SOAP. – Vaginal Bleeding: First Trimester

Merita O’Sullivan

Definition

Vaginal bleeding is common during the first trimester of pregnancy, occurring in 20% to 40% of all pregnancies. It may range from spotting to massive hemorrhage and be intermittent or constant, with or without pain. Types of abortion are:

A.Threatened abortion: Vaginal bleeding with absent or minimal pain and a closed, long, thick cervix.

B.Inevitable abortion: Vaginal bleeding with pain and cervical dilation and/or effacement.

C.Spontaneous abortion: The nonviable products of conception are expelled from the uterus spontaneously. This process may be complete or incomplete.

D.Missed abortion: In utero death of the fetus before 20 weeks’ gestation, with retention of the pregnancy. Vaginal bleeding may occur but the cervix usually remains closed. Ultrasound (US) reveals an intrauterine gestational sac with or without an embryonic/fetal pole but no cardiac activity.

E.Vanishing twin: A single pregnancy that results from very early loss of one embryo of a multiple gestation. May be associated with vaginal bleeding.

F.Vaginal bleeding may also be related to ectopic pregnancy, implantation of the pregnancy, postcoital bleeding, cervical inflammation/infection or cervical, vaginal, or uterine pathology.

Incidence

A.Vaginal bleeding is a common event in pregnancy. Spontaneous abortion, a primary concern in the first trimester, occurs in about 30% of all pregnancies; most occur before the 16th week. Ectopic pregnancy is much less common, occurring in 1 of every 200 pregnancies; 75% of pregnancies occurring after failure of tubal sterilization are likely to be ectopic. Rupture of an extrauterine pregnancy is life threatening and must be excluded in every pregnant woman with vaginal bleeding.

Pathogenesis

A.Spontaneous abortion: The pathogenesis varies according to cause. In most cases, it is caused by embryonic death, with resultant decrease in hormone levels and subsequent sloughing of the uterine decidua. Many of the embryonic deaths occur because of chromosomal abnormalities that are incompatible with life.

B.Ectopic pregnancy: Fertilized ovum is prevented or slowed in its progress down the fallopian tube. Pregnancy is implanted outside of the uterus, most commonly in the fallopian tube.

Predisposing Factors

A.Spontaneous abortion: In most cases, the cause is unknown:

1.Advanced maternal age (AMA; occurs more often in older women): A chromosomal abnormality in the embryo accounts for approximately 50% of cases in older women.

2.Abnormal uterine environment: Uterine septum, submucosal leiomyoma, intrauterine adhesions.

3.Systemic disease: Diabetes, thyroid disease, thrombophilia.

4.Weight extremes (body mass index [BMI] <18.5 or >30).

5.Immunologic deficiencies.

6.Substance use, including caffeine, alcohol, cigarettes, and cocaine.

7.Exposure to teratogens and infections: Food contaminated with Listeria monocytogenes, radiation.

8.Trauma.

9.Previous spontaneous abortion (AB): A history of two or more consecutive spontaneous abortions or a condition associated with spontaneous abortions such as maternal antiphospholipid syndrome or a uterine anomaly.

B.Ectopic pregnancy: Caused by previous damage to the fallopian tube; frequently caused by pelvic inflammatory disease, tubal surgery for infertility, or bilateral tubal ligation.

Common Complaints

A.Spontaneous abortion: Vaginal bleeding occurs that may or may not be associated with cramping or uterine contractions. When a pregnancy is more than 8 weeks’ gestation, the presence of uterine bleeding, uterine contractions, and/or pain are indications of a threatened abortion until proven otherwise.

B.Ectopic pregnancy: Vaginal bleeding and pelvic pain occur soon after the first missed period; the patient may be unaware of pregnancy. Sudden, acute, localized abdominal pain is associated with fallopian tube rupture.

Other Signs and Symptoms

A.Threatened abortion: Slight bleeding may be present over several weeks; cramping; no passage of tissue; positive pregnancy symptoms present, including nausea, vomiting, fatigue, breast tenderness, and urinary frequency.

B.Inevitable abortion: Moderate to profuse vaginal bleeding occurs. Tissue may or may not be passed, uterine cramps or abdominal pain are present, symptoms of pregnancy may be decreased or absent.

C.Incomplete abortion: Moderate to profuse vaginal bleeding, sometimes for several weeks, occurs; reports of passage of tissue; painful uterine cramping or contractions; and symptoms of pregnancy often absent.

D.Complete abortion: Patient experiences profuse bleeding, passage of tissue and large clots, abdominal cramping, or uterine contractions.

E.Ectopic pregnancy: Amenorrhea or irregular vaginal bleeding; abdominal pain is usually present, may be unilateral or generalized and may be associated with vertigo and syncope; shoulder pain, with irritation of phrenic nerve, may be present. Anxiety or palpitations are often noted.

Subjective Data

A.Elicit information about the onset, duration, and progression of symptoms.

B.Ask the patient about vaginal bleeding. When did it start? Is it continuous bleeding, like a period, or is it spotting? How much bleeding has occurred? How many pads have been saturated? What is the size of the blood spots? Determine amount of bleeding: How much blood is on peripad? (a) Scant amount: less than 1-inch diameter, (b) light amount: less than a 4-inch diameter, (c) moderate amount: less than a 6-inch diameter, (d) heavy amount: saturates the peri-pad within 1 hour. Has she passed any blood clots or tissue? Does she feel dizzy or lightheaded?

C.What is her current method of birth control? Was the birth control method used consistently? Has she had a tubal ligation, or has she recently used an intrauterine contraceptive device (IUD)?

D.Ask the patient the first day of her last menstrual period to date the pregnancy. Did she have a positive pregnancy test? If so, when? Has she had an US to confirm pregnancy location and dating?

E.Does she have a history of ectopic pregnancy, adnexal surgery, or pelvic inflammatory disease?

F.Question the patient regarding the presence or absence of abdominal and/or back pain. If present, is it a continuous discomfort, or is it intermittent cramping? Was the onset sudden? How severe is the pain?

G.Is the patient experiencing shoulder pain? This may be referred pain from phrenic nerve irritation because of intraperitoneal bleeding.

H.Does she have a history of assisted reproductive techniques for conception with current pregnancy? This increases the risk for a heterotopic pregnancy, a rare complication of pregnancy in which both an intrauterine and an extrauterine pregnancy occur simultaneously. This condition is also known as a combined pregnancy, multiple-sited pregnancy, or coincident pregnancy.

Physical Examination

A.Check temperature (if indicated), pulse, respirations, and blood pressure (BP). Note postural hypotension and tachycardia. Hemodynamic instability may be noted in cases of profuse bleeding;

assess vital signs and be alert for hypotension, tachycardia, tachypnea, and/or labored breathing.

B.Inspect:

1.Note general overall appearance of discomfort or pain and signs of shock before, during, and after examination.

2.Examine peri-pad to determine amount and color of bleeding, if available.

C.Palpate:

1.Perform abdominal examination for rebound tenderness, masses, softness, tenderness, or abdominal wall distension. Sudden, acute, localized abdominal pain with signs of internal hemorrhage suggest rupture of the fallopian tube.

2.Palpate uterine size. Measure fundal height for consistency with pregnancy dates. If fundal height suggests pregnancy has advanced beyond first trimester, bleeding may be caused by abruption, placenta previa, or rupture of membranes with heavy bloody show.

3.Check iliopsoas and obturator muscle tests.

D.Auscultate:

1.Auscultate the heart, lungs, and bowel sounds to rule out other abdominal problems.

2.If the pregnancy is beyond 10 to 12 weeks’ gestation, a handheld Doppler can be used to auscultate the fetal heart tones.

E.Pelvic examination:

1.Place the patient in a lithotomy position to examine external genitalia to access the volume and potential source of bleeding.

2.Perform sterile speculum examination: Assess color and amount of bleeding. Tissue and the products of conception may be noted at cervical os or in vaginal vault. Assess for Chadwick’s sign. The entire fetus may be noted in the vaginal vault; tissues that remain in the uterus may include portions of fetal membranes or placenta. The speculum exam may reveal a cause of bleeding unrelated to the pregnancy such as a vaginal laceration, vaginal neoplasm, condyloma acuminata, vaginitis, cervical lesions (polyps, fibroids, ectropion), acute cervicitis, or a cervical neoplasm.

3.Bimanual examination: Check Hegar’s sign; elicit this sign cautiously, as a false-positive result may be related to a rough examination. Evaluate cervical dilation; cervical motion tenderness, adnexal, or abdominal tenderness. An adnexal mass and mild uterine enlargement are often present with ectopic pregnancy. A bulging cul-de-sac, represents a hemoperitoneum. Adnexal mass is present in 50% of ectopic pregnancies.