#93253: Bleeding During Pregnancy

The etiologies of miscarriage are only partially understood, and consecutive miscarriages in the same patient are not always due to the same cause [8]. Additionally, the etiology of miscarriage will vary greatly according to gestational age. Preimplantation losses, prefetal losses, and losses with only rudimentary fetal remains generally are due to intrinsic fetal problems (e.g., chromosome abnormality); later losses generally are due to either extrinsic or maternal factors [7,9].

One common cause of spontaneous abortion is a blighted ovum. The blighted ovum involves the fertilization of an egg that results in presence of a gestational sac and placenta but the absence of a fetus. Blighted ovum may be the result of a chromosomal abnormality and will always result in a miscarriage [10]. It has been estimated that at least 50% of clinically recognized SABs are the result of chromosomal anomalies, although some researchers have indicated that the frequency may be as high as 75% to 90% [7,11]. The most common genetic defect is trisomy (i.e., the possession of three copies of a particular chromosome instead of two), followed by X monosomy (i.e., possessing only one copy of a particular chromosome), and polyploidy (i.e., possessing several complete sets of the same chromosomes) [7,11]. Because these abnormalities are random genetic mutations, the statistics still fail to explain a large number of SABs.

The two strongest indicators of threatened spontaneous abortion are extremes of maternal age (younger than 20 years of age or older than 35 years of age) and the presence of vaginal bleeding. Patients 25 to 30 years of age generally have the lowest risk of spontaneous abortion. Those who experience moderate-to-severe bleeding in the first trimester, particularly when accompanied by pain, have been found to be significantly more likely to miscarry than those with less bleeding [12]. Complaints of pain, human chorionic gonadotropin (hCG) levels greater than 500 mIU/mL, and concurrent cervical infection all have been negatively associated with miscarriage [13].

Environmental, autoimmune, mechanical, hormonal influences, plus paternal genetic factors are thought to be responsible for the remaining SABs. Factors not found to be statistically associated with miscarriage include gravidity, parity, prior ectopic pregnancy, one prior miscarriage, prior pelvic surgery, prior cesarean section delivery, prior pelvic inflammatory disease (PID), prior chlamydial or gonorrheal infection, or prior intrauterine device (IUD) use [13].

Spontaneous abortions have been categorized into several different types. This includes threatened abortion, complete abortion, incomplete abortion, missed abortion, and septic abortion (Table 2). Each of these types has a unique etiology and recommended treatment plan.

The diagnosis of spontaneous abortion pieces together several diagnostic components. A combination of ultrasound examination and serum hCG levels should be used in tandem with history and physical examination (Figure 1 and Figure 2).

FLOW CHART OF THE ASSESSMENT AND EVALUATION OF VAGINAL BLEEDING BEFORE 20 WEEKS' GESTATION

Figure 1

Source: Compiled by Author

FLOW CHART OF THE ASSESSMENT AND EVALUATION OF VAGINAL BLEEDING AFTER 20 WEEKS' GESTATION

Figure 2

Source: Compiled by Author

Ultrasound

The American College of Emergency Physicians recommends performing or obtaining a pelvic ultrasound for symptomatic pregnant patients who present to the emergency department with a ß-hCG level below any discriminatory threshold.

(https://www.acep.org/globalassets/new-pdfs/clinical-policies/cp-earlypregnancy-doc.pdf Last Accessed: March 18, 2022)

Level of Evidence: B (Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty)

Ultrasound may be another useful diagnostic tool in the evaluation of first trimester bleeding and threatened abortion. Improved ultrasound technology has enabled early diagnosis of abnormal and ectopic pregnancies, thus decreasing maternal morbidity and mortality [66]. An abnormally shaped gestational sac or slow embryonic heart rate may suggest impending loss [6]. However, the presence of a viable fetus in a patient with bleeding does not always negate the need for quantitative beta hCG testing. Transvaginal ultrasound will usually identify a fetus at quantitative beta hCG levels of 1,500–2,000 mIU/mL [40,67]. Transvaginal ultrasound examination can identify a gestational sac by about four to five weeks' gestation and fetal cardiac activity by five to seven weeks [78,79]. However, multiple gestations with separate placentas and pregnancies with large placentas may demonstrate hCG levels in the 1,500–2,000 mIU/mL range several days before intrauterine pregnancy can be confirmed sonographically [40]. The presence of fetal heartbeat on ultrasound has been shown to be highly predictive of viability of the pregnancy, even in the presence of vaginal bleeding [1,80]. Ultrasound before five weeks' gestation probably is not useful in identifying the uterine or ectopic location of a pregnancy. Prior to seven weeks' gestation, fetal death cannot be confidently ruled out with ultrasound [81].

Some providers order first trimester ultrasound exams to determine whether bleeding has occurred around or behind the placenta or amniotic membranes. Subchorionic hematomas are sometimes found on ultrasound. These hematomas are a collection of fluid believed to be caused by a partial separation of the trophoblast from the uterine wall. The incidence of subchorionic hemorrhage is approximately 1.3% of all pregnancies. Incidences as high as 20% to 25% have been identified in those with vaginal bleeding [83,179]. The clinical significance of subchorionic hemorrhages is unknown. Maternal age, gestational age at the time of diagnosis, and the volume of the hematoma may all contribute to the clinical outcome. Research has suggested that the diagnosis of a subchorionic hematoma at a gestational age less than nine weeks is significantly associated with spontaneous abortion [82].

If the patient is hemodynamically stable, expectant management is the first line of therapy in threatened abortion [1,67]. When a patient initially presents to the office with first trimester bleeding, a quantitative beta hCG should be drawn. The second hCG should be scheduled for approximately 48 hours later. If the patient is seen in the emergency or urgent care department, a second hCG should be scheduled in 48 hours, either with a primary provider, an obstetrician/gynecologist, a nurse practitioner or midwife, or at the initial site. Every effort should be made not to lose the patient to follow-up. It is important to explain to the patient the importance of a second blood test. It can be frustrating to families to learn that the result of the first blood sample is not sufficient to determine whether or not the pregnancy can be expected to continue normally.

Guidelines have been established for ultrasound detection of early pregnancy based on anticipated rise in hCG levels and sensitivity of ultrasonography. Patients with appropriately rising quantitative beta hCG levels should be examined with ultrasound as soon as the levels reach 2,000 mIU/mL [67]. However, the discriminatory hCG level varies with the type of ultrasound machine used; most radiology departments develop their own criteria regarding the level of hCG at which an early pregnancy should be visible. Providers should be familiar with their facilities' capabilities. Ectopic pregnancy can usually be ruled out by normally rising hCG levels and identification of an intrauterine pregnancy. Early pregnancy loss can be diagnosed in patients with ultrasound findings of a mean gestational sac diameter >25 mm with no embryo and no fetal cardiac activity when the crown-rump length is at least 7 mm [184].

Patients should be advised that bed rest will not prevent miscarriage [84]. Normal, reasonable daily activities may be continued. Pelvic rest is indicated until the follow-up appointment has been attended; orgasm and sexual activity should be avoided [85]. Nothing should be inserted into the vagina until bleeding has stopped. Aspirin and NSAIDs may increase bleeding and should not be taken. Acetaminophen is generally considered safe during pregnancy when used at therapeutic doses for short periods of time [39].

One of the most frequently heard complaints is the lack of follow-up and consistency in managing SAB or threatened abortion. When possible, patients should interact with the same provider for follow-up and phone calls. Telephone calls to the patient to offer support and determine if new symptoms have arisen are often appreciated. Such efforts communicate to the patient that the provider understands that the experience is a difficult and, at times, traumatic event.

Whenever managing the care of a patient with a threatened abortion, the availability of someone to promptly evacuate the uterus if hemorrhage occurs is vital. While expectant management may be appropriate, anticipating complications is crucial. Nurse-midwives, nurse practitioners, physician assistants, and family physicians should have ready access to a surgeon who can manage any complications resulting from spontaneous abortion.

Patients and their families should be educated about what to expect following a complete abortion. Bleeding should be monitored closely. Most will continue to have bleeding similar to a light period for about one week after a spontaneous abortion. Spotting may continue longer, but should be reported if it persists more than 10 days. Any foul-smelling discharge, fever, chills, increasing pain, or bright red bleeding that saturates one pad an hour should be reported immediately [85]. Providers should also be notified of any flu-like symptoms.

Pain control can usually be achieved with NSAIDs. Prescription narcotics are not usually needed, but this must be individualized. Application of ice and/or heat to the lower back may alleviate some pain.

Acknowledgment of a patient's grief and a discussion of the common feelings of guilt, anger, and helplessness are appropriate. Planned and unplanned pregnancies bring complex emotional responses. The loss of the pregnancy can be extremely stressful for patients and their support system [6]. Pregnancy loss can result in both acute stress disorder and post-traumatic stress disorder (PTSD) [89]. Most patients will adequately deal with their grief with the support of family, friends, and healthcare providers. However, the magnitude of the loss should not be underestimated. For some, the emotional trauma comes from realizing that the miscarriage is irreversible and is perceived as an unbearable, life-altering event. Some may mourn for much longer than expected, even after the birth of a healthy child [90]. Involved partners also struggle with the loss. Couples may grieve differently and move through the stages of grief at different paces. One should remember to ask the partner if they have any questions or if anything can be done for them [90]. Grief support groups for miscarriage are available, and many Internet sites can offer support and information (Appendix). Patients and their families should be reminded to call if any signs of depression occur, including appetite changes, daily crying for more than one week, sleep pattern changes, hopelessness, and suicidal thoughts or ideation.

Patients are advised that they may resume their normal activities after a day or two of rest. If bleeding becomes heavier after activity, too much activity has probably been resumed too soon. If bleeding becomes heavy enough to saturate one pad an hour, they should be seen immediately. Encourage the patient to consume a healthy diet and an adequate fluid intake. If a patient has been taking prenatal vitamins or a multivitamin, those should be continued.

Vaginal abstinence is stressed until the two-week follow-up appointment has been completed. At two weeks, a pelvic exam should be done to evaluate uterine size and tenderness. Testing for STIs may be completed as appropriate. A urine pregnancy test may be adequate to confirm resolution of the hCG levels, if known.

At the follow-up visit, the patient and partner will often want to discuss planning a future pregnancy. There are two factors that should be taken into consideration during this discussion. The first is physical healing. There is no physiologic evidence for delaying pregnancy attempts following non-molar, non-ectopic pregnancy loss before 20 weeks' gestation. A 2016 study concluded that those who waited three months or less achieved higher live birth rates than those who waited more than three months before trying to conceive [91].

Nevertheless, individuals need time to heal from a loss. Loss of a pregnancy, desired or unwanted, is difficult. Patients and their partners should be advised to delay another pregnancy until they are emotionally able to face the risk of another pregnancy loss. While another loss may be unlikely, it is possible.

If another pregnancy is not desired, birth control options should be discussed and prescribed. Fertility can return as early as 10 days after an abortion. Patients may start an appropriate contraceptive method (e.g., pills, patch, ring, shot, IUD, hormone implant) immediately after a completed spontaneous abortion if desired [92].

Expectant, medical, or surgical management may be appropriate. Immediate surgical treatment or hemotransfusion may be indicated for some patients, such as those who are hemodynamically unstable as a result of heavy bleeding, or those in whom a septic abortion is suspected [68]. In other cases, expectant management (i.e., watchful waiting while conducting necessary examinations and tests) may be chosen [10].

Expectant management is recommended as first-line treatment for patients with incomplete abortion; 82% to 96% of these patients will complete the process spontaneously within two to four weeks [1,184]. The probabilities for successful treatment have been demonstrated to be comparable, but not superior to, medical and surgical intervention. Given the lack of clear superiority among the options, the patient's preference should play a dominant role in the decision making [80,94,95,96,97]. Researchers have found that those undergoing management of first trimester miscarriage would value being offered alternatives (i.e., medical management or surgical management) to expectant management [95,97,98,99,100]. Physician recommendations have been reported to play an important role in patient decision making [98,100].

A D&C or suction curettage may be necessary to complete the abortion in early gestations. Consultation with an obstetrician/gynecologist or a provider qualified to perform the procedure is indicated. When the miscarriage is inevitable, surgical treatment may be necessary to stop the bleeding [10]. In more advanced gestations, high-dose oxytocin may be used to cause the uterus to contract and expel its contents [101]. Once again, the presence of a provider able to perform a D&C and/or manage the complications that may be encountered is critical to patient safety. Pain medication should be used appropriately.

Incomplete abortion has continued to disproportionately contribute to maternal morbidity and mortality in much of the developing world. Although surgical management has been the standard of care worldwide for years, medical management using misoprostol has been gaining attention as a safe, effective, and low-cost alternative treatment [57,97,102]. Misoprostol use avoids surgery and its associated complications and, when compared to expectant management, has demonstrated higher success and acceptability rates in some studies, whereas other studies indicate that expectant management is equally safe and prevents surgery for most [102,103,104,105,106]. Many regimens for using single-dose misoprostol have been studied. One common regimen is 800 mcg vaginally, with a repeat dose 24 to 48 hours later if the first is unsuccessful [184]. A more effective regimen for medical management has been reported, using pretreatment with 200 mg of oral mifepristone (Mifeprex), followed in 24 hours by 800 mcg of vaginally administered misoprostol. In a randomized trial (300 patients), pretreatment with mifepristone followed by treatment with misoprostol resulted in a higher likelihood of successful management (87%) than treatment with misoprostol alone (67%) [185]. Among patients undergoing medical management of incomplete abortion, cramping pain and vaginal bleeding is to be expected for several days, which may persist for two weeks or longer [104].

According to the American College of Obstetricians and Gynecologists (ACOG), Combined mifepristone-misoprostol regimens are recommended as the preferred therapy for medication abortion up to 70 days gestation because they are significantly more effective than misoprostol-only regimens. If a combined mifepristone-misoprostol regimen is not available, a misoprostol-only regimen is the recommended alternative.

(https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation Last Accessed: March 18, 2022)

Strength of Recommendation: A (Recommendation is based on good and consistent scientific evidence.)

Misoprostol has not been approved by the U.S. Food and Drug Administration (FDA) for induction of labor, and it carries a boxed warning for pregnant patients who may receive the drug [39,108]. The FDA-approved use of misoprostol (in conjunction with mifepristone) is for the medical termination of pregnancy of ≤63 days [39].

If a patient undergoing medical abortion has symptoms of nausea, vomiting, diarrhea, or weakness, without fever or other signs of infection, sepsis should be considered. Treatment with antibiotics, with coverage that includes anaerobic bacteria, has been recommended in these cases [39]. Follow-up care of a patient experiencing an incomplete abortion is similar to that for a patient experiencing a complete abortion. Quantitative beta hCG levels are used in this case to confirm that the uterus has been emptied completely; this test should be done weekly until negative. Ultrasound exams are not usually indicated for follow-up in the absence of complications but may be used as an additional diagnostic tool if incomplete abortion status cannot be confirmed with history and exam [57]. However, ultrasound studies prior to suction curettage may be indicated. On rare occasions, one fetus of a multiple gestation is aborted and a normal retained fetus can be delivered at term [6].

Bleeding should be monitored closely. Most patients will continue to have bleeding similar to a light period for about one week after surgical treatment. Spotting may continue longer, but should be reported if it lasts more than 10 days. Patients are advised that they may resume their normal activities within a day or two. Any abnormal symptoms, including persistent heavy bleeding, fever, chills, or vaginal discharge, should be reported immediately. Furthermore, patients should be encouraged to maintain a healthy diet, adequate fluid intake, and consumption of prenatal or multivitamins.

The experience of incomplete abortion interferes with a patient's daily activities and may cause significant emotional and physical pain. Reminders of healthy self-caring activities can help patients and their significant others become grounded again in daily life. Information about what to expect in the coming weeks may help individuals regain a sense of control in their lives.

The physical discomfort accompanying miscarriage quickly resolves [10]. Most report their cramping is gone within days and managed effectively by over-the-counter NSAIDs. If patients have medical contraindications to or intolerance of NSAIDs, stronger prescription pain relief may be indicated.

The patient's partner, when involved, should also be encouraged to return to normal daily activities as soon as possible. Grief and frustration should be acknowledged [10]. Because everyone grieves differently, some patients report feeling like their partners did not understand how hard this loss was for them [109]. Giving permission for a discussion of their feelings of helplessness, anger, failure, and guilt is important. Some partners are simply grateful that their loved one is safe. Patients without an involved partner may experience special challenges locating a source of support. A listing of community and Internet sources of support can be found at the end of this course (Appendix).

Sexual activity should be discouraged until the two-week follow-up appointment has been attended. A pelvic exam is usually done at that time to determine if the uterine size has returned to normal and if any pelvic tenderness exists. Testing for STIs and a Pap test can be performed at this appointment, if indicated. Fertility can return quickly after miscarriage, and birth control should be provided if desired. If another pregnancy is desired, a discussion of both physical and emotional healing is important.

Treatment of missed abortion is generally either uterine evacuation or, at less than 10 weeks, waiting for spontaneous passage of the products of conception. Evacuation usually involves suction curettage (at ≤12 weeks); dilation and evacuation (at 12 to 23 weeks); or medical induction (for those without prior uterine surgery) at 16 weeks to 23 weeks (for the treatment of late fetal death). Late evacuation increases the potential for placental bleeding, uterine perforation, and difficulties dilating the cervix. Preoperative use of cervical dilators (e.g., laminaria), misoprostol, or mifepristone may reduce the incidence of these complications [6]. Surgical evacuation of the uterus for missed abortion is common. Follow-up care of a patient experiencing a surgically complete abortion is similar to that for a patient experiencing a complete abortion. Quantitative beta hCG levels are used in this case to confirm that the uterus has been emptied completely. They should be done weekly until negative [6].

Although evacuation of the uterus using misoprostol has been determined to be an acceptable treatment for missed abortion, there have been reported cases of adverse events and death from the medication [39]. More than 85% of patients reportedly respond to the first dose of misoprostol, and reported success rates following administration of misoprostol have been high [6,110]. Candidates for misoprostol treatment of missed abortions should not have an IUD in place; be free of signs or symptoms of endometritis or sepsis; and have ectopic pregnancy ruled out [57]. Patients must also have immediate access to emergency care, transportation, and communication. Side effects vary but include nausea, vomiting, diarrhea, chills, and pain [39].

The delayed identification of a pregnancy loss that inevitably accompanies missed abortion can compound patient and family grief. Many have already shared the news of their pregnancy with family, friends, and coworkers and now find themselves needing to tell these same people of the loss. Some express regret at having shared their pregnancy too soon. It may be helpful to remind couples that their friends and family would feel saddened knowing that such a loss had occurred and that they were unable to offer their support and help. Care providers should offer open support and information and direct the family to appropriate resources [74,109].

The initial evaluation for septic abortion should include a physical and pelvic exam. A urine test to confirm the existence of a pregnancy is important to rule out other sources of infection, such as pelvic inflammatory disease or toxic shock syndrome. Smears from the cervix should be taken to identify microbes [6]. CBC, electrolyte, blood urea nitrogen (BUN), and creatinine studies are appropriate. Blood type, Rh type, and antibody screen are indicated. Anaerobic and aerobic blood cultures and any available products of conception should be obtained for evaluation [6].

Prompt referral to a provider able to admit the patient, empty the uterus of any remaining products of conception, and initiate treatment with IV antibiotics is critical. A large-bore angiocatheter should be started, and tetanus toxoid should be administered. Abdominal x-rays help detect free air or foreign bodies [6].

Prompt evacuation of the uterus is critical and should be performed within a few hours after initiation of parenteral antibiotics. A regimen of high-dose, broad-spectrum antibiotics is recommended, directed against common gram-positive pathogens, enteric gram-negative bacilli, and anaerobes such as Bacteroides fragilis[6].

Any event that impairs ability of the tube to transport gametes or embryos will predispose an individual to ectopic pregnancy [111,113]. The most common site of ectopic pregnancy is the fallopian tube, accounting for more than 98% of all ectopic gestations [113]. While most who present with ectopic pregnancy have no identifiable risk factors, several factors have been associated with ectopic pregnancy, including a history of PID, history of ectopic pregnancy, history of prior tubal surgery, use of ART, use of IUD for contraception, advanced maternal age, and altered tubal motility [40,111,112,113,114,115]. Because IUDs are effective contraception, the incidence of ectopic pregnancy in those using IUDs is low. However, if a person conceives while using a hormone-releasing IUD, there is an up to 50% chance the pregnancy will be ectopic [116,117]. The risk of ectopic pregnancy in clinical trials of women with IUDs and no other risk factors was about 1 in 1,000 users per year [116,117].

Technologic improvements have made possible the early diagnosis of ectopic pregnancy [114]. Its hallmark has historically been abdominal pain with spotting, usually occurring six to eight weeks after the last normal menstrual period; however, up to 30% of patients with ectopic pregnancies present with no vaginal bleeding [111,114,123]. The pain is generally described as sharp and stabbing. It may be intermittent, vary in intensity, and localize to one side of the pelvis. Other symptoms depend on the location of the ectopic pregnancy and may include chest or shoulder pain, nausea, pain with intercourse, vertigo, syncope, and orthostatic blood pressure changes [111,114]. Amenorrhea may not be present; some simply report a delay in menses or spotting. Approximately 20% of patients with ectopic pregnancy are hemodynamically unstable at presentation [113,114]. Ectopic pregnancy may present with symptoms similar to other conditions, and the differential diagnoses may include appendicitis, salpingitis, spontaneous abortion, ovarian cyst, ovarian torsion, urinary tract infections, degenerating uterine fibroids, and normal pregnancy (Table 4).

Approximately 40% to 50% of ectopic pregnancies are misdiagnosed at initial presentation to an emergency department, primarily due to failure to identify risk factors. Proper history, physical examination, and identification of risk factors are critical to an accurate, timely diagnosis [111,123].

The treatment options for ectopic pregnancy include surgery, medical treatment with a variety of drugs, and expectant management [128].

Surgical Treatment

In comparing systemic methotrexate with tube-sparing laparoscopic surgery for the management of ectopic pregnancy, the ACOG reports that randomized trials have shown no difference in overall tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies.

(https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy Last Accessed: March 18, 2022)

Strength of Recommendation: A (Recommendation is based on good and consistent scientific evidence.)

Historically, laparotomy and salpingectomy have both been used to treat ectopic pregnancy. However, laparoscopic surgery has now become the standard approach in most cases [114,128]. Laparotomy is reserved for patients who are hemodynamically unstable [114].

The mode of surgical treatment of ectopic pregnancy may vary depending on the location of the pregnancy [40]. Most laparoscopic surgical approaches include a linear salpingostomy and the removal of the products of conception in an unruptured pregnancy. Every effort is made to minimize damage to the fallopian tube and preserve the patient's reproductive future. Removal of the affected tube may be necessary and, although extreme, can be an effective treatment. It is the procedure of choice in patients who have completed childbearing and no longer desire fertility, who have a history of ectopic pregnancy in the same tube, or who have severely damaged tubes [114,126].

Treatment failures do occur with laparoscopic procedures [128]. After tubal-sparing surgery, hCG levels should be monitored. A fall in hCG levels of at least 20% every 72 hours is indicative of success [114]. Following surgical treatment of ectopic pregnancy, the elimination of hCG appears to follow a two-phase distribution. The major elimination phase has a half-life of 5 to 9 hours, and the second elimination phase has a 22- to 32-hour half-life [129]. Treatment with methotrexate may be necessary if falling hCG levels do not indicate successful surgical treatment [114,126].

Signs and symptoms that may indicate a diagnosis of GTD include vaginal bleeding, unusual uterine growth rate, absence of usual fetal indications, hyperemesis, hyperthyroidism, pre-eclampsia, anemia, and enlarged ovaries [138].

The European Society for Medical Oncology states that, for nearly all low-risk patients with gestational trophoblastic neoplasia, single-agent chemotherapy with either methotrexate or actinomycin D is the preferred treatment.

(https://www.esmo.org/Guidelines/Gynaecological-Cancers/Gestational-Trophoblastic-Disease Last Accessed: March 18, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Treatment of GTD depends on many factors, including the location and extent of the disease, the type of GTD present, the level of hCG, the duration of the disease, sites of metastasis if any, and the extent of prior treatment [138]. Referral to a specialist able to adequately manage and follow-up GTD should be immediate. Suction curettage is the method of choice of evacuation for complete molar pregnancies. Medical termination of complete molar pregnancies, including cervical preparation prior to suction evacuation, should be avoided where possible [140]. Suction curettage often is the choice for patients who may want to have children in the future [138]. Data from the management of molar pregnancies with mifepristone are limited. Evacuation of complete molar pregnancies with this agent should be avoided because it increases the sensitivity of the uterus to prostaglandins [140].

Tissue should be sent to the pathology lab for final diagnosis and confirmation of GTD. Because of the difficulty in making a diagnosis of a molar pregnancy before evacuation, the laboratory assessment is recommended in order to exclude trophoblastic neoplasia [140]. If an older patient requests sterilization, hysterectomy may be considered [137,138]. Following evacuation of the uterus, hCG levels are recorded at 48 hours and on days 7, 14, and 21 [135]. When hCG levels are no longer elevated, values are obtained at monthly intervals for at least six months. Treatment with methotrexate is not indicated unless the hCG levels continue to rise or remain elevated.

A chest x-ray may be performed as a post-treatment baseline to determine if GTD has spread to the lungs [141]. In some cases, other imaging studies may follow. If GTD is suspected before D&C, a chest x-ray should be performed prior to uterine evacuation [141]. Pelvic ultrasound is performed to identify the presence of theca-lutein cysts [137]. A complete blood count with platelet count and clotting factors, renal and liver function tests, blood type and antibody screen, and hCG level are obtained prior to uterine evacuation in suspected GTD.

Patients are strongly encouraged not to conceive for at least one year after treatment [141]. A pregnancy sooner than one year after treatment will mask any rises in hCG caused by persistent GTD and may delay treatment. An effective contraceptive method should be provided [135].

Blood type, Rh type, and antibody screen are typically ordered. Threatened abortions, ectopic pregnancies, and hydatidiform moles all have risks of fetomaternal hemorrhage and, therefore, can cause RhD alloimmunization [76]. Because the differentiation of partial and complete molar pregnancy may be delayed, it seems reasonable to offer RhoGAM to those with suspected molar pregnancy [76].

Patients and their families will require education, including that a partial molar pregnancy means that normal fetal development and viability are not possible when two sperm fertilize one egg, resulting in severe chromosomal abnormalities. Nevertheless, grief support is an important part of the follow-up of this condition. The fear of carcinoma may delay a patient's reaction to the fact that a pregnancy was lost. Attention should be given to the family's grief. In cases of partial hydatidiform molar pregnancies, the grief may be compounded by the somewhat elective decision to terminate a fetus, even one whose chromosomes are not compatible with life. Follow-up and referrals are appropriate.

Because the placenta is vascular, any stretching or pulling of the structure can cause blood vessels to rupture and bleed. The lower part of the uterus and upper part of the cervix (isthmus) thins and "pulls up" during the last trimester and while in labor. Bleeding is thought to occur as a result of the changes in the lower uterine segment in the third trimester [145,146]. The first bleeding typically occurs at 27 to 32 weeks' gestation [143]. Approximately 25% of patients do not bleed until 36 weeks' gestation [144]. Those with complete placenta previa are more likely to experience bleeding earlier than those with marginal or partial placenta previa. Bright red, painless bleeding during the third trimester in a patient not in labor must be evaluated for placenta previa. The bleeding may be minimal; however, at times it can present as hemorrhage. Some patients with placenta previa will also have uterine irritability accompanying the bleeding. Spotting may occur for several days and then taper off, but it almost always returns after a few days [143,146].

In those with undiagnosed placenta previa close to term, it may be noted that the fetus does not "drop" into the pelvis as expected because of the presence of the placenta blocking the inlet. Fetal malpresentation may also be noted.

Prior to the availability of ultrasound, placenta previa was diagnosed with a very careful and gentle speculum exam and/or a digital exam. Technologic advances have made it unnecessary and inadvisable to perform a pelvic examination on a patient with vaginal bleeding after the point of fetal viability without first obtaining an ultrasound exam. The diagnosis of placenta previa is easily made by ultrasound in the third trimester of pregnancy, and both careful transvaginal and translabial scanning have shown sensitivity in diagnosing placenta previa [145]. Transabdominal ultrasound has an accuracy of 93% to 98%, although false-positive results may occur secondary to focal uterine contractions or bladder distention [143]. Because transvaginal scanning does not increase the risk of bleeding, it is the imaging modality of choice [142]. Studies have indicated that it is safer and more accurate than the transabdominal method [142,143,145,147,148]. Transperineal ultrasonography has been suggested as an alternate method, particularly if instrumentation of the vaginal canal with a probe is a concern. This method may compliment transabdominal ultrasonography and help eliminate the false-positive results [143].

Placenta previa is often misdiagnosed early in pregnancy. The myth of the "migrating placenta" developed because, early in pregnancy, low-lying placentas are not uncommon. The placenta does not move or migrate in pregnancy. As pregnancy advances, the uterine wall stretches and thins. It is also thought that the placenta grows preferentially toward the fundus and moves farther away from the cervical os as the uterus enlarges [142,146]. Ninety percent of patients who have placenta previa diagnosed in the first trimester will not have a placenta previa at term [145,149]. Of those with second trimester ultrasound diagnosis of total placenta previa, only 26% will have persistent placenta previa at term; only 2.5% of partial and marginal placenta previa diagnosed during the second trimester will remain at term [145].

The treatment of placenta previa depends on a number of factors, including the amount of vaginal bleeding, whether the bleeding has stopped, the fetus's gestational age, the patient's health, the fetus's health, and the position of the placenta and the fetus [146]. If hemorrhage is life-threatening, immediate delivery by cesarean section is indicated. If the bleeding is slight, the patient may be sent home after 48 hours of in-house observation or kept in the hospital for the remainder of the pregnancy. Home-based care should occur only if the patient is in close proximity to a hospital, has the constant presence of a companion, and has given fully informed consent for such care [147,148]. Patients who do not have access to emergency transportation should be kept hospitalized. Bed rest may be prescribed to prevent uterine contractions that can result in bleeding [143,146]. Although there is no data to support the practice, pelvic precautions are often prescribed, including avoidance of vaginal intercourse, insertion of items into the vagina, and orgasm, which might result in uterine contractions [143,146]. Patients are otherwise allowed their usual activities, without any excessive exertion [144].

Depending on the amount of bleeding, IV fluids should be started and the patient should be blood typed and screened for crossmatch [143]. Few antepartum patients require emergency transfusions [144]. Baseline CBC, hemoglobin, hematocrit, and platelet functions must be obtained. Increases in blood volume and the hemodynamic changes in pregnancy mask early hypovolemic symptoms. Significant hemorrhage may occur by the time changes are noted in the vital signs. In the absence of massive bleeding or other complications, coagulation studies are not necessary [142].

Timing of delivery is based on gestational age and the severity of the bleeding. In most situations, an elective cesarean section will be scheduled prior to the due date [146]. Some patients with partial or marginal placenta previa can deliver vaginally because the fetal head will descend and act as a tamponade. In some cases, massive hemorrhage prompts delivery [146]. Usually, the blood is maternal and the fetus is not in jeopardy as long as the patient is stabilized [144]. Fetal status should be documented, and electronic fetal monitoring, when available, should be initiated. When the patient and fetus are stable, the use of tocolytics, medications used to inhibit labor, in those with placenta previa has been described. Steroids may be administered between 24 and 34 weeks' gestation to promote fetal lung maturity if delivery is imminent [142,146].

Whenever bleeding occurs in pregnancy, blood type, Rh type, and antibody screen should be reviewed, and all Rh-negative patients should be offered RhoGAM. A Kleihauer-Betke test, which measures fetal hemoglobin transferred to the patient's bloodstream, should be performed to determine if significant fetomaternal hemorrhage has occurred [143,145]. RhoGAM doses are calculated based on the amount of hemorrhage identified.

Patients with placenta previa and their families must be educated to contact their provider immediately if any bleeding occurs, even light spotting.

Obviously, maternal hemorrhage is the most common and life-threatening complication of placenta previa [144]. Anemia and shock may follow. Placenta previa has been associated with intrauterine growth restriction. However, when controlled for gestational age, studies have not found an association between placenta previa and low birth weight [144].

Preterm labor and birth may accompany placenta previa [146]. In about 20% of placenta previa cases, the uterus contracts prematurely [144]. Efforts to arrest preterm labor may be undertaken, and in the third trimester, antenatal steroids may be indicated [144]. Other complications include a prolonged hospital stay, intrapartum hemorrhage, septicemia, thrombophlebitis, cesarean delivery, abruptio placenta, fetal malpresentation, maternal death, DIC, blood transfusion, and hysterectomy [142,144].

Placenta accreta, placenta increta, and placenta percreta are also complications of placenta previa [146]. Placenta accreta refers to the abnormal attachment of the placenta to the myometrium. Placenta accreta spectrum is becoming increasingly common and is associated with significant morbidity and mortality [180]. Placenta increta is seen when the villi invade the myometrium, and placenta percreta is diagnosed when the villi penetrate the uterine wall and extend into the bladder or rectum [144]. Although not completely accurate, practitioners often use the term "placenta accreta" to describe all three situations.

Prior cesarean section or other uterine surgeries are most often associated with placenta accreta [145,147,148]. The placenta accreta rate has increased over the past 50 years, most likely as a result of the increasing cesarean section rates [142,150]. The incidence is now estimated to be 1 in 2,500 deliveries. Ultrasound may be helpful in the prenatal diagnosis of placenta accreta. Magnetic resonance imaging (MRI) and color Doppler studies may also be useful, although MRI is not the preferred recommended modality for initial evaluation [142,143,146,147,150]. The average blood loss recorded at the time of delivery in those with placenta accreta is 3,000–5,000 mL and is a common cause of cesarean hysterectomy [142]. Prenatal diagnosis by imaging, followed by planned, multidisciplinary peripartum management may help reduce morbidity and mortality [142,151,152]. Scheduled cesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal have been associated with reduced maternal morbidity in those with suspected placenta accreta [153].

Other rare conditions often grouped with placenta previa include placental abruption and vasa previa [146]. Placental abruption occurs when the placenta separates from the uterus before birth, potentially depriving the baby of oxygen and nutrients and resulting in dangerous bleeding [146]. Vasa previa occurs when the fetal blood vessels, unsupported by the placenta or umbilical cord, extend across the lower uterine segment and/or cervical os. These may accompany a velamentous cord insertion or a succenturiate lobed placenta [144]. Velamentous cord insertions occur when the umbilical cord does not insert directly into the placenta itself. The vessels are supported only by membranes between the umbilical cord and the placenta. Because fetal blood volume is only 80 to 100 mL/kg, laceration of the fetal vessels will cause hemorrhage and rapid fetal death [142,145,146]. Risk factors for vasa previa include a bilobed or succenturiate lobed placenta, low-lying placenta, multiple gestation, marginal insertion of the umbilical cord into the placenta, and velamentous cord insertion [144].

The incidence rate of vasa previa ranges from 1 in 2,000 to 1 in 6,000 pregnancies [154]. Diagnosis is often made at the time of presentation or rupture of membranes. With ultrasound, diagnosis of bilobed placentas or velamentous or marginal cord insertions can be seen, and the patients at high risk for vasa previa can be identified [142,154]. If vasa previa is suspected, transvaginal ultrasound color Doppler may be used to facilitate the diagnosis; however, even with the use of transvaginal ultrasound color Doppler, vasa previa may be missed. When vasa previa is diagnosed prenatally, an elective cesarean delivery should be offered prior to the onset of labor. Because premature delivery is likely, consideration should be given to administration of corticosteroids at 28 to 32 weeks to promote fetal lung maturation and to hospitalization at about 30 to 32 weeks [154]. When the diagnosis of vasa previa is made prenatally, more than 96% of fetuses survive. Nearly 45% of infants die when the diagnosis is made at the time of labor [154].

When bleeding occurs during pregnancy or in labor, the Apt or Kleihauer-Betke test may be used to determine if fetal cells are present in the vaginal blood to assist in diagnosis [142,143]. If vasa previa is diagnosed antenatally, hospitalization of the patient at about 30 to 32 weeks is considered and steroids administered to promote fetal lung maturity. Amniocentesis is often performed to determine fetal lung maturity before elective delivery. In cases of antenatally diagnosed vasa previa, the obstetrician may choose to deliver at 35 to 36 weeks' gestation without amniocentesis to avoid the potential for laceration of the fetal vessels [142].

While the exact causes of placenta abruption are unknown, some factors have been associated with their occurrence. These factors include [144,145]:

Absolute diagnosis of placenta abruption can only occur after examination of the placenta reveals an adherent clot or loss of functioning placental tissue. This diagnosis may not be accurate if the abruption is recent. Diagnosis is usually based on clinical findings, with supportive evidence from sonographic, laboratory, and pathologic studies [145].

Although vaginal bleeding is the hallmark sign of placental abruption, 10% to 20% of affected patients may have occult or concealed hemorrhage [145]. Other clinical findings include uterine bleeding, abdominal pain, uterine contractions, uterine tenderness, concerning fetal heart rate patterns or fetal death, and DIC [145,155]. The signs and symptoms of placenta abruption depend on the location of the placenta and the degree of separation involved. Abruption of a placenta implanted on the posterior uterine wall may present with severe back pain and contractions [156].

A patient's perception of pain may seem out of proportion to what the provider observes. There is increased uterine tone between contractions; the uterus may never completely relax between contractions. The classic "board-like" description of the abdominal wall will occur with complete or significant abruptions, but not with marginal or small abruptions.

Bleeding may be obvious or absent, although nearly 80% of patients with placenta abruption will exhibit external bleeding [144]. Patients with concealed abruption are often given the diagnosis of preterm labor. Bleeding may occur into the uterine wall, resulting in uterine enlargement. Uterine contractions and tenderness may be seen [144]. The uterine muscle may be saturated with blood, resulting in a Couvelaire uterus. Couvelaire uterus is seldom seen, but the appearance is that of a blue-tinted uterus at the time of cesarean section [144].

According to the American College of Radiology, ultrasound is the imaging modality of choice for evaluation placental abruption, but abruption can be subacute, which can confuse ultrasound findings.

(https://acsearch.acr.org/docs/69465/Narrative Last Accessed: March 18, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

With significant abruption, fetal distress may be apparent on electronic fetal monitor tracings. The fetus will tolerate some loss of placental surface area without distress; however, large interruptions in blood flow will be evident on the fetal heart rate monitor.

Often, placenta abruption is a diagnosis of exclusion. If placenta previa and other causes of vaginal bleeding have been ruled out, placenta abruption becomes the most likely diagnosis [145]. Ultrasound imaging may be useful in only about 50% of placenta abruptions, and false-positive diagnoses have been reported [144,145]. Serum markers for the early identification of placenta abruption have been under investigation [157,158,159]. Possible markers include hCG, maternal serum alpha fetoprotein (MSAFP), and inhibin A. Elevated levels of MSAFP have been associated with a ten-fold increase of placenta abruption [144]. The Kleihauer-Betke test has not proven to be useful to detect placenta abruption [144].

Maternal hemorrhage is the most common and life-threatening complication of placenta abruption, accounting for 6% of all maternal mortality [145]. Fetal mortality has been reported to be as high as 25% to 30% [145]. Significant neonatal mortality and morbidity is due to premature birth.

Other complications include a prolonged hospital stay, cesarean delivery, blood transfusions, and hysterectomy. Severe placenta abruption stimulates the clotting cascade that can result in DIC [144].

The majority of abruptions are marginal, and patients are usually hemodynamically stable on presentation. However, after the diagnosis of placenta abruption has been made, immediate referral to a physician able to manage the problem is indicated. A large-bore IV catheter should be placed to assure intravenous access. An indwelling Foley catheter will permit assessment of maternal urine output. If bleeding is significant, typing and crossmatch for blood transfusion should be ordered [144,145]. Routine laboratory studies include hemoglobin, hematocrit, WBC, and platelet count. Coagulation studies are advisable, to include prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen degradation product, and fibrinogen level should be drawn if significant blood loss is present [144]. A red-topped laboratory tube (i.e., clot tube) can be used to quickly assess bleeding defects. The blood drawn into the tube should form a clot within six minutes. The clot should lyse within 30 minutes. If clotting and lysing do not occur, a coagulation defect has probably occurred [145]. Continuous monitoring of fetal status and uterine activity has been recommended [144].

Timing of delivery is dependent on the degree of separation and maternal or fetal status. With grade 1 abruption, close observation of maternal and fetal status is essential. When the fetus is mature, a controlled induction of labor can be pursued [145]. In patients remote from term and clinically stable, the use of tocolytic agents to inhibit contractions has been described [145]. Unfortunately, a small placenta abruption can stimulate uterine irritability, which causes the placenta to separate further. While bleeding was once considered to be a contraindication to tocolytics, it has become more acceptable to consider a short course of tocolytics in patients with mild bleeding and contractions. If the patient is stable and fetal well-being is established, tocolysis may be valuable to prolong pregnancy 48 hours in order to initiate antenatal steroids for fetal lung maturation. Magnesium sulfate is the most accepted agent for this purpose, although use as a labor tocolytic is off-label for this medication and controversial [144,160]. Evidence of fetal distress can prompt immediate cesarean section. Sixty percent of fetuses will become distressed in labor; continuous electronic fetal monitoring is associated with excellent fetal survival in these cases [145]. The cesarean rate associated with placenta abruption has been reported as 50% to 75% [145].

Patients with mild bleeding may be sent home after evaluation. The decision to send any patient home after a bleeding episode will depend on the help the patient has at home, distance to hospital, ability to comply with medical instructions, and prompt access to transportation [144]. Patients with an abruption should be counseled about the increased risk of recurrence (estimated at about 25%) and associated risk factors [144].

The vascular changes that occur in the cervix during pregnancy, such as hyperemia and an altered squamous epithelium, predispose individuals to bleeding following intercourse. Inquiry regarding recent sexual activity, evaluation of the cervix, and reassurances about the status of the pregnancy may be all that is required in these cases.

Cervical infections such as chlamydia and gonorrhea may result in cervical bleeding. Cultures should be obtained whenever a patient presents with unexplained vaginal bleeding in pregnancy. If cervicitis is diagnosed, the Centers for Disease Control and Prevention (CDC) protocols for the treatment of STIs in pregnancy should be followed [161].

Another possible cause of cervical bleeding is cervical polyps. Cervical polyps occur in about 2% to 5% of persons with cervices [162]. If cervical polyps are discovered in pregnancy, they should not be removed because significant blood loss could result. The patient must be reassured that bleeding may recur from cervical polyps and that any heavy bleeding should still be reported to a provider. Evaluation by a provider able to distinguish normal cervical polyps from potential pathologic cervical disorders should be made [162,163].

Evaluation for lower genital tract malignancy should be considered whenever one encounters vaginal bleeding. Overall, 1 of every 34 persons diagnosed with cervical cancer is pregnant [164]. Although cervical cancer is a rare complication of pregnancy, it remains the most common gynecologic malignancy associated with pregnancy [137,165]. While the incidence of cervical cancer has decreased worldwide, largely due to screening in Westernized societies, the mean age of diagnosis of cervical cancer is 50 years of age [166,167]. The most common complaint of pregnant patients with cervical cancer is bleeding [164]. In general, increases in vaginal discharge and bleeding are the most common symptoms reported with this malignancy. More advanced cancers may be accompanied by malodorous, serosanguineous, or yellow discharge [164]. However, many with cervical cancer are asymptomatic, and diagnosis is made on routine screening [166]. Pelvic pain is less common. Pap tests should be done if any suspicion of cervical pathology exists. False-negative cervical cytology is possible due to the increased mucus and bleeding from cervical eversion in pregnancy. Biopsy by a physician skilled in the procedure may be indicated in ulcerative lesions. If a Pap test is not performed in an urgent care facility or emergency room, the patient should be specifically told it was not obtained. Many arrive in their primary providers' offices assuming that if a speculum examination was conducted, a Pap test was obtained.

Cervical eversion or erosion may present with vaginal bleeding. Cervical eversion is identified by the presence of an irregularly shaped area of reddened, raw tissue around the cervical os. The superficial layers of the squamous epithelium are lost. Cervical eversion can be caused by chronic cervicitis, pregnancy, tampon use, intercourse, and a variety of other triggers [168].

The onset of labor at term, prematurely, or in the event of an insufficient cervical os may be heralded by vaginal bleeding. Bloody show can be frank red, pink, or brown. It may be described as mucousy or watery. The bleeding may be first noticed following cervical examination at term. After placenta previa has been ruled out, perhaps by the availability of a previous ultrasound study, a careful, gentle digital examination of the cervix can confirm labor as the cause of bleeding. In gestations remote from term, when digital exams are not routinely advised, speculum exam or ultrasound may also diagnose cervical dilatation.

Vaginal causes of bleeding that should be evaluated include vaginitis, which may cause excoriation and therefore bleeding, vaginal trauma or laceration, or vulvovaginal cancer. The amount of bleeding and patient discomfort may make assessment of vaginal trauma difficult. Appropriate management and help with visualization are necessary. Although rare, vulvar and vaginal cancers do sometimes occur in persons of childbearing age [169]. It has been suggested that there are two subtypes of vulvar cancer: one that is associated with human papillomavirus (HPV) and one that is not [170]. Genital warts increase the risk of vulvar and cervical cancer and may be a source of bleeding in pregnancy. Nearly 90% of vulvar cancers in younger individuals have been associated with HPV [169]. Vulvar cancers represent approximately 6% to 7% of all gynecologic cancers in the United States [171]. Most are squamous cell carcinoma; melanoma and basal cell carcinoma are less common [169,170]. Fewer than 20 cases of vulvar carcinoma during pregnancy have been reported in the medical literature [137]. Most patients with vulvar cancer present with burning, itching, bleeding, or pain in the vulva. Visual lesions are usually available to biopsy. Referral to the appropriate specialist should be made whenever vulvar or vaginal pathology is suspected [171].

Vaginal infections are another possible cause of bleeding during pregnancy. Infections such as candidiasis, trichomoniasis, and bacterial vaginosis may cause tissue damage significant enough to result in vaginal bleeding during pregnancy. Microscopic evaluation of vaginal discharge and pH testing can quickly diagnose infections that should be treated. Initial herpes infections may result in bleeding from vesicles that have been scratched or from attempted home treatments. Visible lesions should be cultured for herpes simplex virus, and open sores should alert the clinician to the need for additional testing for syphilis and other STIs. As noted, all STIs diagnosed during pregnancy should be treated according to CDC guidelines [161]. Vaginitis treatments are also appropriate during pregnancy.

Careful examination of the anus and rectum should reveal any evidence of genital warts, hemorrhoids, fissures or rectal polyps, ruptured rectal varicosities, or trauma as sources of bleeding. Bleeding from sources higher in the colon, such as Crohn disease, irritable bowel syndrome, and colorectal cancer, are rare but may be appropriately evaluated during pregnancy. The majority of colorectal cancer in pregnancy is rectal and can be palpated on rectal exam. The incidence of colon cancer during pregnancy is about 1 in 13,000 [137].

Severe lower urinary tract infections, such as cystitis and urethritis, may result in the presence of significant blood in the urine. Because asymptomatic bacteriuria is a common risk factor for subsequent pyelonephritis, any evidence of this condition must be attended to. Individuals in advanced pregnancy may not be able to provide a sufficient clean catch urine specimen, and the need for catheterization should be weighed against the risks. Acute pyelonephritis occurs in 1% to 2% of all pregnancies and may result in maternal morbidity and mortality [172,173]. Most pyelonephritis occurs during the second or third trimesters and is believed to be the result of increasing obstruction of the ureters and stasis caused by the pregnant uterus.

Renal stones complicate 0.1% to 0.3% of pregnancies [174]. Urolithiasis is usually accompanied by colicky abdominal pain, recurrent urinary tract infections, and hematuria [174]. Although it is not a frequent cause of noticeable blood in pregnancy, it should be considered. Treatment is conservative, consisting of pain management and hydration [174]. Lithotripsy is contraindicated in pregnancy [175]. Urinary tract cancers are rare during pregnancy.

Another unusual cause of bleeding in pregnancy is the dehiscence of a cesarean section scar. Bloodless, asymptomatic dehiscence of the cesarean section scar usually carries little or no adverse impact on the pregnancy. However, uterine rupture can be life-threatening and may occur in the absence of labor. The incidence of uterine rupture is difficult to determine and is influenced by the type and location of the previous incision, obstetric history, interval between pregnancies, and the type of closure of the hysterotomy incision at the time of primary cesarean section [176,177]. Signs of uterine rupture may include fetal distress, maternal shock, vaginal bleeding, and abdominal or uterine pain [177]. Providers suspicious of uterine rupture should stabilize the patient and immediately transfer to a surgeon who is capable of performing an emergency cesarean section and dealing with the consequences of such an obstetric catastrophe.

In a few cases, the cause of antepartum bleeding cannot be determined. Careful monitoring of the fetus and patient can result in a healthy pregnancy outcome.

Patient A is a woman, 24 years of age, gravida three para two, who reported she believes she is about seven weeks pregnant. Three days previous, she noted some pink vaginal spotting. She presented with painless, dark red vaginal spotting. Patient A reported her last intercourse was more than a week ago. She denied any itching, burning, or malodorous discharge prior to the onset of her symptoms. She denied fever but thinks she had been having chills. Some nausea was reported but no vomiting. She did have a positive home pregnancy test one month ago. She denied uterine cramping, but admitted to some mild upper abdominal cramping. The patient complained of suprapubic pain after urination. The pain occurred after each voiding. The pain did not localize elsewhere and lasted for just a few minutes. Patient A reported some frequency, but attributed this to her pregnancy. Bowel function has been normal. She was appropriately concerned, as her previous pregnancies were uncomplicated. During the previous six months, Patient A has been diagnosed and treated for gonorrhea once and chlamydia twice. Follow-up testing was negative. Patient A has also been treated for recurrent lower urinary tract infection and bacterial vaginosis during the same period of time.

The differential diagnosis for Patient A includes:

Examination revealed normal external genitalia. The vagina was pink with moderate amounts of maroon-colored watery discharge noted. The cervix was pink and appeared closed. No exudate or lesions were noted on the cervix. Cultures for gonorrhea and chlamydia were obtained. Bimanual examination revealed a nontender uterus, anteverted, enlarged to a six- to seven-week gestational size. No masses were appreciated. The uterus was normal shape and configuration. The cervix was long and closed. Cervical motion tenderness was absent. Adnexa were slightly tender to palpation, without mass. Rectal examination was confirmatory.

Urinalysis in the office revealed 10 to 20 WBCs per high-powered field, 20 to 30 RBCs, no bacteria, moderate epithelial cells, and some casts. A urine sample was forwarded to the lab for culture and sensitivity. The routine pregnancy laboratory tests were obtained, and an ultrasound exam was ordered.

Laboratory findings revealed that Patient A is Rh negative with a negative antibody screen. She was offered RhoGAM per protocol and accepted. Her hemoglobin was 12.4, with the remainder of her lab work within normal limits. Her quantitative beta hCG was 14,283 mIU/mL. With an hCG that high, one would expect to be able to identify a fetus or products of conception on ultrasound. The radiologist immediately called to report that Patient A's ultrasound demonstrated a thickened endometrium and a slightly enlarged uterus measuring 9 cm x 6 cm x 8 cm. No gestational sac was noted. The left adnexa revealed a significantly increased vascularity adjacent to the left ovary. The right ovary was normal, with several small follicles.

Ectopic pregnancy was suspected. The hCG levels were borderline for the administration of methotrexate. With the uncertainty of the location of the gestation and the question of the patient's ability to return for close follow-up, the patient was prepared for surgery. At the time of diagnostic laparoscopy, a 4 cm x 5 cm cornual pregnancy was noted on the left side. The tubes and ovaries were normal bilaterally. The left cornu was removed in its entirety to the level of the endometrium; however, the endometrium was not entered.

Cornual pregnancies implant in the area where the fallopian tube enters the uterus. Approximately 1% to 5% of ectopic pregnancies occur in the cornua [40,99,112,113]. The uterine muscle surrounding the cornua permits the pregnancy to grow to a more advanced age, often 12 to 16 weeks, before rupture. Because this area is so vascular, ruptured cornual pregnancies can result in a profuse, rapid, and fatal hemorrhage. This patient's cornual pregnancy was not ruptured at the time of identification, and her postoperative recovery was normal. Urine culture done at the time of the office visit was negative. However, the chlamydia culture was positive, and the patient was treated according to CDC guidelines [161].

Because additional pregnancies were desired, the patient was started on hormone contraception and advised not to conceive for at least one year after her surgery in an effort to allow the uterine incision site to completely heal.

Patient R is 38 years of age, gravida 4 para 2, who had a spontaneous abortion eight months previous. She presented at 15 weeks' gestation. Her initial obstetric appointment was completed at 11 weeks' gestation. No fetal heart tones were auscultated. Because the patient had a definite last menstrual period and the uterine size was appropriate at the time of the examination, no ultrasound was performed. Plans were made to schedule an ultrasound at 20 to 22 weeks' gestation for complete evaluation secondary to a family history of cardiac anomaly.

Laboratory results from her first appointment were as follows:

Physical examination at the time of her first examination revealed a height of 65 inches, weight 212 lbs, and pulse 80 beats/minute. Her blood pressure was 114/72 mm Hg. Uterine size was measured to be 10 to 12 weeks' gestation; cervix was noted to be long and closed.

The patient returned with complaints of brown spotting "off and on" for several days, headache, fatigue, nausea, vomiting, and swelling in her legs. She had been unable to keep food or fluids down for 24 hours.

Her second exam reported a weight of 222 lbs, pulse of 86 beats/minute, and blood pressure of 162/94 mm Hg. Fundal height was recorded as 20 cm, and no fetal heart tones were monitored. Urinalysis (dipped) revealed 1+ protein and negative glucose with large ketones. Mucous membranes are dry, and the patient appears pale. Pitting edema in the calves is noted.

The differential diagnosis for Patient R includes:

An ultrasound exam was ordered and revealed no fetus but the presence of characteristic grape-like clusters in the uterus, and the diagnosis of complete hydatidiform molar pregnancy was made.

The patient was referred to an obstetrician for evacuation and management of this pregnancy. Because diagnosis was made before surgical evacuation of the uterus, a chest x-ray was performed preoperatively. It was within normal limits. CBC, platelet count, PT, PTT, liver function tests, and renal function tests were obtained. An hCG level was also obtained for baseline. Blood type and Rh type were known from her prenatal work-up. The patient did not require RhoGAM.

Patient C is a married woman, 22 years of age, gravida 1 para 0, at seven weeks' gestation according to her last menstrual period. This is a planned and welcome pregnancy. She called the office with complaints of bright red bleeding, lighter than a menstrual period but requiring sanitary pad protection. She also reported intermittent cramping. She denied lightheadedness, dizziness, nausea, vomiting, or focal pain. Although she had not experienced any nausea or vomiting, she reported continued breast tenderness.

On arrival in the office, her vital signs were obtained. Her height was 65 inches; weight 142 lbs; blood pressure 112/68 mm Hg; pulse 76 beats/minute. She appeared to be in some discomfort from the cramping, but her color was good and she was able to answer questions without difficulty. Upon questioning, she denied any trauma, recent intercourse, or changes in discharge preceding the onset of bleeding. Her last Pap test was done four months previous and was normal. Routine cervical cultures at the time were negative for chlamydia and gonorrhea.

Pelvic examination reveals the following:

Bimanual exam indicated a seven- to eight-week gestation-sized, anteverted uterus, mildly tender to palpation. No adnexal masses were appreciated; the cervix felt closed.

The results of laboratory studies indicated:

An ultrasound examination was performed. An intrauterine pregnancy was noted, with a fetus and fetal cardiac activity of 136 beats per minute. A normal gestational sac was seen consistent with a pregnancy of seven weeks two days. The placenta was low lying but did not cover the cervical os. No subchorionic hemorrhage was apparent.

The differential diagnosis for Patient C includes:

Because the patient continued to bleed, a repeat quantitative beta hCG in 48 hours was ordered. When bleeding is light, it is also appropriate to repeat the ultrasound exam in two weeks to follow growth and viability.

The patient was educated about the warning signs and symptoms of spontaneous abortion. She was encouraged to call with changes in symptoms, including bleeding saturating more than a pad an hour, passage of clots, severe cramping, lightheadedness, dizziness, fever, chills, or any other symptoms that make her uncomfortable.

Two days later, the patient returned to have her hCG repeated. She was accompanied to the office by her husband. Her repeat hCG was 1,500 mIU/mL. She continued to bleed lightly but had not saturated a pad an hour. She denied fever, chills, or passing any clots. Her vital signs remained stable, and she was afebrile.

The pelvic exam was unchanged from two days previous, with the exception of the bimanual examination. Palpation of the uterus was more uncomfortable for the patient than noted in the previous exam.

Patient C and her husband were told that the falling hCG levels indicate a pregnancy loss or miscarriage. Definitive diagnosis was made when the ultrasound revealed intrauterine fetal death, no fetal cardiac activity, and a collapsing gestational sac. A diagnosis of incomplete abortion or abortion in progress was made.

The options of care were discussed with the patient and her husband. They were offered the choices of expectant management, medical management, or surgical evacuation of the uterus. This couple chose expectant management and was sent home with instructions to call if the bleeding saturated a pad an hour, the bleeding became foul smelling, or if she developed fever or chills. Vaginal abstinence was encouraged. The patient was instructed in NSAID pain relief measures but was asked to call if additional pain control is needed. Plans were made for a follow-up telephone call later that week, and the couple was encouraged to call with any questions or concerns. A follow-up appointment was scheduled in two weeks, at which time hCG levels could be measured if indicated, birth control provided, and the patient's grief response assessed.

This section provides a partial listing of resources available to patients, families, or healthcare providers seeking support and/or information regarding pregnancy loss. Local support groups can be found in many medical centers and phone book listings.