Early Pregnancy Bleeding: Causes, Assessment & Reassurance
First-Trimester Bleeding: Differential Diagnosis & Management
Vaginal bleeding occurs in 20–30% of pregnancies; ~50% of these continue as viable pregnancies. Evaluation distinguishes threatening from benign causes.
Common Causes
| Cause | Timing | Characteristics | Viability |
|---|
| Implantation bleeding | 6–12 dpo (week 3–4) | Light, pink/brown, 1–2 days, no pain | Normal |
| Subchorionic hematoma | 6–12 weeks | Bleeding ± cramps; US shows fluid collection | Usually viable; ↑ miscarriage risk if large |
| Cervical ectropion/friability | Anytime | Postcoital, post-exam; bright red, scant | Normal |
| Cervical polyp | Anytime | Bright red, painless; visible on speculum | Normal |
| Threatened miscarriage | <12 weeks | Bleeding + closed cervix + viable US | Viable (but ↑ loss risk) |
| Inevitable/incomplete miscarriage | <12 weeks | Bleeding + open cervix ± tissue passage | Nonviable |
| Ectopic pregnancy | 6–10 weeks | Pain + bleeding; US: no IUP + adnexal mass | Nonviable; life-threatening |
| Molar pregnancy | 8–12 weeks | Bleeding + high hCG + "snowstorm" US | Nonviable; malignant potential |
Diagnostic Approach
- Vital signs, abdominal/pelvic exam: Hemodynamic stability, cervical os, adnexal tenderness
- Quantitative β-hCG: Baseline + serial (48h)
- Transvaginal ultrasound: Gold standard
- Gestational sac @ β-hCG 1500–2000 (discriminatory zone)
- Yolk sac @ 5–6 wks, fetal pole @ 6 wks, cardiac activity @ 6–7 wks
- Blood type: Rh status for RhIg (if Rh-neg, give 50–300 mcg at any bleeding)
Management by Diagnosis
- Viable IUP (threatened AB, SCH, cervical): Reassurance, activity modification (no strict bed rest), progesterone controversial (some guidelines support vaginal micronized 400 mg/day if hx loss), RhIg if indicated, follow-up US
- Nonviable/EP: Expectant, medical (misoprostol/methotrexate), or surgical (D&C, laparoscopy) per patient preference/stability
Red Flags: Immediate ER
- Heavy bleeding (pad/hr), syncope, hypotension
- Severe unilateral pain (ruptured ectopic)
- Fever, sepsis signs
Patient Counseling Points
- Bleeding ≠ miscarriage; many pregnancies with bleeding succeed
- No evidence bed rest improves outcomes
- Sex/exercise not prohibited unless specific diagnosis (placenta previa, incompetent cervix)
- Rh-negative: Anti-D within 72h of any sensitizing event
Early ultrasound is the single most valuable tool. It transforms uncertainty into a plan.
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