First Trimester Bleeding

Initial Management Algorithm

Implantation Bleeding

Subchorionic Hemorrhage

Patient with h/o positive pregnancy test presents with first trimester bleeding. No vaginal, cervical, or hemorrhoid bleeding noted on exam.

  • U/S shows embryonic cardiac activity, blood present between chorion and uterine wall

  • Patient informed that risk for spontaneous abortion is 9% given presence of cardiac activity

  • Schedule for f/u in 1 week

Initial evaluation of First Trimester Bleeding in Pregnancy of Unknown Location (PUL). Source: www.reproductiveaccess.org. Diagnosis and treatment algorithm is also available through the Reproductive Health Access Project.

Initial evaluation of First Trimester Bleeding in Pregnancy of Unknown Location (PUL). Source: www.reproductiveaccess.org. Diagnosis and treatment algorithm is also available through the Reproductive Health Access Project.

Ectopic Pregnancy

Patient with h/o previous ectopic pregnancy, smoking, pelvic inflammatory disease (PID), and tubal surgery presents with abdominal pain and bleeding. LMP 6 weeks ago with IUD in place. No adnexal tenderness, rebound tenderness, cervical motion tenderness, or tissue lacerations. No products of conception present on speculum exam.

  • Obtain urine pregnancy test, CBC, blood type, and Rh status

  • Initial beta-hCG > 1500 mIU and increased < 50% after 48 hours

  • Trans-vaginal ultrasound (TVUS)

    • Failed to visualize intrauterine gestational sac and/or embryonic pole

    • Adnexal mass present

  • Treatment

    • Rh negative: Administer RhoGam

    • Medically stable: Discuss expectant management vs. methotrexate termination

      • Repeat beta-hCG in 4 to 7 days to ensure decrease of 15%

      • Failure of beta-hCG to decrease by 15%: Refer for surgical intervention

    • Ongoing pelvic pain, unstable vital signs, signs of intraperitoneal bleeding and/or failure of medical management: Refer for laparoscopic surgical intervention

Notes

  • Affects 1-2% of pregnancies

  • Major risk factors include previous tubal surgery (OR 21.0), previous ectopic pregnancy (OR 8.3), IUD (OR 5.0), h/o PID (OR 3.4), and smoking (OR 1.7-3.9)

  • Physical exam

    • Ectopic pregnancies often bleed even though they are not ruptured.

    • Rebound abdominal pain or cervical motion tenderness may indicate hemoperitoneum (surgical emergency)

  • Beta-hCG

    • Increases by 50% in 48 hours in 99% of viable pregnancies

    • For values >1500 mIU, an intrauterine pregnancy should be visible on U/S (note that the flow chart below uses >3000 mIU as a threshold)

    • For values <1500 mIU, repeat beta-hCG every 48 hours until a trend is established

  • For intrauterine pregnancies, TVUS should visualize a gestational sac with a yolk sac by 6 WGA

  • Consider laparoscopy if diagnosis is not clear within 10 days

Gestational Trophoblastic Disease

Pt with presents with first trimester bleeding. No vaginal, cervical, or hemorrhoid bleeding noted on exam.

  • Obtain baseline beta-hCG, CBC, CMP, TSH

  • U/S showing snowstorm appearance of amorphous material

  • Schedule prompt surgical evaluation

  • Rh negative: administer 250 IU anti-D immunoglobulin s/p surgical evacuation

  • Pt to f/u s/p surgical evacuation for serial beta-hCG on days 1, 7, 14, and 21

  • Prescribe combined hormonal OCP during f/u provided no contraindications exist

Second and Third Trimester Bleeding

Placenta previa

Pt with h/o placenta previa before 20 WGA presents with late-pregnancy painless vaginal bleeding. Denies recent placement of object(s) in vagina. VSS. Bright red blood per os observed on speculum exam; no cervical abnormalities noted.

  • Obtain CBC, fibrinogen, PT, PTT, blood type, antibody screen; G/C if delivery is not imminent

  • Obtain fetal NST

  • U/S to evaluate for placenta within 2cm of internal cervical os at > 28 WGA

  • <37 WGA with preterm contractions; administer tocolytic

  • <34 WGA with preterm contractions; administer corticosteroids

  • Repeat U/S at 36 WGA to determine appropriate mode of delivery and r/o placenta accreta due to previous c-section

  • Perform amniocentesis at 36-37 WGA to document pulmonary maturity

  • Pelvic rest advised

 

Placental abruption

Pt with h/o HTN, thrombophilia, tobacco/stimulant abuse presents with late-pregnancy vaginal bleeding and abdominal pain. Denies recent placement of object(s) in vagina. VSS. Bright red blood per os observed on speculum exam; no cervical abnormalities noted.

  • Obtain CBC, fibrinogen, PT, PTT, blood type, antibody screen; G/C if delivery is not imminent

  • Obtain fetal NST

  • U/S to evaluate for blood between placenta and myometrium

  • Rh neg.; Kleihauer-Betke test and administer Rhogam

  • <34 WGA with minor abruption; administer tocolytic, corticosteroids

  • Pt to be admitted for chronic monitoring if abruption recurs

  • Pt advised to stop tobacco/stimulant use

 

Vasa previa

Pt with late-pregnancy painless vaginal bleeding that started s/p SROM. Denies recent placement of object(s) in vagina. VSS. Bright red blood per os observed on speculum exam; no cervical abnormalities noted.

  • Obtain CBC, fibrinogen, PT, PTT, blood type, antibody screen; G/C if delivery is not imminent

  • Obtain fetal NST; if reassuring, analyze vaginal vault blood for fetal cells/hemoglobin (Apt test)

  • U/S to evaluate for vasa previa

  • Screen for vasa previa at 37-38 WGA during future pregnancies

Postpartum Hemorrhage

Pt with h/o coagulopathy presents with > 500mL EBL s/p vaginal delivery. Poor uterine tone, trauma, non-intact placenta noted on exam.

  • Obtain 16 gauge IV access; administer LR at 2:1 ratio of EBL

  • Initiate fundal message, Pitocin 40 IU/L IV

  • Cytotec (misoprostol) 1000mg rectally

  • No h/o asthma: Hemabate/Carboprost (15-methyl PGF2 alpha) 250mcg; repeat q15min, max 8 doses

  • No HTN: Methergine 0.2mg IM; repeat q2-4 hours

  • If bleeding continues despite medical therapy, obtain STAT labs with coags & fibrinogen; call blood bank and OB service