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18. Vaginal Bleeding in Early Pregnancy
18.1 Introduction
Vaginal bleeding is a common complication in early pregnancy and is seen in 20–25% of pregnancies in the first trimester. Fifty percent of pregnancies which have bleeding in early gestation ultimately abort [1]. It is a commonly encountered presentation in early pregnancy units. Any woman in reproductive age group presenting with bleeding per vaginum should be suspected to have pregnancy or pregnancy-related complications. The presentation may vary from a stable patient to a life-threatening condition as may happen in ectopic pregnancy, incomplete abortion, septic abortion, or trauma. Careful history taking and examination accompanied with ultrasound and beta hCG values help in appropriate management and optimal outcomes.
In this chapter we present the causes of bleeding in early pregnancy, relevant history, and examination to be done followed by investigations and diagnosis. Overall management of the cases would be discussed together last.
18.2 Causes of Bleeding in Early Pregnancy
The bleeding in early pregnancy may be because of pregnancy-related causes like abortion, ectopic, etc. or those incidentally associated with normal pregnancy like traumatic tears, polyps, infections, etc. Miscarriages are the most common cause of bleeding in early pregnancy (Table 18.1).
18.2.1 History
Like for any medical disease, first the condition of the patient should be assessed. If she is hemodynamically compromised, resuscitative measures like starting IV fluids, oxygen, and arranging blood should be done. Then a brief quick relevant history should be taken.
History of amenorrhea with acute abdominal pain/collapse and adnexal tenderness may indicate a ruptured ectopic. Similarly fever, abdominal pain, foul smelling discharge, hypotension with pallor, abdominal tenderness, and peritonitis may indicate a septic abortion with or without septic shock.
If patient is stable, then relevant history should be taken to arrive at a diagnosis.
History of amenorrhea is important. Last menstrual period should be documented and gestational age should be calculated. It is important to note that patient may present with ectopic pregnancy without any amenorrhea. Duration and flow of last menstrual period is important to note whether it was a normal period or an episode of bleeding only. It can also be implantation bleeding.
Cramping pain may signify process of expulsion of products/clots as in miscarriage.
The amount, color, and duration of bleeding with history of passage of clots should be asked to estimate blood loss. Fresh blood may signify threatened or incomplete abortion. Vaginal, cervical lesions and trauma will also cause fresh red-colored bleeding. Old brownish bleeding may be seen in missed abortion, molar pregnancy, or subchorionic bleeding.
History of passage of any products is important. It may signify products or may be a decidual cast in ectopic pregnancy rarely. Passage of grapelike products denote vesicular mole.
Any other systemic complaints should be evaluated like burning micturition, bowel symptoms like constipation, inability to pass flatus, vomiting, decreased urine output, etc. This helps in diagnosing septicemia, subacute intestinal obstruction, etc.
Associated history of interference, instrumentation, should be taken.
History of drug intake like abortifacients, nonsteroidal anti-inflammatory drugs, and hormones is important. History of assisted reproduction methods may point toward heterotopic pregnancy.
Past history of ectopic, abdominal pain, pelvic inflammatory disease, and abortions should be taken as they are risk factors for repeat disease in this pregnancy.
18.2.2 Signs and Symptoms
One should be very considerate and gentle in examining the patient. Patient’s general condition, pallor, tachycardia, blood pressure, chest, and cardiovascular system should be evaluated quickly.
Abdomen should be palpated for uterine size if palpable which is normally felt per abdomen after 12 weeks. Any associated mass-like fibroids or ovarian should be noted. Tenderness, guarding, doughy abdomen, and rigidity if present may signify peritonitis, or hemoperitoneum. Shifting dullness should be seen.
Local examination should be done. Vulva is seen externally for any disease and the amount of bleeding. Per speculum examination may reveal any vaginal or cervical lesions like cervicitis, vaginitis, polyps, cervical cancer, etc. Presence of postcoital tear should be looked for. Dilated cervical os with blood and/or products coming from it may signify incomplete or inevitable abortion.
Any products lying in the vagina or being extruded from the cervix are noted. They should be gently removed with ovum forceps and examined for chorionic villi and send for histopathological examination.
Bimanual pelvic examination would reveal uterine size, softness, mobility of the uterus, adnexal masses, and cervical motion tenderness. It should be assessed whether size of the uterus corresponds with the period of gestation or not. It may be smaller in complete abortion, incomplete abortion, or missed abortion. Enlarged uterus with closed os with bleeding will indicate threatened abortion, or if the uterus is soft and normal size, it may indicate complete abortion. Bulky uterus with os open or closed signifies inevitable or incomplete abortion. Normal size uterus with tender adnexal mass would point toward ectopic.
The uterus may be larger in vesicular mole or multiple pregnancy or if associated with fibroids.
Features of peritonitis, intestinal obstruction with a toxic patient with infected discharge from the os, or products lying in the cavity may suggest septic abortion or intestinal injury following perforation. If handheld Doppler is available after 11–12 weeks of gestation, fetal cardiac activity can be confirmed.
Pouch of Douglas should be palpated for any collection fullness, nodules. Any foreign body in the vagina or cervical canal should be also noted for any attempted induced abortion.
18.2.3 Laboratory Investigations
Hemoglobin is done to assess the blood loss and anemia. Blood group and Rh should be known. Increased total leukocyte count and differential count with increased poly morphs will indicate sepsis.
Kidney function tests may be deranged in sepsis and blood loss. Coagulation profile should be done in massive hemorrhage and sepsis.
Urine for pregnancy test to confirm pregnancy should be done. Urine microscopic examination should be done to find pus cells and bacteria for urinary tract infection.
If clinical examination and history is not conclusive, then ultrasound and beta hCG may be done.
All Rh-negative women with bleeding should receive RhO(D) immune globulin, to protect against development of Rh alloimmunization.
Ultrasound examination: Transvaginal sonography is a valuable tool to assess location and viability of early pregnancy. For a normal pregnancy by 5 weeks of period of gestation, a 5 mm intrauterine sac should be visible. It is important to distinguish it from pseudogestational sac of ectopic pregnancy [1]. Yolk sac is visible at 6 weeks when gestational sac is greater than 10 mm in diameter. Cardiac activity should be present when the embryo exceeds 5 mm in length [1]. If these discriminatory criterions are not met, it may indicate pregnancy failure, and evaluation should be done again after 1 week to confirm findings of a loss.
Patients with positive urine pregnancy test with bleeding per vaginum, transvaginal ultrasound tells us about intrauterine pregnancy and its viability. It also reveals any retained products of conception in incomplete abortion.
Empty uterus on ultrasound with adnexal mass with positive urine pregnancy test is almost diagnostic of ectopic pregnancy (Fig. 18.1). Hemoperitoneum can be easily picked by ultrasound examination. Molar pregnancy, subchorionic hematoma, multiple gestations, and demise of one of the twins are other important findings in work up of an early pregnancy bleeding which can be confirmed by ultrasound.
If urine pregnancy test is positive and the uterus is empty with no adnexal mass, then the term pregnancy of unknown location is used. In this situation differential can be complete abortion, emerging normal pregnancy, or ectopic pregnancy.
18.2.4 Measurement of Beta Unit of Human Chorionic Gonadotropin
The beta hCG can be detected in the blood around 22–23 days of last menstrual period. The routinely available urinary pregnancy test kits detect beta hCG of 25 miu/ml [2]. This test is positive in most of the ectopic pregnancies.
The level of beta hCG beyond which an intrauterine sac should certainly be seen on ultrasound scan is called discriminatory level. This varies in different reports. A level of 1500–200 IU/l is generally taken at which pregnancy should be visible on transvaginal scan.
If the pregnancy location is not seen, then diagnosis of ectopic is almost certain. Complete abortion, failing intrauterine pregnancy, and very early twin pregnancy can be the other differentials.
If the values are below the discriminatory levels, then pregnancy won’t be visible on ultrasonography and may be called a pregnancy of unknown location. Serial beta hCG levels may be needed to arrive at a diagnosis. For a normal developing intrauterine pregnancy, beta hCG rise is seen to be at least 50% in 48 h in almost 99% of normal pregnancies [3]. Twenty percent of ectopics also may show beta hCG rise of 50% in 48 h [4].
Slowly rising titers may indicate ectopic pregnancy or failing intrauterine pregnancy. Falling beta hCG may indicate nonviable intrauterine pregnancy or resolving ectopic pregnancy. The rate of decrease for a spontaneous abortion is dependent on the initial β-hCG level. The average rate of decrease in the first 48 h is typically greater than 70%. A rate of decrease less than 21–35% (depending on initial level) is inappropriate, and an ectopic pregnancy should be suspected [4]. One should think of gestational trophoblastic neoplasia if the titers are very high.
18.2.5 Diagnosis and Management
18.2.5.1 Ectopic Pregnancy
Ectopic pregnancies constitute 1–2% of all first trimester pregnancies. Risk factors for ectopic pregnancies are prior tubal pregnancy, surgeries on fallopian tube like recanalization, sexually transmitted diseases, pelvic inflammatory disease and other infections like appendicitis, and in our country tuberculosis. Infertility and ART also increase the risk of ectopic pregnancies.
At a value of 1500–2000 mIU/mL of beta hCG, intrauterine gestational sac is always seen [1]. If at this level sac is not seen on the ultrasound, a diagnosis of ectopic is almost confirmed. Very early multiple gestations may have higher beta hCG values early on before pregnancy is visible. Heterotopic pregnancy should also be thought of [5].
Adnexal mass, cervical movement tenderness, free fluid in the pelvis with empty uterus, and a positive urine pregnancy test are almost diagnostic of ectopic pregnancy. Clinical history and examination should always be correlated.
Management of ectopic pregnancy can be medical or surgical or expectant.
18.2.6 Medical Management
Differential diagnosis of bleeding in early pregnancy
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