see also: [[abnormal vaginal bleeding (non-pregnancy)]], [[Ectopic pregnancy]], [[postpartum haemorrhage]], ==[[Ectopic pregnancy#Ultrasound|early pregnancy ultrasound]]== - [RWH - bleeding in early pregnancy](x-devonthink-item://BD447CA0-14AB-4953-8C54-7C4F19505521?page=1) - [Abortion Medical Management to 9 Weeks of Pregnancy](x-devonthink-item://C200971E-B482-4615-9E3A-D8D49FFE6E50) > this document contains information about first trimester bleeding (aka threatened miscarriage, ectopic, etc) and [[#Bleeding after the first trimester of pregnancy]] > [!key points] > - [[Ectopic pregnancy]] must always be considered > - patients with a threatened miscarriage and USS confirming live intrauterine pregnancy have an 85-90% chance of pregnancy progressing to term > - [[Anti-D]] generally not indicated for *threatened miscarriage* < 12 weeks gestation, but consider giving if there is heavy or repeated bleeding or associated abdo pain, especially closer to 12 weeks > - early pregnancy bleeding can have *pelvic exam* IF haemodyanmic compromise; ==late pregnancy bleeding should **never** have speculum or digital vaginal exam== until the site of the placenta is determined by ultrasound,to avoid disrupting a low-lying placenta and **precipitating torrential haemorrhage** # definitions - **miscarriage** - preg loss occurring before 20 weeks' gestation or foetus <400g if gestation is unknown - **threatened miscarriage** - any vaginal bleeding other than spotting in first 20 weeks of gestation - **inevitable miscarriage** - imminent or in the process of happening - **complete miscarriage** - all products of conception have been expelled - **failed pregnancy** - USS criteria (see: [[Ectopic pregnancy#Ultrasound|early pregnancy ultrasound]] - ==crown rump length >6 to 10 mm with no cardiac activity== - ==gestational sac ≥ 20-25mm with no foetal pole== # causes of early pregnancy bleeding - [[Ectopic pregnancy]] - abortion/miscarriage - threatened - failed pregnancy: - incomplete or inevitable - complete - septic - trophoblastic disease (molar pregnancy) - incidental/[[abnormal vaginal bleeding (non-pregnancy)|non-pregnancy related vaginal bleeding]] # management flowchart when pt well eg when not suspecting [[Ectopic pregnancy]] ![[Pasted image 20240317151620.png]] ![[Pasted image 20240618222816.png|RWH pain and bleeding early pregnancy guideline]] --- # Bleeding after the first trimester of pregnancy see: [[antepartum haemorrhage]], [[postpartum haemorrhage]] - *antipartum haemorrhage* - bleeding >20 weeks gestation and before onset of labour - [[postpartum haemorrhage]] - heavy (?500mL) vaginal bleeding within 24 hours of delivery - **secondary postpartum haemorrhage** - bleeding >24 hours up to 6 weeks after delivery, usually due to infection or retained products of conception ## antipartum haemorrhage **incidental causes**: - cervical erosion or ectropion - often post coital - cervical polyps - cerical malignancy - vaginal or cervical infection - haemorrhoids - vulval varices > - vaginal blood mixed with mucus is called a *show* and is due to mucus plug dislodging as the cervical begins to dilate > - usually at the time of, ir within a few days of, labour > - not significant unless pregnancy is preterm or associated with rupture of membranes > - as a general guide ==when a woman needs to wear a pad to soak up blood, she should be assessed as having an antipartum haemorrhage== ### placenta previa see: [[antepartum haemorrhage#Placenta praevia]] - when placenta is in lower uterine segment - ==bleeding is usually bright red and painless== - [[placental abruption]] can complicate this ### vasa praevia see: [[antepartum haemorrhage#Vasa praevia]] - foetal vessels running in amniotic membranes distant from the placental mass and across cervical os - vessels can rupture - can lead to fetal compromise - first indication may be **foetal bradycardia** or other abnormalities of foetal heart on [[CTG monitoring]] # Related Questions ## first trimester bleeding - [ ] 1Q: [First trimester bleeding](x-devonthink-item://93BDB055-D606-4878-9FA5-0BEFF977FEF7?page=11) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=5) - [ ] 2Q: [First Trimester Bleeding](x-devonthink-item://0987D972-A221-4F8A-B7D7-B0DCC349A2B3?page=8) -- [Answer](x-devonthink-item://C7FCB01A-E668-44AF-8C95-C298A40F8D68?page=6) ## pv bleeding - [ ] 3Q: [PV bleeding](x-devonthink-item://707C2E83-C5B4-4D98-99ED-FC32BF6F417F?page=5) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=10) ## third trimester bleeding - [ ] 4Q: [Third trimester bleeding](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=53) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=58)