Overview of the etiology and evaluation of vaginal bleeding in pregnant women
- Errol R Norwitz, MD, PhD, MBA
Errol R Norwitz, MD, PhD, MBA
- Professor and Chair
- Department of Obstetrics and Gynecology
- Tufts Medical Center and Tufts University School of Medicine
- Joong Shin Park, MD, PhD
Joong Shin Park, MD, PhD
- Professor, Department of Obstetrics and Gynecology
- Seoul National University College of Medicine, Korea
Vaginal bleeding is a common event at all stages of pregnancy. The source is virtually always maternal, rather than fetal. Bleeding may result from disruption of blood vessels in the decidua (ie, pregnancy endometrium) or from discrete cervical or vaginal lesions. The clinician typically makes a provisional clinical diagnosis based upon the patient's gestational age and the character of her bleeding (light or heavy, associated with pain or painless, intermittent or constant). Laboratory and imaging tests are then used to confirm or revise the initial diagnosis.
An overview of the etiology and evaluation of vaginal bleeding in pregnant women will be reviewed here. Specific causes of bleeding and their management are discussed in detail separately. (See individual topic reviews on each subject).
FIRST TRIMESTER BLEEDING
Overview — Vaginal bleeding is common in the first trimester, occurring in 20 to 40 percent of pregnant women. It may be any combination of light or heavy, intermittent or constant, painless or painful. The four major sources of nontraumatic bleeding in early pregnancy are:
●Miscarriage (threatened, inevitable, incomplete, complete)
- Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev 2012; :CD003518.
- Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol 2008; 112:661.
- Jindal P, Regan L, Fourkala EO, et al. Placental pathology of recurrent spontaneous abortion: the role of histopathological examination of products of conception in routine clinical practice: a mini review. Hum Reprod 2007; 22:313.
- Isoardi K. Review article: the use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas 2009; 21:440.
- Lane BF, Wong-You-Cheong JJ, Javitt MC, Glanc P, Brown DL, Dubinsky T, Harisinghani MG, Harris RD, Khati NJ, Mitchell DG, Pandharipande PV, Pannu HK, Podrasky AE, Shipp TD, Siegel CL, Simpson L, Wall DJ, Zelop CM, Expert Panel on Women's Imaging. ACR Appropriateness Criteria® first trimester bleeding. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 7 p. [55 references] http://www.guideline.gov/content.aspx?f=rss&id=43883&osrc=12.
- Morse CB, Sammel MD, Shaunik A, et al. Performance of human chorionic gonadotropin curves in women at risk for ectopic pregnancy: exceptions to the rules. Fertil Steril 2012; 97:101.
- Silva C, Sammel MD, Zhou L, et al. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol 2006; 107:605.
- Seeber BE. What serial hCG can tell you, and cannot tell you, about an early pregnancy. Fertil Steril 2012; 98:1074.
- van Mello NM, Mol F, Ankum WM, et al. Ectopic pregnancy: how the diagnostic and therapeutic management has changed. Fertil Steril 2012; 98:1066.
- Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol 2013; 121:65.
- Tongsong T, Srisomboon J, Wanapirak C, et al. Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study. J Obstet Gynaecol (Tokyo 1995) 1995; 21:331.
- Tannirandorn Y, Sangsawang S, Manotaya S, et al. Fetal loss in threatened abortion after embryonic/fetal heart activity. Int J Gynaecol Obstet 2003; 81:263.
- De Sutter P, Bontinck J, Schutysers V, et al. First-trimester bleeding and pregnancy outcome in singletons after assisted reproduction. Hum Reprod 2006; 21:1907.
- SPEERT H, GUTTMACHER AF. Frequency and significance of bleeding in early pregnancy. J Am Med Assoc 1954; 155:712.
- Harville EW, Wilcox AJ, Baird DD, Weinberg CR. Vaginal bleeding in very early pregnancy. Hum Reprod 2003; 18:1944.
- Williams MA, Mittendorf R, Lieberman E, Monson RR. Adverse infant outcomes associated with first-trimester vaginal bleeding. Obstet Gynecol 1991; 78:14.
- Berkowitz GS, Harlap S, Beck GJ, et al. Early gestational bleeding and pregnancy outcome: a multivariable analysis. Int J Epidemiol 1983; 12:165.
- Ananth CV, Savitz DA. Vaginal bleeding and adverse reproductive outcomes: a meta-analysis. Paediatr Perinat Epidemiol 1994; 8:62.
- Weiss JL, Malone FD, Vidaver J, et al. Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol 2004; 190:745.
- Yang J, Hartmann KE, Savitz DA, et al. Vaginal bleeding during pregnancy and preterm birth. Am J Epidemiol 2004; 160:118.
- Chung TK, Sahota DS, Lau TK, et al. Threatened abortion: prediction of viability based on signs and symptoms. Aust N Z J Obstet Gynaecol 1999; 39:443.
- Gracia CR, Sammel MD, Chittams J, et al. Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies. Obstet Gynecol 2005; 106:993.
- Harger JH, Hsing AW, Tuomala RE, et al. Risk factors for preterm premature rupture of fetal membranes: a multicenter case-control study. Am J Obstet Gynecol 1990; 163:130.
- Hasan R, Baird DD, Herring AH, et al. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol 2009; 114:860.
- Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol 2010; 115:935.
- Velez Edwards DR, Baird DD, Hasan R, et al. First-trimester bleeding characteristics associate with increased risk of preterm birth: data from a prospective pregnancy cohort. Hum Reprod 2012; 27:54.
- McPherson JA, Odibo AO, Shanks AL, et al. Adverse outcomes in twin pregnancies complicated by early vaginal bleeding. Am J Obstet Gynecol 2013; 208:56.e1.
- Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. BMJ 1997; 315:32.
- Towers CV, Burkhart AE. Pregnancy outcome after a primary antenatal hemorrhage between 16 and 24 weeks' gestation. Am J Obstet Gynecol 2008; 198:684.e1.
- Magann EF, Cummings JE, Niederhauser A, et al. Antepartum bleeding of unknown origin in the second half of pregnancy: a review. Obstet Gynecol Surv 2005; 60:741.
- Bhandari S, Raja EA, Shetty A, Bhattacharya S. Maternal and perinatal consequences of antepartum haemorrhage of unknown origin. BJOG 2014; 121:44.
- FIRST TRIMESTER BLEEDING
- - History
- - Physical examination
- - Transvaginal ultrasonography
- Other imaging tests
- - Laboratory tests
- Differential diagnosis and management
- - Ectopic pregnancy
- - Threatened miscarriage
- - Inevitable miscarriage
- - Complete and incomplete miscarriage
- Complete miscarriage
- Incomplete miscarriage
- - Missed abortion
- - Vanishing twin
- - Vaginitis, trauma, tumor, warts, polyps, fibroids
- - Ectropion
- - Physiologic or implantation bleeding
- SECOND AND THIRD TRIMESTER BLEEDING
- Prior to 20 weeks of gestation
- - Evaluation
- - Differential diagnosis
- Bleeding after 20 weeks of gestation
- - Evaluation
- - Differential diagnosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS