Management of Vaginal Bleeding During First Trimester of Pregnancy
The first step in management is prompt evaluation of the vaginal bleeding occurring in a pregnant woman. Since excessive bleeding can lead to shock, intravenous access should be established as soon as possible where bleeding is seen to be in large amounts.
Initial evaluation will start with history and physical examination (including a pelvic examination). This will be followed by laboratory tests and ultrasonography.
Special attention is given to :
- Amount of bleeding (number of pads soaked).
- Passage of clots or tissues (products of conception).
- If bleeding is associated with pain.
Symptoms to be carefully noted are :
- Vaginal discharge.
- Fever and chills.
- Vital signs such as temperature (fever), increased pulse rate and low blood pressure will give an indication about blood loss, shock and infection.
- Abdominal examination is done to assess uterine size and evaluation of pain.
- A Doppler ultrasound probe can be used to check for fetal heart sounds.
- Pelvic examination is necessary to assess the amount of bleeding, pelvic pain, identify any products coming out and to check if the os (opening of the cervix) is closed or open (this will determine the type of abortion).
- Urine pregnancy test to confirm pregnancy.
- Urinalysis to check for urine infection.
- Blood count, blood grouping and Rh typing. Rh testing will determine if Rho(D) immune globulin will need to be given (if the woman is Rh Negative with an Rh Positive fetus).
- Cross matching of blood is done in case of heavy bleeding where blood transfusion may become necessary.
- Quantitative beta-hCG (beta subunit of human chorionic gonadotropin) measurement, in conjunction with ultrasound results, can help to identify an ectopic pregnancy.
- A beta-hCG level of > 1500 mIU/mL with no intrauterine pregnancy on ultrasonography will point to a diagnosis of ectopic pregnancy.
- If no intrauterine pregnancy is seen on ultrasonography but the beta-hCG level is < 1500 mIU/mL, intrauterine pregnancy may still be possible.
- Serial beta-hCG level (which usually doubles every two days in early pregnancy) may show lower than normal levels in cases of ectopic pregnancy or miscarriage.
- Cervical cultures – where septic abortion is suspected.
- Transvaginal pelvic ultrasonography will determine the state of the pregnancy and fetus.
- Ultrasound can also help to diagnose the type of abortion, ectopic pregnancy, molar pregnancy or a ruptured corpus luteum cyst.
Depending upon the diagnosis, further treatment will be undertaken.
The patient may be managed at home with the appropriate advice and medication.
- Bed rest (till bleeding and pain stops).
- Adequate fluid intake.
- Avoid intercourse (for 3 weeks).
- Tampons should not be used.
- Avoid douching.
- Mild sedatives.
- Drugs containing progesterone (opinion varies regarding benefit of progesterone in threatened abortion).
Incomplete and Inevitable Abortion
A dilation and curettage (D&C) or a suction curettage will need to be done to ensure that all the products of conception have been removed from the uterus. The drug misoprostol is an alternative to surgical treatment.
No treatment may be necessary if expulsion of all the products of conception is confirmed by examination and ultrasound.
A D&C may be done or the patient sent home and monitored for spontaneous expulsion of the products. Misoprostol may be used as an alternative method.
Intravenous antibiotics is usually necessary. Immediate evacuation of the uterus to remove the infected products.
A D&C is necessary. Follow up is important to test beta-hCG levels at regular intervals and check for choriocarcinoma.
A ruptured ectopic pregnancy is the most dangerous cause of vaginal bleeding in the first trimester of pregnancy and is potentially life-threatening for the mother. An immediate laparoscopy or laparotomy becomes necessary in these cases.
For unruptured ectopic pregnancy :
- Medical therapy – methotrexate.
- Surgery – to remove the ectopic pregnancy and conserve as much of the tube as possible (salpingotomy), especially in women who desire further pregnancies. Removal of the fallopian tube (salpingectomy) may become necessary in some cases. Laparoscopic surgery is preferred but laparotomy may be done.
If Diagnosis is Uncertain
Diagnostic suction D&C with diagnostic laparoscopy may be done.