Early pregnancy bleeding

Last updated
Early pregnancy bleeding
Other namesFirst trimester bleeding, hemorrhage in early pregnancy
Specialty Obstetrics
Complications Hemorrhagic shock [1]
Causes Ectopic pregnancy, threatened miscarriage, pregnancy loss, implantation bleeding, gestational trophoblastic disease, polyps, cervical cancer [1] [2]
Diagnostic method Typically includes speculum examination, ultrasound, hCG [1]
TreatmentDepends on the underlying cause [1]
Frequency~30% of pregnancies [1]

Early pregnancy bleeding (also called first trimester bleeding) is vaginal bleeding before 14 weeks of gestational age. [1] [2] If the bleeding is significant, hemorrhagic shock may occur. [1] Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain. [1]

Contents

Common causes of early pregnancy bleeding include ectopic pregnancy, threatened miscarriage, and pregnancy loss. [1] [2] Most miscarriages occur before 12 weeks gestation age. [2] Other causes include implantation bleeding, gestational trophoblastic disease, polyps, and cervical cancer. [1] [2] Tests to determine the underlying cause usually include a speculum examination, ultrasound, and hCG. [1]

Treatment depends on the underlying cause. [1] If tissue is seen at the cervical opening it should be removed. [1] For those in whom the pregnancy is intrauterine and who have fetal heart sounds, watchful waiting is generally appropriate. [3] Anti-D immune globulin is usually recommended in those who are Rh-negative. [4] Occasionally, surgery is required. [1]

About 30% of women have bleeding in the first trimester (0 to 14 weeks gestational age). [1] [5] Bleeding in the second trimester (12 to 24 weeks gestational age) is less common. [6] About 15% of those who realize they are pregnant have a miscarriage. [1] Ectopic pregnancy occurs in under 2% of pregnancies. [1]

Differential diagnosis

The differential diagnosis depends on whether the bleeding occurs in the first trimester or in the second or third trimesters.

Obstetric causes of first trimester bleeding include the following:

Obstetric causes of second/third trimester bleeding include the following:

Other causes of early pregnancy bleeding include the following:

Pathophysiology

Early pregnancy bleeding is usually from a maternal source rather than a fetal one. The maternal source may be a disruption in the vessels of the decidua or a lesion in the cervix or vagina. In the earlier stages of pregnancy, the cervix can be vulnerable to bleeding as new blood vessels are being grown. [15] Vasa praevia is a rare condition that can result in bleeding from the fetoplacental circulation. Vasa praevia happens most often when the umbilical cord grows in a way that it directly enters the membrane, and therefore blood vessels that are unprotected by the umbilical cord or placental tissue can rupture and lead to bleeding. [16] Another common source of bleeding can be due to abnormal development of the embryo. The most common early fetal abnormality is abnormal number of chromosomes causing loss of the pregnancy and bleeding. [17]

Diagnostic approach

The initial assessment of vaginal bleeding in early pregnancy must first consider hemodynamic stability and the degree of pain or bleeding.  A hemodynamically unstable individual would necessitate an immediate transfer to the emergency department. It is important to recognize that women may suffer significant blood loss before any signs of hemodynamic instability are evident. [18]

The initial evaluation of early pregnancy bleeding involves a history and physical examination. [19] The relevant history includes determining the gestational age of fetus and characterizing the bleeding. Bleeding that is at least as heavy as menstrual bleeding or associated with clots, tissue, lightheadedness, or pelvic discomfort is associated with increased risks of ectopic pregnancy and spontaneous abortion. [19] Discomfort in the middle of the abdomen is more closely associated with spontaneous abortion; discomfort on a side of the abdomen is more closely associated with ectopic pregnancy. Risk factors for ectopic pregnancy or spontaneous abortion should also be considered. [19]

The physical examination includes assessing vital signs and performing an abdominal and pelvic examination. Signs of hemodynamic instability or peritonitis require emergent intervention. [19] A pelvic examination may reveal non-obstetric causes of bleeding such as bleeding from the vagina or cervix. It may also show visible products of conception suggestive of an incomplete abortion. [19]

If the person is stable and a pelvic exam is unrevealing, transvaginal ultrasonography and/or serial measurement of hCG is generally recommended to assess fetal location and viability. [19] Reviewed data from observational studies determined that ultrasound examination and hCG concentration could replace pelvic examination in the initial evaluation of early pregnancy bleeding. [20] Transvaginal ultrasound is frequently used in the evaluation of bleeding in early pregnancy. [21]

Before 10 weeks gestation, a slower than normal increase in hCG suggests early pregnancy loss or ectopic pregnancy. [19] By approximately 10 weeks, hCG plateaus and ultrasound is preferred to determine the location of the pregnancy (i.e., intrauterine or ectopic). [19] In the presence of prior pelvic imaging, fetal heart tracing with Doppler sonography is sufficient to assess fetal viability beginning at 10–12 weeks of gestation. Bleeding associated with an intrauterine, viable pregnancy suggests threatened early pregnancy loss. [19] Bleeding associated with an intrauterine, nonviable pregnancy suggests early pregnancy loss. [19] If the viability of an intrauterine pregnancy is uncertain, repeat ultrasonography coupled with laboratory measurement of progesterone and/or serial hCG can be helpful. [19] The absence of either intrauterine or ectopic pregnancy on imaging is suggestive of a complete early pregnancy loss (if the pregnancy was previously seen on imaging) or a pregnancy of unknown location (if the pregnancy was not previously seen on imaging). [19]

Management

The management of early pregnancy bleeding depends on its severity and cause. [1]

Women with significant first-trimester bleeding (more than spotting) should have a red blood cell antibody screen. Women who are Rh-negative are usually given anti-D immune globulin to prevent RhD isoimmunization. [4] Those with significant blood loss who become hemodynamically unstable require rapid intervention.[ citation needed ]

Early pregnancy loss can be treated with watchful waiting, medication, or uterine aspiration based on shared decision-making between the mother and provider. [19] For those with incomplete abortion, watchful waiting is the recommended method as more than 90% of these individuals will complete the process spontaneously within four week. [22] Women who decide on expectant management may experience more days of bleeding and longer completion time as compared to surgical management. Serious complications of watchful waiting are rare. [23] Effective medical management entails 200 mg of oral mifepristone (Mifeprex) followed 24 hours later by 800 mcg of vaginally administered misoprostol. [24] Bed rest and progesterone therapy have not been shown to increase the likelihood of a viable outcome. [19] [25]

Ectopic pregnancy is treated with methotrexate therapy or surgery. Typically, an intramuscular injection of 50 mg per m^2 of methotrexate is given followed by close monitoring of b-hCG levels 4 and 7 days after injection. B-hCG levels should decrease by at least 15% between those two timepoints. [26] Surgery is required for individuals who have failed or have contraindications to methotrexate therapy, are experiencing significant blood loss, or have signs of ectopic rupture. [1]

Epidemiology

First trimester bleeding is more common than second or third trimester bleeding. [6] First trimester bleeding may be associated with complications in later pregnancy, including placental abruption, smaller estimated fetal weight, stillbirth, and perinatal death. [27] [28] [29]

Related Research Articles

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Miscarriage</span> Natural death and expulsion of an embryo or fetus before its independent survival

Miscarriage, also known in medical terms as a spontaneous abortion, is the death and expulsion of an embryo or fetus before it can survive independently. The term miscarriage is sometimes used to refer to all forms of pregnancy loss and pregnancy with abortive outcomes before 20 weeks of gestation.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.

Bloody show or show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by thinning and dilation of the cervix, leading to detachment of the cervical mucus plug that seals the cervix during pregnancy and tearing of small cervical blood vessels, and is one of the signs that labor may be imminent. The bloody show may be expelled from the vagina in pieces or altogether and often appears as a jelly-like piece of mucus stained with blood. Although the bloody show may be alarming at first, it is not a concern of patient health after 37 weeks gestation.

Obstetrical bleeding is bleeding in pregnancy that occurs before, during, or after childbirth. Bleeding before childbirth is that which occurs after 24 weeks of pregnancy. Bleeding may be vaginal or less commonly into the abdominal cavity. Bleeding which occurs before 24 weeks is known as early pregnancy bleeding.

<span class="mw-page-title-main">Vacuum aspiration</span> Gynaecological procedure

Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion or retained fetal and placental tissue, or to obtain a sample of uterine lining. It is generally safe, and serious complications rarely occur.

Dilation and evacuation (D&E) or dilatation and evacuation is the dilation of the cervix and surgical evacuation of the uterus after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Abdominal pregnancy</span> Medical condition

An abdominal pregnancy is a rare type of ectopic pregnancy where the embryo or fetus is growing and developing outside the uterus, in the abdomen, and not in a fallopian tube, an ovary, or the broad ligament.

<span class="mw-page-title-main">Trophoblastic neoplasm</span> Medical condition

Gestational trophoblastic neoplasia (GTN) is group of rare diseases related to pregnancy and included in gestational trophoblastic disease (GTD) in which abnormal trophoblast cells grow in the uterus. GTN can be classified into benign and malignant lesions. Benign lesions include placental site nodule and hydatidiform moles while malignant lesions have four subtypes including invasive mole, gestational choriocarcinoma, placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT). The choriocarcinoma has 2 significant subtypes including gestational and non-gestational and they are differentiated by their different biological feature and prognosis. Signs and symptoms of GTN will appear vary from person to person and depending upon the type of the disease. They may include uterine bleeding not related to menstruation, pain or pressure in pelvis, large uterus and high blood pressure during pregnancy. The cause of this disease is unknown but the identification of the tumor based on total beta-human chorionic gonadotropin (β-hCG) in the serum.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.
<span class="mw-page-title-main">Vasa praevia</span> Condition in which fetal blood vessels cross or run near the internal opening of the uterus

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

<span class="mw-page-title-main">Velamentous cord insertion</span> Velamentous placenta

Velamentous cord insertion is a complication of pregnancy where the umbilical cord is inserted in the fetal membranes. It is a major cause of antepartum hemorrhage that leads to loss of fetal blood and associated with high perinatal mortality. In normal pregnancies, the umbilical cord inserts into the middle of the placental mass and is completely encased by the amniotic sac. The vessels are hence normally protected by Wharton's jelly, which prevents rupture during pregnancy and labor. In velamentous cord insertion, the vessels of the umbilical cord are improperly inserted in the chorioamniotic membrane, and hence the vessels traverse between the amnion and the chorion towards the placenta. Without Wharton's jelly protecting the vessels, the exposed vessels are susceptible to compression and rupture.

<span class="mw-page-title-main">Chorionic hematoma</span> Medical condition

Chorionic hematoma is the pooling of blood (hematoma) between the chorion, a membrane surrounding the embryo, and the uterine wall. It occurs in about 3.1% of all pregnancies, it is the most common sonographic abnormality and the most common cause of first trimester bleeding.

<span class="mw-page-title-main">Circumvallate placenta</span> Medical condition

Circumvallate placenta is a rare condition affecting about 1-2% of pregnancies, in which the amnion and chorion fetal membranes essentially "double back" on the fetal side around the edges of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface. Circumvallate placenta is a placental morphological abnormality associated with increased fetal morbidity and mortality due to the restricted availability of nutrients and oxygen to the developing fetus.

<span class="mw-page-title-main">Cervical pregnancy</span> Medical condition

A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.

The anomaly scan, also sometimes called the anatomy scan, 20-week ultrasound, or level 2 ultrasound, evaluates anatomic structures of the fetus, placenta, and maternal pelvic organs. This scan is an important and common component of routine prenatal care. The function of the ultrasound is to measure the fetus so that growth abnormalities can be recognized quickly later in pregnancy, to assess for congenital malformations and multiple pregnancies, and to plan method of delivery.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Breeze, C (May 2016). "Early pregnancy bleeding". Australian Family Physician. 45 (5): 283–6. PMID   27166462.
  2. 1 2 3 4 5 Stables, Dorothy; Rankin, Jean (2010). Physiology in Childbearing: With Anatomy and Related Biosciences. Elsevier Health Sciences. p. 423. ISBN   978-0702044113.
  3. ↑ Deutchman, M; Tubay, AT; Turok, D (1 June 2009). "First trimester bleeding". American Family Physician. 79 (11): 985–94. PMID   19514696.
  4. 1 2 Coppola, PT; Coppola, M (August 2003). "Vaginal bleeding in the first 20 weeks of pregnancy". Emergency Medicine Clinics of North America. 21 (3): 667–77. doi:10.1016/S0733-8627(03)00041-5. PMID   12962352.
  5. ↑ Hendriks, Erin; MacNaughton, Honor; MacKenzie, Maricela Castillo (2019-02-01). "First Trimester Bleeding: Evaluation and Management". American Family Physician. 99 (3): 166–174. ISSN   1532-0650. PMID   30702252.
  6. 1 2 Beebe, Richard; Myers, Jeffrey (2010). Professional Paramedic, Volume II: Medical Emergencies, Maternal Health & Pediatrics. Cengage Learning. p. 704. ISBN   9781285224909.
  7. ↑ American College of Obstetricians Gynecologists' Committee on Practice Bulletins—Gynecology (November 2018). "ACOG Practice Bulletin No. 200". Obstetrics & Gynecology. 132 (5): e197–e207. doi:10.1097/aog.0000000000002899. ISSN   0029-7844. PMID   30157093. S2CID   13149908.
  8. ↑ Hasan, R.; Baird, D. D.; Herring, A. H.; Olshan, A. F.; Jonsson Funk, M. L.; Hartmann, K. E. (2009). "Association Between First-Trimester Vaginal Bleeding and Miscarriage". Obstetrics & Gynecology. 114 (4): 860–867. doi:10.1097/AOG.0b013e3181b79796
  9. ↑ Mouri, Michelle; Rupp, Timothy J. (2020), "Threatened Abortion", StatPearls, StatPearls Publishing, PMID   28613498 , retrieved 2020-03-15
  10. ↑ Harville, E.W. (2003-09-01). "Vaginal bleeding in very early pregnancy". Human Reproduction. 18 (9): 1944–1947. doi: 10.1093/humrep/deg379 . ISSN   1460-2350. PMID   12923154.
  11. ↑ Altieri, Andrea; Franceschi, Silvia; Ferlay, Jacques; Smith, Jennifer; La Vecchia, Carlo (November 2003). "Epidemiology and aetiology of gestational trophoblastic diseases". The Lancet. Oncology. 4 (11): 670–678. doi:10.1016/s1470-2045(03)01245-2. ISSN   1470-2045. PMID   14602247.
  12. ↑ Fan, Dazhi; Wu, Song; Liu, Li; Xia, Qing; Wang, Wen; Guo, Xiaoling; Liu, Zhengping (2017-01-09). "Prevalence of antepartum hemorrhage in women with placenta previa: a systematic review and meta-analysis". Scientific Reports. 7: 40320. Bibcode:2017NatSR...740320F. doi:10.1038/srep40320. ISSN   2045-2322. PMC   5220286 . PMID   28067303.
  13. ↑ Ruiter, L.; Kok, N.; Limpens, J.; Derks, J. B.; de Graaf, I. M.; Mol, Bwj; Pajkrt, E. (July 2016). "Incidence of and risk indicators for vasa praevia: a systematic review". BJOG: An International Journal of Obstetrics and Gynaecology. 123 (8): 1278–1287. doi:10.1111/1471-0528.13829. ISSN   1471-0528. PMID   26694639. S2CID   43666201.
  14. ↑ Brenner, Paul (September 1996). "Differential diagnosis of abnormal uterine bleeding". American Journal of Obstetrics and Gynecology. 175 (3): 766–769. doi:10.1016/s0002-9378(96)80082-2. PMID   8828559.
  15. ↑ "Bleeding During Pregnancy". www.acog.org. Retrieved 2022-09-18.
  16. ↑ Derbala, Yasmine; Grochal, Frantisek; Jeanty, Philippe (January 2007). "Vasa previa". Journal of Prenatal Medicine. 1 (1): 2–13. ISSN   1971-3282. PMC   3309346 . PMID   22470817.
  17. ↑ Simpson, Joe Leigh; Carson, Sandra Ann (2013). "Genetic and Nongenetic Causes of Pregnancy Loss". The Global Library of Women's Medicine. doi:10.3843/GLOWM.10319. ISSN   1756-2228.
  18. ↑ Breeze, Carol (May 2016). "Early pregnancy bleeding". Australian Family Physician. 45 (5): 283–286. ISSN   0300-8495. PMID   27166462.
  19. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Hendriks, Erin; MacNaughton, Honor; MacKenzie, Maricela Castillo (February 2019). "First Trimester Bleeding: Evaluation and Management". American Family Physician. 99 (3): 166–174. ISSN   1532-0650. PMID   30702252.
  20. ↑ Isoardi, Katherine (December 2009). "Review article: the use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding". Emergency Medicine Australasia. 21 (6): 440–448. doi: 10.1111/j.1742-6723.2009.01227.x . ISSN   1742-6723. PMID   20002713. S2CID   42681031.
  21. ↑ Webster, Katie; Eadon, Hilary; Fishburn, Sarah; Kumar, Geeta (2019-11-13). "Ectopic pregnancy and miscarriage: diagnosis and initial management: summary of updated NICE guidance". BMJ. 367: l6283. doi:10.1136/bmj.l6283. ISSN   0959-8138. PMID   31722871. S2CID   208019482.
  22. ↑ Luise, C. (2002-04-13). "Outcome of expectant management of spontaneous first trimester miscarriage: observational study". BMJ. 324 (7342): 873–875. doi:10.1136/bmj.324.7342.873. ISSN   0959-8138. PMC   101397 . PMID   11950733.
  23. ↑ Trinder, J; Brocklehurst, P; Porter, R; Read, M; Vyas, S; Smith, L (2006-05-17). "Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)". BMJ. 332 (7552): 1235–1240. doi:10.1136/bmj.38828.593125.55. ISSN   0959-8138. PMC   1471967 . PMID   16707509.
  24. ↑ Schreiber, Courtney A.; Creinin, Mitchell D.; Atrio, Jessica; Sonalkar, Sarita; Ratcliffe, Sarah J.; Barnhart, Kurt T. (2018-06-07). "Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss". New England Journal of Medicine. 378 (23): 2161–2170. doi:10.1056/nejmoa1715726. ISSN   0028-4793. PMC   6437668 . PMID   29874535.
  25. ↑ Coomarasamy, Arri; Devall, Adam J.; Cheed, Versha; Harb, Hoda; Middleton, Lee J.; Gallos, Ioannis D.; Williams, Helen; Eapen, Abey K.; Roberts, Tracy; Ogwulu, Chriscasimir C.; Goranitis, Ilias (2019-05-09). "A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy". New England Journal of Medicine. 380 (19): 1815–1824. doi: 10.1056/NEJMoa1813730 . hdl: 20.500.11820/491f0b87-4acb-4869-a058-79104059ce8c . ISSN   0028-4793. PMID   31067371.
  26. ↑ Barnhart, Kurt T. (2009-07-23). "Ectopic Pregnancy". New England Journal of Medicine. 361 (4): 379–387. doi:10.1056/nejmcp0810384. ISSN   0028-4793. PMID   19625718.
  27. ↑ Tikkanen, Minna (February 2011). "Placental abruption: epidemiology, risk factors and consequences: Placental abruption, epidemiology". Acta Obstetricia et Gynecologica Scandinavica. 90 (2): 140–149. doi: 10.1111/j.1600-0412.2010.01030.x . PMID   21241259. S2CID   10871832.
  28. ↑ Bever, Alaina M.; Pugh, Sarah J.; Kim, Sungduk; Newman, Roger B.; Grobman, William A.; Chien, Edward K.; Wing, Deborah A.; Li, Hanyun; Albert, Paul S.; Grantz, Katherine L. (June 2018). "Fetal Growth Patterns in Pregnancies With First-Trimester Bleeding". Obstetrics & Gynecology. 131 (6): 1021–1030. doi:10.1097/AOG.0000000000002616. ISSN   0029-7844. PMC   6223322 . PMID   29742672.
  29. ↑ Ananth, Cande V.; Savitz, David A. (January 1994). "Vaginal bleeding and adverse reproductive outcomes: a meta-analysis". Paediatric and Perinatal Epidemiology. 8 (1): 62–78. doi:10.1111/j.1365-3016.1994.tb00436.x. ISSN   0269-5022. PMID   8153019.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.