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Vaginal Bleeding in Pregnancy: Hemorrhage Causes, Evaluation, and Management

Vaginal bleeding in pregnancy affects 15–25% of pregnancies. While not always pathological, hemorrhage (heavy bleeding) is an obstetric emergency requiring immediate evaluation.

Major Causes by Trimester

First Trimester (<14 weeks)

  • Threatened miscarriage: Bleeding + closed cervix + viable embryo (50% continue).
  • Early pregnancy loss: Inevitable, incomplete, complete, missed abortion.
  • Ectopic pregnancy: Implantation outside uterus (95% tubal). Rupture → life-threatening hemorrhage. Rule out first.
  • Molar pregnancy: Abnormal trophoblast proliferation; bleeding + high hCG + "snowstorm" US.
  • Cervical: Polyp, ectropion, cervicitis — usually spotting.

Second/Third Trimester (≥14 weeks)

  • Placenta previa: Placenta covers internal os. Painless, recurrent bright red bleeding. Diagnosed by transvaginal US.
  • Placental abruption: Premature separation. Painful, dark bleeding + uterine tenderness + fetal distress. Concealed hemorrhage possible (no vaginal blood).
  • Vasa previa: Fetal vessels cross internal os. Rupture → rapid fetal exsanguination. Prenatal diagnosis (color Doppler) critical.
  • Uterine rupture: Prior C-section/myomectomy scar. Catastrophic.
  • Cervical insufficiency: Painless dilation → preterm delivery ± bleeding.
  • Bloody show: Mucus + blood at term — normal labor sign.

Emergency Assessment (ABCDE)

  1. Airway/Breathing/Circulation: IV access (2 large-bore), fluids, blood products, monitor vitals, Foley.
  2. History: Gestational age, bleeding amount/color/pain, trauma, prior C-section, placenta location.
  3. Exam: Speculum (cervical source, dilation), NO digital vaginal exam until placenta previa excluded by US.
  4. Ultrasound: Fetal heart, placenta site, retroplacental clot, free fluid.
  5. Labs: CBC, type & screen, coagulopathy panel, fibrinogen, Kleihauer-Betke (fetomaternal hemorrhage).

Management Principles

  • Placenta previa: Expectant if stable/preterm (corticosteroids, tocolytics, hospitalization); C-section at 36–37 weeks or for hemorrhage.
  • Abruption: Delivery if fetal distress/maternal instability; vaginal if favorable; C-section if not.
  • Vasa previa: Elective C-section 34–36 weeks; emergency if ruptured.
  • Ectopic: Methotrexate (unruptured, stable, hCG <5000); laparoscopy (ruptured/high hCG).

Key Message

Any bleeding in pregnancy warrants prompt clinical evaluation. Heavy bleeding + hemodynamic instability = activate massive transfusion protocol, emergent delivery. Early ultrasound and hCG triage first-trimester bleeding.

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