Pregnancy: Vaginal Bleeding

• Vaginal bleeding in early pregnancy
  • Causes of vaginal bleeding in early pregnancy
  • Clinical assessment of vaginal bleeding in early pregnancy
  • Miscarriage
  • Ectopic pregnancy
  • Molar pregnancy

• Antepartum haemorrhage
  • Placenta praevia
  • Abruptio placenta

Vaginal bleeding in pregnancy can be divided into vaginal bleeding in early pregnancy (<20 weeks gestation), or antepartum haemorrhage (>20 weeks gestation).

Vaginal bleeding in early pregnancy

Early pregnancy bleeding is defined as bleeding from the genital tract prior to 20 weeks gestation. Approximately 20% of known pregnancies will have some form of spotting or bleeding in early pregnancy.

Causes of vaginal bleeding in early pregnancy

Early pregnancy bleeding can result from:

• Complications related to the pregnancy:
  • Miscarriage;
  • Ectopic pregnancy; or
  • Molar pregnancy.
• Other:
  • Genital tract trauma;
  • Vaginal infection; or
  • Cervical cancer.

The outcomes of early pregnancy bleeding are varied with most (60%) having an ongoing pregnancy, 30% will have early pregnancy failure, 9.5% will have an ectopic pregnancy and 0.5% will be the result of other causes including molar pregnancy.

Clinical assessment of vaginal bleeding in early pregnancy

It is important that you see your health professional as soon as possible. This is especially important if you know that you have a rhesus negative blood group which will require an injection of anti D within 72 hours of the onset of bleeding.

The doctor will need to take a complete gynaecological history including questions specific to the vaginal bleeding such as:

• Duration;
• Heaviness in relation to normal period;
• Passing of any tissue or clots;
• Associated pain;
• Feelings of faintness; and
• Blood group.

Other history such as past medical or surgical history may also be important.

The examinations performed may vary depending on your clinical presentation. Generally your doctor may take your vital signs, which are measurements including pulse, blood pressure and temperature. They may also like to have a feel of your abdominal area noting any tenderness or masses that may be present. A speculum examination, similar to the method of performing a pap smear, can enable the doctor to assess your cervix. A digital (finger) examination may be required to feel for any tenderness in the area of your ovaries.

It may also be necessary for your doctor to order some blood tests and/or an ultrasound.

Miscarriage

Miscarriage affects up to one in four women throughout their lifetime. It is defined as the loss of a foetus less than 20 weeks gestation.

Approximately 75% of miscarriages occur prior to 10 weeks gestation. The majority are the result of a chromosomal abnormality of the foetus. Second trimester miscarriages are much less frequent accounting for only 1-2%.

If early pregnancy loss has been confirmed by the appropriate investigations there are three management options:

1. Surgical removal of the products of conception by dilatation and curettage (D&C);
2. Medical (drug) management with the insertion of prostaglandins in tablet form into the vagina; or
3. Expectant management where no treatment is given and repeat investigations performed after a period of time to ensure that all the products of conception have been passed.

Ectopic pregnancy

Occurring in 1.5-2.0% of pregnancies, ectopic pregnancy involves the implantation of a fertilised ovum outside of the uterus. Implantation most commonly takes place in the fallopian tubes and less commonly in the cervix, ovary, abdomen or scar from a caesarean section.

Risk factors include:

• Pelvic inflammatory disease;
• Previous surgery to your fallopian tubes;
• Previous ectopic pregnancy;
• Cigarette smoking;
• Age >35; and
• Many lifetime sexual partners.

This condition is potentially life threatening and needs to be excluded in all sexually active women presenting with vaginal bleeding and positive pregnancy test. Initially, vaginal bleeding may be the only sign, but later the woman may experience crampy abdominal or pelvic pain and shock.

More information on ectopic pregnancy.

Molar pregnancy

Molar pregnancy, also known as hydatidiform mole, is a name given to a range of pregnancy associated tumours. They are the result of abnormal fertilisation and while most are benign, some may be malignant.

Molar pregnancy usually presents as:

• painless vaginal bleeding;
• passage of vesicles,
• exaggerated pregnancy symptoms +/- hyperemesis;
• hyperthyroidism;
• anaemia;
• large uterus for dates;
• raised bHCG; and
• multiple grape-like vesicles distending the uterus visible either grossly or via ultrasound.

Management of a molar pregnancy typically involves surgical removal by D&C. A chest radiograph may also be required. Following the procedure your bHCG will need to be monitored closely until they fall below a certain level (<2 IU/L) and then monthly for six months after that time. It is important that you avoid becoming pregnant for at least six months following this fall in bHCG levels.

More information on molar pregnancy

 

 

Antepartum haemorrhage

Antepartum haemorrhage, defined as bleeding from the genital tract following 20 weeks gestation, occurs in 2-5% of pregnancies. The majority of causes are the result of either placenta praevia or abruptio placenta.

Placenta praevia

A diagnosis of placenta praevia is made when part or the entire placenta is inserted into the lower segment of the uterus. This may totally (placenta praevia major) or partially (placenta praevia minor) cover the internal cervical os (opening of the cervix). As well as causing bleeding during the pregnancy, it may cause bleeding during labour and delivery or in the post-partum period. The bleeding may be severe and life threatening meaning a normal vaginal delivery is usually not possible with cases of placenta previa major.

Risk factors include:

• Increasing parity;
• Increasing maternal age;
• Abnormalities in the uterus;
• Smoking;
• Cocaine abuse;
• Multiple pregnancies;
• Previous placenta praevia;
• Caesarean section;
• Termination of pregnancy; and
• Intrauterine surgery.

Presentation is typically painless, unprovoked vaginal bleeding, which may vary between minor to massive bleeding.

Diagnosis can be made with transvaginal ultrasound, which is the most accurate and safest method of diagnosis.

Management is largely dependant on the wellbeing of both the mother and the foetus, the degree of blood loss, degree of placenta praevia and gestational age.

More information on placenta praevia.

Abruptio placenta

Abruptio placenta, also known as placenta abruption, is defined as bleeding from the premature separation of a normally located placenta and occurs in approximately 1 in 100 pregnancies. In most cases (70%), blood loss from the vagina is evident, however, in 30% of cases, the bleeding is located between the placenta and uterine wall and there is no blood loss evident from the vagina.

Risk factors include:

• Pre-eclampsia;
• Blunt abdominal trauma;
• External cephalic version;
• Smoking;
• Cocaine use;
• Multiple pregnancy;
• Increasing maternal age;
• Increasing parity;
• Polyhydramnios; and
• Previous history of placental abruption.

Presentation is typically of sudden onset abdominal pain with or without signs of shock. Stillbirth is apparent in approximately 30% of cases.

Diagnosis is made on clinical grounds with ultrasound having a very low detection rate.

Management includes resuscitation and stabilisation of the shocked patient with further management dictated by several factors including severity of blood loss, maternal and foetal condition, gestational age, parity and state of the cervix.

More information on abruptio placenta

More information

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For more information about pregnancy, including preconception advice, stages of pregnancy, investigations, complications, living with pregnancy and birth, see Pregnancy.

 

References

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2. Baskett TF. Essential management of obstetric emergencies. 4^th ed. 2004. Clinical Press Limited, Redland, Bristol.
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7. Ectopic pregnancy – United States, 1990-1992. MMWR Morb Mortal Wkly Rep 1995; 44: 46-8.
8. Auda BM, Takai IU, Chama CM, Bukar M, Kyari O. Hydatidiform mole as seen in a university teaching hospital: a 10-year review. Journal of Obstetrics and Gynaecology 2009; 29: 322-5.
9. KEMH clinical guidelines B 2.3.1 Management of a woman with an APH. April 2009. Available from: <http://www.wnhs.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.3.1.pdf> [25 July 2009].
10. Sinha P, Kuruba N. Ante-partum haemorrhage: an update. Journal of Obstetrics and Gynaecology 2008; 28: 377-81.