By Dr. Erica Daniels, MD
SignatureCare Emergency Center – Bellaire

Vaginal bleeding is common in the first half of pregnancy. This can be scary but most of the time, the bleeding stops on its own, and the pregnancy will continue normally.

The bleeding usually results from disruption of blood vessels or from a discrete cervical or vaginal lesion.

The doctor typically makes a clinical diagnosis based upon the gestational age and the character of bleeding (eg, spotting, light or heavy flow, intermittent or constant, associated with pain or painless).

Physical examination and laboratory and/or imaging tests are then used to support or revise the initial diagnosis.

Bleeding can be associated with a pregnancy loss or an ectopic pregnancy, which can be life-threatening.

When to go to the ER for Vaginal Bleeding

Patients with heavy bleeding (eg, soaking ≥1 pad/hour for more than two hours, or passing large clots), lightheadedness/syncope, and/or pelvic pain generally warrant prompt evaluation in an emergency department so supportive measures and treatment can be rapidly initiated if the patient is found to be unstable.

What to expect:

Labs: to confirm the pregnancy (blood or urine pregnancy test), screen for anemia (CBC), check blood type (ABORh), rule out infection (urinalysis) and document level of pregnancy hormone (beta hcg). Beta hCG is a pregnancy hormone in the blood. This test might be repeated 48 hours later to see how the level has changed.

Ultrasound: commonly performed transvaginally. This uses a probe inserted inside the vagina, to use sound waves to see the fetus.

Ultrasonography is the cornerstone of the evaluation of bleeding in pregnancy. It is most useful in bleeding patients with a positive pregnancy test in whom an intrauterine pregnancy has not been previously confirmed by imaging studies.

In these patients, ultrasound examination is performed to determine whether the pregnancy is intrauterine or extrauterine (ectopic) and, if intrauterine, whether the pregnancy is viable (cardiac activity present) or nonviable.

Pelvic exam: a speculum and gloved hand inserted inside the vagina checks the vagina, cervical os, uterus and adnexa/ovaries in order to assess the volume and source of bleeding, check for blood clots & products of conception, see whether the cervical os is open or closed, gauge size and tenderness of the uterus and adnexa/ovaries, and rule out mass.

Understanding Medical Terminology: The laymen’s term “abortion” is called an elective abortion in the medical terminology; however, the term abortion medically refers to loss of pregnancy, planned or otherwise.

For example, a spontaneous abortion or complete abortion is the medical term for a miscarriage. Whereas, a threatened abortion is vaginal bleeding with a viable pregnancy.

What Else Can Cause Bleeding during early pregnancy

Ectopic pregnancy – This is when the pregnancy is located in the wrong place in the body, outside of the uterus. It can cause vaginal bleeding and belly pain, and needs immediate treatment. Ectopic pregnancy is sometimes called a “tubal pregnancy.”

Irritation or injury in the vagina or cervix – Pregnancy can make the cervix more likely to bleed after sex or a routine exam (like a Pap test). Occasionally, a wound, growth, or mass could also cause bleeding.

Implantation – Some people have a small amount of bleeding when the egg implants into the lining of the uterus.

Threatened abortion: (eg, threatened miscarriage) diagnosis of exclusion in patients with vaginal bleeding, a closed cervix, and sonographic visualization of an intrauterine pregnancy with detectable embryonic/fetal cardiac activity.

Vaginal Bleeding Prognosis and Treatment

The prognosis is most favorable when bleeding is light and limited to early pregnancy (ie, less than 6 weeks of gestation) and worsens when bleeding is heavy or extends into the second trimester.

For most patients with ongoing pregnancies, no effective interventions are available, but patients can be reassured of the relatively low likelihood of adverse outcome.

Patients who are discharged from the emergency department are reminded to take a prenatal vitamin, use acetaminophen for pain instead of NSAIDs which are contraindicated in pregnancy and to comply with instructions for close outpatient follow-up, usually at 48 hours intervals.

Any worsening or progression of symptoms should prompt immediate return to care.

———————————————
Dr. Erica Daniels, MD, is an Emergency Medicine Specialist in Houston, TX and has over 13 years of experience in the medical field. She graduated from University of California Davis Medical Center. She currently practices at Signature Care Emergency Center-Bellaire. Dr. Daniels is board certified in Emergency Medicine.