Vaginal bleeding in early pregnancy

PROBLEM

• Vaginal bleeding occurs during the first 22 weeks of pregnancy.

GENERAL MANAGEMENT

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately. 

• If the woman is in shock, consider ruptured ectopic pregnancy (Table S-4).

• Start an IV infusion and infuse IV fluids.

DIAGNOSIS

• Consider ectopic pregnancy in any woman with anaemia, pelvic inflammatory disease (PID), threatened abortion or unusual complaints about abdominal pain.

Note: If ectopic pregnancy is suspected, perform bimanual examination gently because an early ectopic pregnancy is easily ruptured.

• Consider abortion in any woman of reproductive age who has a missed period (delayed menstrual bleeding with more than a month having passed since her last menstrual period) and has one or more of the following: bleeding, cramping, partial expulsion of products of conception, dilated cervix or smaller uterus than expected.

• If abortion is a possible diagnosis, identify and treat any complications immediately (Table S-2).

TABLE S-1 

Diagnosis of vaginal bleeding in early pregnancy 

TABLE S-2 

Diagnosis and management of complications of abortion 

BOX S-1 Types of abortion 

MANAGEMENT

If unsafe abortion is suspected, examine for signs of infection or uterine, vaginal or bowel injury (Table S-2, page S-9) and thoroughly irrigate the vagina to remove any herbs, local medications or caustic substances. 

THREATENED ABORTION

• Medical treatment is usually not necessary. 

• Advise the woman to avoid strenuous activity and sexual intercourse but bed rest is not necessary.

• If bleeding stops, follow up in antenatal clinic. Reassess if bleeding recurs.

• If bleeding persists, assess for fetal viability (pregnancy test/ultrasound) or ectopic pregnancy (ultrasound). Persistent bleeding, particularly in the presence of a uterus larger than expected, may indicate twins or molar pregnancy. 

Do not give medications such as hormones (e.g. oestrogens or progestins) or tocolytic agents (e.g. salbutamol or indomethacin) as they will not prevent miscarriage. 

INEVITABLE ABORTION

• If pregnancy is less than 16 weeks, plan for evacuation of uterine contents. If evacuation is not immediately possible:

- Give ergometrine 0.2 mg IM (repeated after 15 minutes if necessary) OR misoprostol 400 mcg by mouth (repeated once after 4 hours if necessary);

- Arrange for evacuation of uterus as soon as possible.

• If pregnancy is greater than 16 weeks:

- Await spontaneous expulsion of products of conception and then evacuate the uterus to remove any remaining products of conception;

- If necessary, infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 40 drops per minute to help achieve expulsion of products of conception.

• Ensure follow-up of the woman after treatment.

INCOMPLETE ABORTION

• If bleeding is light to moderate and pregnancy is less than 16 weeks, use fingers or ring (or sponge) forceps to remove products of conception protruding through the cervix.

• If bleeding is heavy and pregnancy is less than 16 weeks, evacuate the uterus:

- Manual vacuum aspiration is the preferred method of evacuation. Evacuation by sharp curettage should only be done if manual vacuum aspiration is not available;

- If evacuation is not immediately possible, give ergometrine 0.2 mg IM (repeated after 15 minutes if necessary) OR misoprostol 400 mcg orally (repeated once after 4 hours if
necessary).

• If pregnancy is greater than 16 weeks:

- Infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 40 drops per minute until expulsion of products of conception occurs;

- If necessary, give misoprostol 200 mcg vaginally every 4 hours until expulsion, but do not administer more than 800 mcg;

- Evacuate any remaining products of conception from the uterus.

• Ensure follow-up of the woman after treatment (see below).

COMPLETE ABORTION 

• Evacuation of the uterus is usually not necessary.

• Observe for heavy bleeding.

• Ensure follow-up of the woman after treatment (see below).

FOLLOW-UP OF WOMEN WHO HAVE HAD AN ABORTION

Before discharge, tell a woman who has had a spontaneous abortion that spontaneous abortion is common and occurs in at least 15% (one in every seven) of clinically recognized pregnancies. Also reassure the woman that the chances for a subsequent successful pregnancy are good unless there has been sepsis or a cause of the abortion is identified that may have an adverse effect on future pregnancies (this is rare). 

Some women may want to become pregnant soon after having an incomplete abortion. The woman should be encouraged to delay the next pregnancy until she is completely recovered.

It is important to counsel women who have had an unsafe abortion. If pregnancy is not desired, certain methods of family planning (Table S-3) can be started immediately (within 7 days) provided:

• There are no severe complications requiring further treatment;

• The woman receives adequate counselling and help in selecting the most appropriate family planning method.

TABLE S-3

Family planning methods 

Also identify any other reproductive health services that a woman may need. For example some women may need:

• tetanus prophylaxis or tetanus booster;

• treatment for sexually transmitted diseases (STDs);

• cervical cancer screening.

ECTOPIC PREGNANCY

An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The fallopian tube is the most common site of ectopic implantation (greater than 90%).

Symptoms and signs are extremely variable depending on whether or not the pregnancy has ruptured (Table S-4). Culdocentesis (cul-de-sac puncture) is an important tool for the diagnosis of ruptured ectopic pregnancy, but is less useful than a serum pregnancy test combined with ultrasonography. If non-clotting blood is obtained, begin immediate management. 

TABLE S-4

 Symptoms and signs of ruptured and unruptured ectopic pregnancy 

^a Distended abdomen with shifting dullness may indicate free blood.

DIFFERENTIAL DIAGNOSIS

The most common differential diagnosis for ectopic pregnancy is threatened abortion. Others are acute or chronic PID, ovarian cysts (torsion or rupture) and acute appendicitis.
If available, ultrasound may help distinguish a threatened abortion or twisted ovarian cyst from an ectopic pregnancy.

IMMEDIATE MANAGEMENT

• Cross-match blood and arrange for immediate laparotomy. Do not wait for blood before performing surgery.

• At surgery, inspect both ovaries and fallopian tubes:

- If there is extensive damage to the tubes, perform salpingectomy (the bleeding tube and the products of conception are excised together). This is the treatment of choice in most cases; 

- Rarely, if there is little tubal damage, perform salpingostomy (the products of conception can be removed and the tube conserved). This should be done only when the conservation of fertility is very important to the woman, as the risk of another ectopic pregnancy is high.

AUTOTRANSFUSION

If significant haemorrhage occurs, autotransfusion can be used if the blood is unquestionably fresh and free from infection (in later stages of pregnancy, blood is contaminated with amniotic fluid, etc. and should not be used for autotransfusion). The blood can be collected prior to surgery or after the abdomen is opened:

• When the woman is on the operating table prior to surgery and the abdomen is distended with blood, it is sometimes possible to insert a needle through the abdominal wall and
  collect the blood in a donor set. 

• Alternatively, open the abdomen:

- Scoop the blood into a basin and strain through gauze to remove clots; 

- Clean the top portion of a blood donor bag with antiseptic solution and open it with a sterile blade; 

- Pour the woman’s blood into the bag and reinfuse it through a filtered set in the usual way;

- If a donor bag with anticoagulant is not available, add sodium citrate 10 mL to each 90 mL of blood.

SUBSEQUENT MANAGEMENT

• Prior to discharge, provide counselling and advice on prognosis for fertility. Given the increased risk of future ectopic pregnancy, family planning counselling and provision of a family planning method, if desired, is especially important (Table S-3).

• Correct anaemia with ferrous sulfate or ferrous fumerate 60 mg by mouth daily for 6 months.

• Schedule a follow-up visit at 4 weeks. 

MOLAR PREGNANCY

Molar pregnancy is characterized by an abnormal proliferation of chorionic villi.

IMMEDIATE MANAGEMENT

• If the diagnosis of molar pregnancy is certain, evacuate the uterus:

- If cervical dilatation is needed, use a paracervical block;

- Use vacuum aspiration. Manual vacuum aspiration is safer and associated with less blood loss. The risk of perforation using a metal curette is high;

- Have three syringes cocked and ready for use during the evacuation. The uterine contents are copious and it is important to evacuate them rapidly.

• Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute to prevent haemorrhage once evacuation is under way.

SUBSEQUENT MANAGEMENT

• Recommend a hormonal family planning method for at least 1 year to prevent pregnancy (Table S-3). Voluntary tubal ligation may be offered if the woman has
  completed her family.

• Follow up every 8 weeks for at least 1 year with urine pregnancy tests because of the risk of persistent trophoblastic disease or choriocarcinoma. If the urine pregnancy test is not negative after 8 weeks or becomes positive again within the first year, refer the woman to a tertiary care centre for further follow-up and management.

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