1. Summary:
Décription:
Any bleeding during pregnancy should be considered abnormal
Etiology varies with gestational age
Bleeding may vary from scant brown staining to bright-red, life-threatening hemorrhage associated with
shock
May be painless or associated with degrees of pain varying from cramps or back pain to severe abdominal
pai
Fetus may or may not be compromised
It is very important to remember Rho(D) immune globulin administration for Rhesus-negative women to
prevent hemolytic disease of the newborn in subsequent pregnancies
Immediate action
If there is heavy bleeding, hemodynamic compromise, collapse, or fetal compromise, transfer urgently to
the emergency department or delivery suite
Suspected ectopic or molar pregnancy should be referred urgently to an obstetric and gynecology
specialist
Key points
Heavy bleeding with hemodynamic compromise requires immediate hospitalization and further evaluation
and treatment regardless of gestational age
Rho(D) immune globulin should be considered for all Rhesus negative mothers following any episode of
vaginal bleeding in pregnancy regardless of gestational age
Patients more than 20 weeks gestational age with vaginal bleeding should not be examined vaginally
(bimanual or speculum) unless the placental site is known or shown to not be previa.
Background
Cardinal features
Any bleeding in pregnancy should be regarded as abnormal, although no cause is found in 50% of cases
of bleeding in early pregnancy
Source of bleeding may be vagina, cervix, or uterus
Possible causes vary with gestational age
Ectopic pregnancy is potentially the most serious cause of first-trimester bleeding, presenting with bleeding
and pain
Bleeding may vary from scant, brown staining to bright red, life-threatening hemorrhage associated with
shock
May be painless or associated with degrees of pain varying from cramps or back pain to severe abdominal
pain
Fetus may or may not be compromised
It is very important to remember Rho(D) immune globulin administration for Rhesus-negative women to
prevent hemolytic disease of the newborn in subsequent pregnancies
Causes
Common causes
50% of first-trimester bleeding has no detectable cause
80% of third-trimester bleeding is due to preterm labor, local lesions of lower genital tract, or no
discoverable cause
7% of third-trimester bleeding is due to placenta previa and 13% is caused by significant placental
abruption
Implantation bleed occurs at the time of embryo implantation, about the same time as first missed period
Spontaneous abortion may be threatened, complete, incomplete, or inevitable
Ectopic pregnancy
Bloody show at term
Cervical lesions: polyps, decidual reaction, neoplasia
Cervicitis/vulvovaginitis
Vaginal or postcoital trauma
Blood dyscrasias
Rare causes

2. Trophoblastic disease: molar pregnancy, choriocarcinoma
Vasa previa: velamentous insertion of cord in lower uterine segment leaving vessels unsupported and
prone to tearing. May be rapidly fatal to fetus
Serious causes
Ectopic pregnancy: most common cause of first trimester maternal death
Trophoblastic disease: although most cases are benign, trophoblastic disease may rapidly progress to
invasive mole or frank choriocarcinoma
Placental abruption: hemorrhage may be life-threatening to mother and fetus
Placenta previa: hemorrhage may be life-threatening to mother and fetus
Vasa previa: fetal death occurs in at least 50-90% of cases
Contributory or predisposing factors
Pelvic inflammatory disease and previous ectopic pregnancy predispose to ectopic pregnancy
Risk factors for placental abruption include hypertension (found in 40-50% of cases), trauma,
polyhydramnios, multiple pregnancy, high parity, smoking, cocaine use, chorioamnionitis, and preterm
premature rupture of membranes
Risk factors for placenta previa include advancing age, multiparity, African or Asian race, smoking, cocaine
use, previous placenta previa, one or more previous cesarean sections or other uterine surgery, and
previous suction curettage for spontaneous or induced abortion
Epidemiology
Incidence and prevalence
Incidence
Hydatidiform mole: 0.67/1000 pregnancies in the US
Choriocarcinoma: 0.05/1000 pregnancies
Vasa previa: 0.3/1000 deliveries
Abruption severe enough to result in death of fetus: 2.4/1000 deliveries
Frequency of any cancer in association with pregnancy: 1/1000 live births
Frequency of cervical cancer diagnosed in pregnancy: 0.4-0.5/1000 pregnancies
Frequency
10-15% of clinically recognized pregnancies are lost
Of married women in the US, 4% experience two fetal losses and 3% experience three or more losses
20-25% of patients in the US have vaginal spotting/bleeding in first trimester. Spontaneous abortion occurs
in 50% of these
1-2% of all pregnancies in the US are ectopic; 108,000 cases of ectopic pregnancy reported in the US in
1992
Average reported frequency for placental abruption is about 1/120 deliveries (0.83%)
Average reported frequency for placenta previa is <1/200 deliveries (<0.5%)
Demographics
Age
Age is a significant risk factor for trophoblastic disease: women over 40 have a 5.2-fold increased risk
compared with mothers aged 21-35 years
Increased risk of placenta previa with advancing age
Race
Ectopic pregnancy is more frequent in women of African origin
Risk of placenta previa is higher in women of African or Asian background
Genetics
Spontaneous abortion is more common in pregnancies of abnormal karyotype, e.g. trisomies, triploidy,
monosomy, structural chromosomal abnormalities, translocations

3. Most complete molar pregnancies have 46XX karyotype of paternal derivation
Codes
ICD-9 code
180.0 Cervical dysplasia, cancer
184.0 Vaginal cancer
616.0 Cervicitis
616.10 Vulvovaginitis
622.7 Cervical polyps
630 Hydatidiform mole
631 Other abnormal product of conception
633 Ectopic pregnancy
634 Spontaneous abortion
640 Hemorrhage early in pregnancy
641 Antepartum hemorrhage, abruptio placentae, and placenta previa
Diagnosis
Clinical presentation
Symptoms
Amount of bleeding reported may be small or large
Blood may be brown or bright red
May be painless, or painful cramps and/or back pain may be reported
Reduced or lack of fetal movement, depending on degree of fetal compromise
Weakness, dizziness, fainting
Signs
Signs depend on cause of bleeding but may include varying degrees of the following:
Shock with tachycardia and hypotension, orthostatic hypotension
Pallor (if bleeding is severe)
Tender abdomen, especially with ectopic pregnancy
Tender uterus
Blood in vagina
Tender adnexa
Open internal os
Absent fetal heart tones
Associated disorders
Cocaine abuse is associated with preterm labor and placental abruption in particular.
Differential diagnosis
At any gestational age:
Vaginal lacerations caused by trauma
Cervicitis
Vulvovaginitis
Cervical polyps
Cervical neoplasia
At gestational age up to 20 weeks:
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

4. Low-lying placenta
At gestational age above 20 weeks:
Molar pregnancy
Placenta previa
Placental abruption, marginal separation of placenta
Vasa previa
Spontaneous abortion
Ectopic pregnancy
Trophoblastic disease
Placental abruption
Placenta previa
Lesions of the cervix and vagina
Vasa previa
Workup
Diagnostic decision
Diagnosis is based on history and examination and confirmed with appropriate special investigations
Stage of gestation needs to be taken into account when considering the etiology of bleeding in pregnancy
Aim to exclude disorders requiring urgent treatment first: ectopic pregnancy and trophoblastic disease in
early pregnancy; placenta previa and placental abruption in later pregnancy
First trimester bleeding:
Obtain serum hCG level: obtain pelvic ultrasound if hCG >2000 milli-international units/mL
Pelvic ultrasound: if positive for gestational sac there is no need for further work-up of ectopic; if negative
for gestational sac follow serial serum hCG levels
If initial serum hCG <2000 milli-international units/mL, follow serial quantitative hCG levels (every 48h) until
level >2000 milli-international units/mL and then proceed with pelvic ultrasound
Guidelines
Fleischer AC, Andreotti RF, Bohm-Velez M, et al, Expert Panel on Women's Imaging. First trimester
bleeding. American College of Radiology (ACR); 2005
Thurmond A, Fleischer AC, Andreotti RF, et al, Expert Panel on Women's Imaging. Second and third
trimester bleeding. American College of Radiology (ACR); 2005
Morin L, Van den Hof MC; Diagnostic Imaging Committee, Society of Obstetricians and Gynaecologists of
Canada. Ultrasound evaluation of first trimester pregnancy complications. J Obstet Gynaecol Can
2005;27:581-91
ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American
College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of
patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33
Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of
placenta previa. J Obstet Gynaecol Can 2007;29:261-73
SOGC clinical guidelines. Gynecological and Obstetric Management of Women with Inherited Bleeding
Disorders. J Obstet Gynaecol Can 2005;27:707-18
Royal College of Obstetricians and Gynaecologists (RCOG). The management of gestational trophoblastic
neoplasia. London (UK): Royal College of Obstetricians and Gyneacologists (RCOG); 2004 (Guideline; no.
38)
The American Academy of Family Physicians has produced the following guidance information:
Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician 2007;75:1199-206
Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician
2005;72:1243-50
Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915-26
Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-
14
Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604

5. Don't miss!
A high percentage of ectopic pregnancies are missed on initial consultation.
Questions to ask
Presenting condition
When was your last menstrual period? Helps date the pregnancy but often difficult to obtain accurate
information. Different etiologies of bleeding are more likely to occur at different gestations
Have you had a positive pregnancy test? Many patients will do a home pregnancy test. An ectopic
pregnancy may occasionally present before the first missed period. A negative test excludes, with
reasonable accuracy, a complication of pregnancy as the cause of bleeding provided it is not done too
early or on dilute urine
Have there been any complications in this pregnancy? Previous episodes of bleeding may have been
treated
What is the bleeding like, when did it start, what has been the duration, volume, color? Try to establish
nature of bleeding
Have you felt the baby moving? Fetal movements, which are usually felt from about 14-16 weeks, will
decrease or stop if fetus is compromised
Have you passed any tissue or clots? Tissue may have been passed with an incomplete spontaneous
abortion. Clots may be passed with heavier bleeding. Vesicles may be passed with hydatidiform mole but
this is usually a late sign
Is there any relation to intercourse? May indicate postcoital trauma to cervical or vaginal lesions as cause
of bleeding. May also provoke bleeding from placenta previa
Is there anything of significance in past obstetric history? Ask about number of pregnancies, operative
deliveries, prior pelvic surgery, pregnancies or deliveries complicated by placental abruption or placenta
previa, elective or spontaneous abortion, previous preterm labor, incompetent cervix, previous ectopic
pregnancy
Is there anything of significance in the past gynecologic history? Ask about diethylstilbestrol exposure,
genital trauma, abnormal Papanicolaou smears, contraceptive method, infertility treatment, gynecologic
surgery
Are there any associated symptoms? Bleeding from spontaneous abortion may be associated with crampy
pain. Products in the os may cause extreme pain; ectopic pregnancy leads to abdominal or pelvic pain in
the majority of cases; typically, bleeding from placenta previa is painless and that due to placental
abruption is painful. Weakness, dizziness, and syncope may be associated with hypovolemia and are
warning signs of a ruptured ectopic pregnancy; vaginal discharge may be associated with infection; urinary
symptoms may be present with infection, which may cause bleeding mistaken for vaginal bleeding
Contributory or predisposing factors
Are there any risk factors for pelvic inflammatory disease that may predispose to ectopic pregnancy? Prior
pelvic inflammatory disease, known current sexually transmitted disease, multiple partners, recent abortion
Are there any risk factors for ectopic pregnancy? Prior ectopic pregnancy, use of intrauterine device,
infertility, tubal surgery
Is there a previous history of trophoblastic disease? The risk of trophoblastic disease is increased in
patients with a previous history
Is there a history of bleeding tendency or easy bruising? May indicate blood dyscrasia
Is the patient taking any anticoagulants or platelet inhibitors? Possible if previous history of
thromboembolic disease or pregnancy-induced hypertension
Is there a known history of coagulation disorder? For example, von Willebrand's disease
Is there evidence of cocaine abuse? An important risk factor for placental abruption and preterm labor
Does the patient smoke? Placental abruption, ectopic pregnancy, and cervical neoplasia are more common
in smokers
Family history
Is there a history of diethylstilbestrol exposurein utero? Associated with vaginal malignancy and uterine
abnormalities
Is there a family history of coagulation disorders? May be a family history in some inherited

6. coagulopathies, with women displaying a tendency rather than frank disease (hemophilia A and B); von
Willebrand's disease should be considered
Examination
General examination: to assess for level of distress, color, hydration. Patient with larger volume blood loss
may be pale and dehydrated
Record vital signs: including pulse (tachycardia with hypovolemia), blood pressure (may be hypotensive or
have orthostatic hypotension with hypovolemia), respirations, temperature
Perform cardiopulmonary examination: to assess fitness for anesthesia. May be chest signs and effusion in
choriocarcinoma
Examine the skin: ecchymoses or petechiae may be present in women with blood dyscrasias
Examine the abdomen: to assess for distension due to gravid uterus, scars, trauma; palpate for
tenderness, guarding, signs of peritoneal irritation that may be present in ectopic pregnancy, masses,
organomegaly, inguinal lymph nodes
Auscultate: for fetal heart tones
Examine the pelvis: do not perform in suspected placenta previa unless prepared for emergency cesarean
delivery and full resuscitation, since examination may provoke torrential hemorrhage
Examine external genitals: to assess for vulvar lesions, cystocele, rectocele, urethral pathology
Perform speculum examination: to assess for vaginal wall lesions, cervical lesions, vaginal discharge,
blood in vaginal vault or internal os, prolapse, tears
Perform bimanual examination: to assess uterine size, adnexal masses, tenderness, cervical motion
tenderness, internal os
Summary of tests
Urine pregnancy test is a simple test to confirm the patient is pregnant
Quantitative beta-human chorionic gonadotropin (hCG): measurement of hCG in plasma permits accurate
quantification to determine whether pregnancy is normal or pathologic. Raised level can be detected before
the missed period, at about 6-7 days after ovulation, at the time of implantation
Hematology studies (complete blood count, blood group and screen, and Rhesus typing, including anti-D
immunity): can determine the amount of blood loss and if there is a need for blood transfusion
Coagulation studies (platelets, prothrombin time, thrombin time, partial thromboplastin time, disseminated
intravascular coagulation panel): can indicate a bleeding diathesis
Ultrasound: the most useful diagnostic test for vaginal bleeding in pregnancy
Progesterone level <5mg/dL suggests a nonviable pregnancy; >25mg/dL suggests a good prognosis. Not a
frequently used test, but it may be used by a specialist in cases of doubt
Infection screening: cervical cultures/wet mount may be required to diagnose cervicitis; vaginal swabs may
culture causative organism in vulvovaginitis but most cases are due to Candida albicans
Papanicolaou smear: should be done at initial antenatal visit if no recent result is available
Culdocentesis: may be useful if there is no easy access to other diagnostic facilities in cases where
hemoperitoneum is suspected secondary to ruptured ectopic pregnancy; performed by a specialist
Laparoscopy and/or laparotomy: may be performed by specialist to diagnose/treat ectopic pregnancy
Biopsy of vulvar or vaginal lesions: referral to a gynecologist is preferable, since such lesions may bleed
profusely during pregnancy
Fetal monitoring: may be performed by specialist for gestations >20 weeks to ascertain fetal well being and
uterine contractions
Order of tests
Urine pregnancy test
Quantitative beta-human chorionic gonadotropin (hCG)
Hematology studies
Coagulation studies
Ultrasound
Infection screening
Papanicolaou smear
Tests
Body fluids

7. Urine pregnancy test
Quantitative beta-human chorionic gonadotropin (hCG) level
Hematology studies
Coagulation studies
Infection screening
Imaging
Ultrasound
Special tests
Papanicolaou smear
Clinical pearls
Be aware of heterotropic pregnancy (combined intrauterine and ectopic). This is a rare event (incidence
1:30,000).
Consider consult
Refer for definitive diagnosis in ectopic pregnancy. May be difficult to make the diagnosis clinically and a
high index of suspicion is required to pursue a definitive diagnosis
Any woman with bleeding late in the second trimester should be evaluated immediately, preferably in
hospital
Treatment
Goals
Resuscitate as necessary. Stabilize hemodynamically, secure intravenous line, provides adequate blood
and fluid replacement
Exclude serious causes, and refer as appropriate
Ensure fetal health as well as maternal
Reassure as appropriate
Prevent Rhesus isoimmunization and hemolytic disease of newborn due to anti-D antibodies in a
subsequent pregnancy
Immediate action
Hemodynamic stabilization may be required immediately before patient is transferred to the hospital or
specialist center
Urgent transfer to the hospital for all suspected ectopic pregnancies
Therapeutic options
Summary of therapies
Choice of therapy depends on etiology of bleeding
In first trimester, many patients may be managed as outpatients if ectopic pregnancy is excluded. Any
woman with bleeding in late second trimester and beyond should be evaluated immediately, preferably in
hospital
Reassurance may be the only appropriate measure for those with implantation bleeds, threatened
spontaneous abortion, or minor bleeding of no apparent cause
General advice includes bed rest and no coitus. Does not influence outcome of spontaneous abortion, but
may be important for placenta previa
Hemodynamic stabilization is important. Secure intravenous line and adequate blood and fluid replacement
for patients with heavy bleeding
Expectant or conservative management may be appropriate for some cases of spontaneous abortion.
Complete spontaneous abortion is better managed expectantly since this has a lower complication rate
than surgical management. Medical evacuation may be of use in incomplete spontaneous abortion.
Emergency dilatation and curettage may be necessary for incomplete spontaneous abortion with heavy

8. bleeding
Rho(D) immune globulin is important for Rhesus-negative women to prevent hemolytic disease of the
newborn in subsequent pregnancies
Laparotomy or laparoscopy with salpingectomy or salpingostomy may be required for ectopic pregnancy
Cesarean section may be required urgently in later pregnancy where life of the mother or fetus is at risk
due to heavy bleeding from placenta previa or abruption. Placenta previa mortality has fallen from 25% to
<1% in the past 40 years, owing to expectant management and liberal use of cesarean section
Cesarean section is appropriate if pregnancy has reached 37 weeks or lung maturity is documented by
amniocentesis at the time of bleeding, in the presence of life-threatening maternal hemorrhage, or beyond
24 weeks for fetal distress, and for patient in labor beyond 34 weeks. Usually performed by a specialist
If bleeding is not life-threatening, patient may be managed expectantly with close monitoring in hospital or,
if stable, bed rest at home with easy readmission for further bleeding. Fetus at 32 weeks has 80% chance
of achieving 36 weeks in utero and the gains that that confers
Trophoblastic disease should be managed in a specialist center and involves suction curettage and
monitoring of human chorionic gonadotropin levels with hysterectomy or chemotherapy for more invasive
disease
Cervical and vaginal lesions, including benign cervical lesions, should be referred to a specialist for
removal
Guidelines
ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American
College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of
patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33
Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of
placenta previa. J Obstet Gynaecol Can 2007;29:261-73
SOGC clinical guidelines. Gynecological and Obstetric Management of Women with Inherited Bleeding
Disorders. J Obstet Gynaecol Can 2005;27:707-18
Royal College of Obstetricians and Gynaecologists (RCOG). The management of gestational trophoblastic
neoplasia. London (UK): Royal College of Obstetricians and Gyneacologists (RCOG); 2004 (Guideline; no.
38)
ACOG practice bulletin. Prevention of Rh D alloimmunization. Washington, D.C: American College of
Obstetricians and Gynecologists (ACOG), 1999 (ACOG practice bulletin; no. 4). Summary from the
National Guideline Clearinghouse
The American Academy of Family Physicians has produced the following guidance information:
Sakornbut E, Leeman L, Fontaine P. Late pregnancy bleeding. Am Fam Physician 2007;75:1199-206
Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician
2005;72:1243-50
Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915-26
Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-
14
Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604
Order of therapies
Rho(D) immune globulin
Efficacy of therapies
Administration of Rho(D) immune globulin reduces the risk of Rhesus alloimmunization to 0.2%
Ectopic pregnancy: rate of persistent ectopic pregnancy is about 8% following laparoscopic salpingectomy
Trophoblastic disease: suction curettage successfully treats 75-80% of cases of molar pregnancies; 20%
go on to require further treatment
Placenta previa: maternal mortality is <1% and perinatal mortality is <10% with the use of ultrasound
diagnostic techniques, expectant management, and liberal use of cesarean delivery
Placental abruption: perinatal mortality is about 0.9/1000 births overall with expectant management and
emergency cesarean delivery
Medications and other therapies
Medications

9. Rho(D) immune globulin
Summary of evidence
Evidence
Administration of Rho(D) immune globulin to Rhesus-negative women at 24 weeks' and 34 weeks'
gestation during the first pregnancy reduces the risk of Rhesus-D alloimunisation from 1.5% to 0.2%
[1]Level A
Clinical pearls
Most cases of placental separation are mild and self-resolve
Vaginal bleeding from abdominal wall trauma warrants in-hospital monitoring
Never
Never omit to perform a pregnancy test in a woman of childbearing age presenting with abdominal pain or
abnormal vaginal bleeding
Never perform a digital examination on a pregnant woman who presents with bleeding until ultrasound has
excluded placenta previa
Management in special circumstances
Ectopic pregnancy is potentially fatal without intervention
Placental abruption, placenta previa, and vasa previa are risks for rapid fetal death
Coexisting disease
Patients with blood dyscrasias will need referral to a hematologist and specialist treatment.
Patient satisfaction/lifestyle priorities
Some patients may prefer expectant or conservative management to surgical interventions where possible.
Patient and caregiver issues
Questions patients ask
Does bleeding mean that I will miscarry? 20-25% of pregnant women in the US experience bleeding; of
these, half go on to miscarry
Will I miscarry again? Risk of recurrence starts to rise after third spontaneous abortion
Have I done anything to cause this bleeding? Highly unlikely that any patient action will cause bleeding
Could I have done anything to prevent bleeding? Reassure patient that bleeding is beyond her control
Health-seeking behavior
Has the patient previously been to the emergency department? Up to 40% of cases of ectopic pregnancy
are misdiagnosed at initial consultation.
Follow
Depends on diagnosis
Patients with first-trimester bleeding are more likely to deliver preterm and should be followed closely
through the remainder of the pregnancy
Bereavement and genetic counseling is appropriate for all pregnancy losses
Trophoblastic disease requires long-term follow-up, monitoring hCG levels until normal for at least 6
months. Also requires assessment in subsequent pregnancies
Ectopic pregnancies that have been treated conservatively or by salpingostomy require follow-up with

10. human chorionic gonadotropin luevels until negative to exclude the possibility of persistent ectopic
pregnancy
Plan for review
Patients with early pregnancy bleeding that resolves should be given routine antenatal care
Patients undergoing dilatation and curettage should consult soon after for counseling as required and
contraceptive advice as appropriate
Laparotomy and laparoscopy require routine surgical follow-up
Information for patient or caregiver
spontaneous abortion: if managed medically, patient should be advised to report if heavy bleeding occurs
Ectopic pregnancy: if being managed conservatively, patients should report if symptoms suggesting
rupture occur, i.e. increased pain, dizziness, syncope
Placenta previa and placental abruption: confer increased risk in subsequent pregnancies
Ask for advice
Question 1
Do all suspected ectopic pregnancies need treatment?
Answer 1
Some will spontaneously abort, but ectopic pregnancy is life-threatening and all presumed cases should be
treated.
Question 2
Does a threatened abortion of a live fetus need Rho(D) immune globulin therapy?
Answer 2
These require no treatment.
Consider consult
Refer conditions requiring surgical treatment, e.g. ectopic pregnancy, incomplete spontaneous abortion
Trophoblastic disease should be managed in a specialist center
Bleeding complications of later pregnancy may need urgent cesarean section. Placental abruption places
mother and fetus in high-risk position that should be managed by an experienced obstetrician with neonatal
and maternal resuscitation facilities. Placenta previa may need urgent cesarean delivery
Seek perinatal consult for high-risk pregnancy
Outcomes
Prognosis
Depends on cause, severity, and rapidity of diagnosis
Patients with bleeding in first and early second trimester are more likely to deliver preterm
Ectopic pregnancy may persist in current pregnancy, necessitating further intervention, or recur in
subsequent pregnancy
Preterm labor may occur in subsequent pregnancy
Spontaneous abortion: 20% risk of spontaneous abortion in subsequent pregnancy
Placenta previa maternal mortality <1% and perinatal mortality <10%
Progression of disease
Recurrence
Trophoblastic disease may rarely recur. There is a 1 in 74 risk of further molar pregnancy in subsequent
gestations. 20% of molar pregnancies require further treatment after suction curettage; 3-5% progress to
choriocarcinoma. Pregnancy must be avoided until at least 6 months of normal human chorionic
gonadotropin levels are recorded after molar pregnancy

11. Abruption may recur in 5-17% and in up to 25% with two prior episodes. The influence that risk factors
such as hypertension have on this is not clear
Clinical complications
Vaginal bleeding in pregnancy may lead to:
Shock from large volume blood loss
Disseminated intravascular coagulation, especially in placental abruption
Anemia
Anti-D antibodies may result from fetal-maternal hemorrhages in RhD-negative women who are carrying a
RhD-positive fetus
Fetal/maternal death
Infection
Preterm labor and delivery of baby with associated complications
Consider consult
Women in shock from large volume blood loss should be transferred to the hospital as soon as possible
Prevention
Primary prevention
Modifiable risk factors
Tobacco
Stop smoking, preferably before conception.
Alcohol and drugs
Stop drugs of abuse, particularly cocaine.
Sexual behavior
Use barrier methods of contraception, particularly at a young age, to prevent spread of sexually transmitted
disease and reduce risk of cervical cancer.
Secondary prevention
It is not known how modification of risk factors affects recurrence of conditions causing bleeding in
pregnancy (e.g. control of hypertension and risk of recurrent placental abruption).
Screening
Screening for Chlamydia may be useful for selected patients to prevent pelvic inflammatory disease:
Sexually active women under 25
Women with a new sexual partner
Women with multiple partners in the previous 12 months
Women using nonbarrier methods of contraception
Women with symptoms of cervical friability, mucopurulent discharge, or intermenstrual bleeding
Screening for cervical cancer is cost-effective.
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Spontaneous abortion is fetal loss before 20 weeks' gestation or delivery of a fetus weighing under 500g.
Fetal loss before 12th week is termed 'early' and between 12 and 20 weeks' gestation is termed 'late.'

12. Features
Vaginal bleeding for >3 days carries 15-20% chance of spontaneous abortion
Profuse bleeding with pain has a higher association with spontaneous abortion than painless bleeding
Uterine size may be smaller than dates in cases of missed abortion
Cervix may be dilated with fetal tissue passed through the os
Inevitable if internal os open, threatened if os is closed
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Ectopic pregnancy is defined as pregnancy occurring outside the endometrial lining of the uterus; 96% are
tubal but ectopic pregnancy may also be ovarian, cervical, or abdominal.
Features
Risk factors include pelvic inflammatory disease, previous ectopic pregnancy, previous tubal surgery,
intrauterine device use, and assisted reproduction
Abnormal vaginal bleeding or amenorrhea occurs in 75% of patients
Abdominal pain and tenderness
Adnexal tenderness
Peritoneal signs (acute abdomen)
Shoulder pain (referred)
Shock
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Trophoblastic disease includes hydatidiform mole, invasive mole, choriocarcinoma, and placental site
trophoblastic tumor. Hydatidiform mole runs benign course in 75-80% of cases; only 3% result in
choriocarcinoma. Choriocarcinoma, which is highly malignant and frequently metastatic, may occur after
any pregnancy but is most common after hydatidiform mole.
Features
Gestational trophoblastic disease usually presents with vaginal bleeding and cramps in the first trimester or
early in the second trimester
Passage of classic vesicular tissue may occur but is usually a late sign
Uterus is large for dates in about 50% of cases
No signs of normal intrauterine pregnancy, no fetal heart tones
Vaginal bleeding is most common presentation in choriocarcinoma
Uterine perforation and hemorrhage may occur in choriocarcinoma; fatal intra-abdominal bleeding may
occur
Metastases appear early in choriocarcinoma. Dark hemorrhagic nodules may appear on vagina and vulva;
also occur in lung, brain, liver, kidney, bone, and many unusual sites
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Placental abruption is separation of the placenta from the uterine wall before delivery of the fetus, initiated
by bleeding into the decidua basalis from small arterial vessels that are pathologically altered and prone to
rupture. A hematoma forms, causing separation and ultimately destruction of placenta in the affected area.
Process may be self-limiting and of no further consequence to the pregnancy, or there may be continued
dissection and separation of placenta by blood under pressure continuing into the myometrium and
peritoneal surface.
Features
80% of cases occur before onset of labor
Classic symptoms are vaginal bleeding, abdominal pain, uterine contractions, and uterine tenderness
Bleeding may be revealed or concealed: 10% of women have concealed bleeding
80% of cases have external bleeding. Actual blood loss is often much greater than perceived as only a

13. small portion of that lost from the circulation makes its way through the cervix
Grade 1: mild vaginal bleeding, uterine irritability, stable vital signs, normal fetal heart rate, normal
coagulation profile
Grade II: moderate vaginal bleeding, hypertonic uterine contraction, orthostatic hypotension, fetal
compromise, abnormal coagulation status
Grade III: severe bleeding (may be concealed), hypertonic uterine contractions, hypovolemic shock, fetal
death, thrombocytopenia, fibrinogen <150mg
Risk factors include hypertension (found in 40-50% of cases), trauma, polyhydramnios, multiple pregnancy,
high parity, smoking, cocaine use, chorioamnionitis, and preterm premature rupture of membranes
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The placenta encroaches on or overlies the internal os during the third trimester. A low-lying placenta is a
possible placenta previa before the third trimester; it is more common in early pregnancy and often
resolves without becoming symptomatic.
Features
Sudden onset of painless bleeding in second or third trimester
Absence of pain distinguishes placenta previa from placental abruption, although painful labor may initiate
bleeding from placenta previa
Peak incidence in early third trimester
May be no obvious precipitating cause, e.g. pelvic examination, intercourse, or onset of labor
Digital examination should not be performed unless a cesarean delivery can be performed if required
Risk factors include advancing age, multiparity, African or Asian race, smoking, cocaine use, previous
placenta previa, one or more previous cesarean births, prior suction curettage for spontaneous or induced
abortion, and placenta accreta
Patients with a history of cesarean section and placenta previa have an incidence of placenta accreta of
16-25% and most will require cesarean hysterectomy
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The placenta encroaches on or overlies the internal os during the third trimester. A low-lying placenta is a
possible placenta previa before the third trimester; it is more common in early pregnancy and often
resolves without becoming symptomatic.
Features
Sudden onset of painless bleeding in second or third trimester
Absence of pain distinguishes placenta previa from placental abruption, although painful labor may initiate
bleeding from placenta previa
Peak incidence in early third trimester
May be no obvious precipitating cause, e.g. pelvic examination, intercourse, or onset of labor
Digital examination should not be performed unless a cesarean delivery can be performed if required
Risk factors include advancing age, multiparity, African or Asian race, smoking, cocaine use, previous
placenta previa, one or more previous cesarean births, prior suction curettage for spontaneous or induced
abortion, and placenta accreta
Patients with a history of cesarean section and placenta previa have an incidence of placenta accreta of
16-25% and most will require cesarean hysterectomy
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Lesions of the cervix and vagina include cervical cancer (the most commonly diagnosed malignancy in
pregnancy), benign cervical lesions, cervical polyps, cervicitis (chlamydial or gonococcal), vulvovaginitis
due to candidal infection, vaginal lacerations, and vulvovaginal metastases of choriocarcinoma.
Features
Cervical cancer is an uncommon cause of bleeding in pregnancy; friable exophytic lesion of the cervix is
seen on speculum examination
Polyps and lacerations may also be seen on speculum examination

14. Candidiasis affects 15% of pregnant women and causes itching, burning, dyspareunia, excoriations that
may bleed or become secondarily infected, and a thick, white, curd-like discharge
Cervicitis may cause mucopurulent discharge and bleeding postcoitally or intermenstrually
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Vasa previa is velamentous insertion of the cord in the lower uterine segment, leaving vessels unsupported
and prone to tearing. A high index of suspicion is essential for its diagnosis, and immediate delivery is
required.
Features
Rupture of fetal vessel leading to severe fetal compromise
Fetal mortality is 50-90%
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