1. Vaginal Bleeding in the Pregnant Patient
Focus on Primary Care Management
Lopita Banerjee M.Sc, MD, CCFP
Andrea Pansoy M.Sc, CCPA

2. Outline Anatomy Definition Epidemiology
Causes of first trimester bleeding
Management
Final Summary
Questions

3. Anatomy

4. Definition Any bleeding from genital tract in pregnancy
Can be divided according to gestational age: first trimester bleeding (or first 20 weeks of pregnancy) and antepartum hemorrhage (second half of pregnancy)
Remains a major cause of perinatal mortality and maternal morbidity in the developed world

5. 1Am Fam Physician. 2009 Jun 1;79(11):985-992.
Epidemiology
Incidence of First Trimester Bleeding: 25-30%
Miscarriage occurs in 50% of bleeding cases1
Even if viable, higher complication risk post-bleed
Half of conceptions miscarry in first 12 weeks
Late Trimester Bleeds complicate 4% of pregnancies
1Am Fam Physician Jun 1;79(11):

6. Additional articles for reference
Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol Oct;114(4):860-7.
Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol Nov;106(5 Pt 1):993-9.
Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am Mar;42(2):

7. Case 1
Vanessa, age 32, G1P0 - you have recently seen her 3 weeks ago at GA 5 for early pregnancy visit
Has been doing everything ‘right’, taking vitamins
Stopped feeling nauseous for a few days, and then bright red spotting last night with mild cramps
Comes in urgently for assessment

8. First Trimester Bleeding
Implantation bleeding
Subchorionic hemorrhage: blood collected between chorion and uterine wall
Miscarriage: aka spontaneous abortion, <20 weeks
Blighted ovum/anembryonic pregnancy
Ectopic pregnancy
Gestational trophoblastic disease
Cervical/vaginal/uterine lesions, polyps
Trauma
Infection

9. Implantation Bleeding
Defined as bleeding that occurs 10 to 14 days after conception
Attachment of fertilized egg to endometrium
Lighter and shorter than normal period

10. Subchorionic Hemorrhage
Blood collected between chorion and uterine wall
Usually can monitor with ultrasounds q1-2 weeks depending on active bleeding
Most resorb independently

11. Miscarriage or SA
Threatened Abortion - bleeding, cervix closed, viable IUG; risk 50%
Inevitable Abortion - bleeding, cervix dilated, cramping, no POC expelled yet
Incomplete Abortion - incomplete evacuation of products

12. Miscarriage or SA
Missed Abortion - retained non-viable pregnancy up to 4 weeks
Septic Abortion - incomplete SA with secondary infection
Recurrent Spontaneous Abortion - three or more consecutive pregnancy losses
Blighted Ovum - gestational sac + placenta with no yolk sac; failure of embryo development

13. History & Tests Accurate dating – LMP
Amount of bleeding - determines stability - 1 regular sanitary pad can hold up to 20 cc of blood; regular period loss 50 cc per day
Vitals
Fetal heart rate
Investigations- serial BHCGs and ultrasound

14. BHCG BHCG 1,500 to 2,000 mIU per mL - gestational sac on ultrasound
BHCG doubles (increases by 80%) every 48 hours in a viable pregnancy

15. Discriminatory Findings in Early Pregnancy
Menstrual Age
Embryologic Event
Lab & U/S Findings
3-4 w
implantation site
decidual thickening
4 w
trophoblast
peritrophoblastic flow on colour flow Doppler
4-5 w
gestational sac
BHCG
5-6 w
yolk sac
embryo
cardiac activity
gest sac>10 mm
gest sac > 18mm
gest sac > 5 mm

16. Case 1 Initial Findings Was not really sure of LMP - irregular cycles
Ultrasound - gestational sac with no fetal heart rate detected, no active bleeding, small subchorionic hemorrhage
May be 5 weeks gestation
Next steps?

17. Management
Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical signs of intraperitoneal bleeding
? viable pregnancy

18. Case 1 Continued
10 days later - ultrasound shows no FHR, gest sac noted
Started to cramp a bit last night and your patient thought it was okay to wait as there was no bleeding; this morning before she came in she noted some bright pink spotting.
What now?

19. Patient Presentation
May present with bright red bleeding and contractions or lower abdominal pain
Key - how much blood loss (quantity, rate), vital signs
Serial BHCG and ultrasound help guide treatment
Consider speculum exam
Significant stress to patient and family

20. Management Watch and wait Misoprostol - can be done in office
Surgical D&C - referral to OB or speciality clinic
RhoGAM if required for Rh negative patients

21. Medical Management of Spontaneous Abortion
Different procedures and protocols available
Misoprostol 800 mcg PV x 1 dose, can repeat in 24 hours and at 48 hours
No significant effect after third dose
Works approximately 84% of the time1
Side effects - hypotension, N&V, abdo pain, + bleeding
Warn re: bleeding and when to go to ER
1Am Fam Physician Jul 1;84(1):75-82.

22. Misoprostol Follow-up
Initial BHCG and ultrasound
Repeat ultrasound in 2 weeks with BHCG
May want to follow BHCG to 0

23. Case 1 Follow-up Visit Seen in clinic 2 weeks later
Patient is worried that she did something to cause the SA
Heard that stress can be a factor - work is difficult, and she recently had to travel
“What did I do wrong?”

24. Myths About Pregnancy Loss
SA not related to:
Stress
Sexual activity
Air travel
Exercise
Contraceptive use
HPV infection
Grief is normal for this loss - supportive counselling and education, other support resources

25. Risk Factors Advanced maternal age
Cigarette smoking, EtOH use, alcohol abuse, drug use
Occupational chemical exposure
Excessive caffeine mg/day
Uterine anomalies
Incompetent cervix
Diabetes mellitus
Progesterone deficiency
Thyroid disease
Connective tissue disorder
Trauma

26. Case 2
Sheryl, age 27 – presents to clinic c/o sharp LLQ pain, started yesterday evening
Has also been having intermittent spotting for past 2 weeks
Has not had a menstrual period in 6 months as she has a Mirena IUD
How would you proceed?

27. Case 2 Exam Findings Abdo – N BS, LLQ tenderness to palpation
Speculum exam – cervix closed, IUD strings visualized, small amount of dark red blood
Bimanual – uterus firm, mobile, no CMT, L adnexal tenderness
Urine dipstick – 3+ blood, 1+ leukocytes
Urine BHCG – positive
What do you do next?

28. Ectopic Pregnancy
Implantation of fertilized ovum outside of the uterus
2% of all pregnancies
Second most common cause for maternal mortality - accounts for 6% of maternal deaths
Surgical management - referral to OB emergently

29. Risk Factors for Ectopic Pregnancy
Previous tubal surgery
Previous ectopic pregnancy
In utero DES exposure
History of PID
History of infertility
History of chlamydial or gonococcal cervicitis
Documented tubal abnormality
Tubal ligation
Current IUD use

30. Take Home Message Have high index of suspicion!
History and physical examination alone rarely leads to the diagnosis or exclusion of ectopic pregnancy
Serum BHCG and pelvic u/s are key to confirming the diagnosis
history and physical examination alone rarely leads to the diagnosis or exclusion of an EP, with most diagnosed earlier in the course of the disease. One-third of women with an EP have no clinical signs and up to 10% have no symptoms

31. Case 3
Miranda, 30 years old, G3P2 – seen in clinic c/o 3 day hx. of dark brown vaginal discharge
Newly pregnant, GA ~ 6wks based on LMP
Has initial prenatal visit booked next week but concerned about the discharge
What next?

32. Case 3 continued Speculum exam – cervix closed, dark brown blood noted
Pelvic u/s and blood work ordered
Serum BHCG – 132,745 mIU/mL
Ultrasound report - enlarged uterus, no gestational sac seen, multiple cystic structures in grape-like clusters

33. Gestational Trophoblastic Disease
A group of rare tumours that form in the tissue (trophoblast cells) that surrounds an egg after it is fertilized, and connect the fertilized egg to the wall of the uterus and form part of the placenta
In GTD, a tumour forms instead of a healthy fetus.
Includes hydatidiform moles (molar pregnancy, usually benign) and gestational trophoblastic neoplasia.

34. GTD Malignant transformation to choriocarcinoma in 10-20%
Locally Invasive Mole: Chorioadenoma destruens (66%)
Gestational Choriocarcinoma (33%)
Hyperthyroidism
Pregnancy Induced Hypertension

35. Management Evacuation of Uterus Dilatation and Evacuation
Dilatation and Curettage
Avoid Hysterectomy, Hysterotomy, or Pitocin
Increased risk of metastasis (Relative Risk: 3.0)
Clamp uterine vessels early if Hysterectomy needed
Chemotherapy Indications after D&C
Quantitative BHCG persistently elevated
Persistent uterine bleeding
Evidence of trophoblastic metastasis - brain, lungs

36. Monitoring and Prognosis
Follow quantitative BHCG levels until 0
Serial BHCG for 6 months to 1 year
Use contraception during this time
Chemotherapy if BHCG rises or does not fall to 0
Methotrexate usually used
Recurrence rate of complete mole: 20%
May recur as locally invasive or metastatic
Recurrence rate in future pregnancies: 1-2%

37. Case 4
Amanda, 27 years old, G2P0 – new patient to your clinic, currently GA 6 weeks
Seen in clinic today due to c/o post-coital bleeding lasting 1 day, no associated cramping
Speculum exam – cx closed, small amount of dark red blood
What do you do next?

38. Case 4 Investigations
Next urgent OB u/s appointment is not until 3 days from now
Serial BHCG ordered – initially 28,674 IU/L; 30,621 IU/L
OB u/s showed IUP, GA 5 weeks 6 days based on exam, yolk sac seen, no FHR detected
BHCG done on same day of u/s was 32,356 IU/L
Patient has not had any further bleeding
How would you proceed?
IU/L. She was asked
to repeat the test the next day; results showed a level of
IU/L.

39. Case 4 Continued
The patient was sent for a repeat OB u/s 10 days later which showed a viable pregnancy

40. Don’t Always Assume Miscarriage
Serum BHCG has been shown to vary from 440 to IU/L among women whose pregnancies resulted in normal term deliveries1
BHCG should not be used as the only determinant of a viable pregnancy, must correlate with ultrasound
1Clin Lab Med Jun;23(2):257-64, vii.

41. Cervical Lesions May have polyps or other vaginal lesions Infections
Trauma - remember sexual assault, IPV
Use other resources available

42. Late Trimester Bleeding
placenta praevia
partial and total

43. Late Trimster Bleeding
abruptio placentae
surgical emergency

44. Care After Loss Rh negative – need for RhoGam
Contraception - all methods safe
No good evidence suggesting ideal inter pregnancy interval - folic acid supplementation
Psychological impact - grief counselling

45. Approaches to Grief Counseling After Miscarriage
Acknowledge and attempt to dispel guilt
Acknowledge and legitimize grief
Provide comfort, sympathy, and ongoing support
Reassure the patient about the future
Counsel the patient on how to tell family and friends about the miscarriage:
Warn patients of the anniversary phenomenon
Include the patient’s partner in your psychological care
Assess level of grief and adjust counseling accordingly
Reference: Am Fam Physician. 2009 Jun 1;79(11):

46. Resources for Grieving Parents
gresources

47. Summary Have high index of suspicion and keep a broad differential
Transvaginal ultrasound and BHCG titres should be used to investigate early pregnancy bleeding and to monitor management outcome
Don’t hesitate to consult if concerned
Be available to provide support to your patient

48. Thank you!
Questions?