterm contractions (contractions prior to 37 wk gestation that do not result in cervical change), and abdominal pain or cramping secondary to other medical conditions. There are many conditions that may cause preterm contractions or premature labor. These include:

  • Infection
    • Chorioamnionitis
    • Genital tract infections, including bacterial vaginosis, gonorrhea, chlamydia
    • Urinary tract infections, including pyelonephritis, cystitis, or asymptomatic bacteruria
    • Gastroenteritis
  • Trauma
  • Placental abruption
  • Illicit drug use
  • Preterm premature rupture of membranes
  • Appendicitis
  • Nephrolithiasis
  • Pancreatitis
  • Cholelithiasis

DIAGNOSIS

  • Requires regular uterine contractions (≥ 3 contractions of 30 seconds each over a 30-minute period) and concurrent cervical change at < 37 weeks’ gestation.
  • Assess for contraindications to tocolysis (e.g., infection, nonreassuring fetal testing, placental abruption).


WORKUP

  • History and physical exam to rule out trauma, abuse, other causes of abdominal pain, and infection.
  • Fetal heart rate monitoring and tocometry to determine fetal status and contraction frequency.
  • Speculum exam to visually assess the cervix and assess for PROM, bleeding, infection, or advanced cervical dilation.
    • If the patient is , < 35 wk gestation, a Fetal Fibronectin (FFN) test should be collected prior to performing a digital exam or transvaginal ultrasound.
    • A FFN test can help predict preterm delivery if the patient has a cervical length on transvaginal ultrasound of < 30 mm.
  • Digital exam to determine cervical dilation and effacement, and fetal station.
  • LABS:
    • CBC, CMP, amylase, and lipase.
    • Urine analysis and culture,
    • Urine toxicology screen,
    • Collect tests for GBS,
    • Gonorrhea, and Chlamydia,
    • Perform a wet prep for yeast, bacterial vaginosis, and trichomonas,
    • Fetal fibronectin,
    • Consider PT, PTT, INR, 
    • Amniocentesis may be performed if an intraamniotic infection is suspected.
  • IMAGING : A formal Ultrasound is indicated to determine estimated fetal weight, fetal presentation, amniotic fluid volume, placental location and appearance, and cervical length.

TREATMENT

  • Hydration and bed rest, Smoking cessation.
  • Deliver promptly if:  (+) Premature labor, (+) intraamniotic infection suspected or when they have cervical dilation > 5 cm, a persistently nonreassuring fetal heart rate tracing, intrauterine growth restriction, or vaginal bleeding concerning for placental abruption.
  • Unless contraindicated, begin Tocolytic therapy between 24 wk and 33 6/7 wk (β-mimetics, MgSO4, Ca2+ channel blockers, PGIs) and give Steroids to accelerate fetal lung maturation.
  • Give penicillin or ampicillin for GBS prophylaxis if preterm delivery is likely.
  • CHRONIC Rx
    • Patients with a history of prior spontaneous preterm birth may be candidates for prophylactic use of 17 alpha-hydroxyprogesterone caproate between 16 wk and 36 wk gestation.
    • Patients with a history of preterm birth and short cervix may also be candidates for prophylactic or rescue cerclage.
    • There is no evidence supporting the use of maintenance tocolytic therapy
  • REFERRAL
    • Women who present in preterm labor should be referred to an obstetrician and transferred to a facility with a neonatal intensive care unit.
    • For women who present for prenatal care with a history of preterm delivery, early referral to an obstetrician is also recommended.

COMPLICATIONS

  • RDS, intraventricular hemorrhage, PDA, necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, death.
 

2. Chorioacarcinoma

  • ?

3. Placental Abruption

Pathophysiology:
  • Premature (before onset of labor) separation of normally implanted placenta.

Risk factors:

  • Hypertension,
  • Abdominal/pelvic trauma,
  • Tobacco or cocaine use,
  • Previous abruption,
  • Rapid decompression of over-distended uterus.

Symptoms:

  • PAINFUL, dark vaginal bleeding that does not spontaneously cease. Abdominal pain, uterine hypertonicity. Fetal distress.

Diagnosis:

  • Primarily clinical.
  • Transabdominal/Transvaginal ultrasound sensitivity is only 50%; look for retroplacental clot; most useful for ruling out previa.

Management:

  • Stabilize patients with mild abruption and a premature fetus.
  • Manage expectantly (hospitalize; start IV and fetal monitoring; type and cross blood; bed rest).
  • Moderate to severe abruption: Immediate delivery (vaginal delivery with amniotomy if mother and fetus are stable; C-section for maternal or fetal distress).
  • Summary:
    • – Live fetus + rigid uterus = C-Section
    • – Live fetus + soft uterus = induction of labor

Complications:

  • Hemorrhagic shock.
  • Coagulopathy: DIC in 10%.
  • Recurrence risk is 5-16% and rises to 25% after two previous abruptions.
  • Fetal hypoxia.
 

4. Placenta Previa

Pathophysiology:
  • Abnormal placental implantation:
    • Total: Placenta covers the cervical os.
    • Marginal: Placenta extends to the margin of the os.
    • Low-lying: Placenta is in close proximity to the os.

Risk factors:

  • Prior C-sections, grand multiparous, advanced maternal age, multiple gestation, prior placenta previa.

Symptoms:

  • Painless, bright red bleeding that often ceases in 1-2 hours with or without uterine contractions. Usually no fetal distress.

Dx:

  • Labs: CBC to monitor hemoglobin and hematocrit, A Kleihauer-Betke preparation of maternal blood in all Rh-negative women and Rhimmune globulin when indicated.
  • Transabdominal/Transvaginal ultrasound sensitivity is > 95%; look for abnormally positioned placenta.
    • TVS has become the gold standard for the diagnosis of placent previa.
    • It is safe even in the presence of active bleeding.
    • A distance of < 20 mm from placental edge to interior cervical os is becoming a new criterion for performing term cesarean delivery in women with placenta previa.
  • MRI has also been effective in detecting placenta previa, although sonography remains the preferred method.

 Management:

  • NO vaginal exam!
  • Stabilize patients with a premature fetus; manage expectantly.
  • IF contracting -- Give tocolytics.
  • Cross-matched blood
  • Serial ultrasound to assess fetal growth; resolution of partial previa.
  • If 24-34 weeks Gestation -- Give betamethasone to help with fetal lung maturity (With or without contractions)
  • Deliver by C-section.
  • Indications for delivery include:
    • Labor,
    • Life-threatening bleeding,
    • Fetal distress,
    • Documented fetal lung maturity, and
    • 36 weeks’ GA.
  • Uncontrollable hemorrhage after placental removal should be anticipated as a result of the poorly contractile nature of the lower uterine segment. The need for hysterectomy to control bleeding should be discussed with the patient before delivery, if possible.
  • If no bleeding: Complete pelvic rest until resolution of the previa is confirmed on serial ultrasounds or until delivery.
  • If actively bleeding: Admit and stabilize the mother; immediate C-section delivery if fetal/maternal status is nonreassuring.
  • If bleeding resolves: Conservative inpatient management with bed rest, corticosteroids, and serial ultrasounds; C-section once fetal lung maturity is confirmed at approximately 34 weeks.

Complications:

  • ↑ risk of placenta accreta
  • Vasa previa (fetal vessels crossing the internal os).
  • Preterm delivery, premature rupture of membranes (PROM), IUGR, congenital anomalies.
  • Recurrence risk is 4-8%.
 

5. Vasa Previa

  • Rupture of membrane
  • PainLESS vaginal bleed
  • Fetal bradycardia

Tx:

  • If term and/or unstable: Immediate C-section.
  • If preterm and stable: Inpatient conservative management; C-section when fetal lungs are mature.
  • Transvaginal ultrasound with color Doppler and/or Apt/Kleihauer-Betke tests to determine the origin of bleeding if the diagnosis is unclear. Rule out DIC.
 

6. Uterine Rupture

  • Hx of Uterine Scar (Previous C-Section)
  • PainFUL
  • Loss of FHR and Uterine contractions
  • Recession of fetal head
  • Most reliable clinical symptom: Fetal Distress
    • Signs of fetal distress are often the only manifestation of uterine rupture.

Tx:

  • EMERGENCY C-SECTION

Which one of the following is the most reliable clinical symptom of uterine rupture? (check one)
A. Sudden, tearing uterine pain
B. Vaginal bleeding
C. Loss of uterine tone
D. Fetal distress

Correct. D

  • Fetal distress has proven to be the most reliable clinical symptom of uterine rupture.
  • The “classic” signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent.
  • Pain and bleeding occur in as few as 10% of cases.
  • Even ruptures monitored with an intrauterine pressure catheter fail to show loss of uterine tone. 

Ref: Toppenberg KS, Block WA Jr: Uterine rupture: What family physicians need to know. Am Fam Physician 2002;66(5):823-828.