Author: Ashleigh Lawrence-Ball / Questions: Becky Maxwell / Codes:  / Published: 06/02/2018

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The nurse at triage comes to speak to you: “There’s a pregnant 28year old with vaginal bleeding in the waiting room. She’s been here nearly four hours – can you go and sort her out quickly please?”

Bleeding in early pregnancy is a common presentation to most EDs and up to 30% of women will have some kind of vaginal bleeding before 12 weeks gestation. Many of these women (50-80%) will go on to have a perfectly normal pregnancy, but do not underestimate the psychological stress the uncertainty can have on a woman (and her partner).

In this blog, we’re going to talk about the 2 commonest causes of PV bleeding in early pregnancy (defined by NICE as less than 13 weeks gestation), some of the complications, and how they should be managed in the ED.

Ectopic Pregnancy

There’s an old adage in emergency medicine – a young woman, with abdominal pain or PV bleeding must be assumed to have an ectopic pregnancy until proven otherwise – and this is wise because of the 11/1000 ectopic pregnancies, 0.02% of these women will die. This is a significant cause of mortality in young people.

History

Always ask patients if they could be pregnant. If they say no, it’s worth asking why not – many people still just cross their fingers.

You should have a low threshold for performing pregnancy tests on young women who come through the department. Pregnancy tests can be negative so if your patient is sexually active, using no contraception, and you think they’ve got an ectopic be really careful in discharging them.

The majority of women presenting with PV bleeding will either not know they are pregnant or won’t have attended their first dating scan at 12 weeks. This means for most patients, you won’t know if the pregnancy is intrauterine or not.

One or more of the following risk factors will be present in around 50% ectopic pregnancies, so they’re worth asking about in your history:

  • Presence of an intrauterine contraceptive device or current use of the progesterone only pill (including Micronor® Noriday® Norgeston® Cerazette®)
  • The current pregnancy was conceived using assistive fertilisation techniques (e.g. IVF)
  • Previous pelvic inflammatory disease, sexually transmitted infection or tubal surgery (including ligation)
  • Previous ectopic pregnancy

Symptoms

  • Pain – abdominal or shoulder tip
  • Vaginal bleeding
  • Syncope

Ectopic pregnancies tend to have pain as their predominant symptom. If the pain lateralises to one side (right or left) an ectopic pregnancy is present until proven otherwise. If it’s crampy lower abdominal pain, still think ectopic! Women can also have shoulder tip pain from diaphragmatic irritation by peritoneal blood. If you did a vaginal examination, women may show signs of cervical excitation.

Although pain is the predominant symptom, ectopic pregnancies can also present with vaginal bleeding so do not be falsely reassured by women who only report a small amount of blood loss. If an ectopic pregnancy does rupture, large amounts of blood collect in the peritoneal cavity and very little may be lost PV.

It is really important to think about the possibility of an ectopic pregnancy in patients who present with syncope. Even if they are well now, they could have compensated for the large amount of blood sitting in their belly. Consider doing a pregnancy test on all patients of childbearing age with syncope.

Investigations

The pregnancy test is the most important test. Bloods aren’t going to change your ED management, but can be useful to guide further care – the Hb doesn’t drop quickly, so might be normal in the ED. Progesterone and serum HCG levels are more useful as a trend not as a single level (See this BestBet for further details).

A “FAFF” scan might be useful, but remember, it’s a rule in not a rule out. Be clear to the patient that you are NOT looking for fetal heartbeat, or even the presence of a fetus. A FAFF scan is a Focussed Assessment for Free Fluid – like a FAST scan for non trauma – and in the haemodynamically unstable young woman this may be useful to help guide your management when there’s any diagnostic uncertainty.

Management

If your patient is unwell, and haemodynamically unstable, you need to be resuscitating them, and liasing immediately with senior emergency department, gynaecology and anaesthetic colleagues. Remember to get those large-bore cannulas in early and send off a group and save sample.

The stable patients are a little different to manage. Query ectopic pregnancies will require discussion with gynaecology for an Early Pregnancy scan. Read your department’s policy to know how this happens where you work.

Miscarriage

Approximately 20% of all pregnancies in the UK will end in miscarriage. As doctors there is little to nothing we can do to prevent this outcome, and it’s important that the patient and her family know that there is very little they could have done either. Many of these spontaneous early miscarriages are due to structural defects within the foetus or gestational sac itself, although the risk is also increased with certain systemic diseases or infections as well as smoking and drug use.

You should understand the terminology of miscarriage, as many of these patients will be managed as outpatients, and may re-attend, either with on-going pain and bleeding or with a complication of the miscarriage.

A threatened miscarriage is the presence of PV bleeding and pain but the cervical os is closed and there will be a foetal heartbeat. Many of these women will go on to have an otherwise normal pregnancy.

An inevitable miscarriage is the presence of PV bleeding and pain and the cervical os is open, meaning that the products of conception will eventually be passed. These pregnancies are non-viable.

An incomplete miscarriage is one where some of the products of conception have yet to be passed and may result in cervical shock.

A septic miscarriage is where the products of conception have become infected, leading to systemic illness. These patients should be referred to gynaecology for further management.

Assessment and Management

As always in emergency medicine, these patients need to be assessed for haemodynamic instability and resuscitated first. Bear in mind that young women may compensate well, and therefore may have lost a lot of blood (2 or more litres) before they become tachycardic or hypotensive.

If you’ve got a haemodynamically unstable young woman with a positive pregnancy test in front of you you’re going to want to call the gynaecology team ASAP. Place your standard 2 large bore IV cannulae, hang the O negative and alert the blood bank that you may require the massive transfusion protocol. It is likely this woman will need to go to theatre promptly and is going to need help to stay stable.

In a patient with an incomplete abortion, products of conception can become lodged in the cervical os, causing vagal stimulation resulting in cervical shock. These women will be bradycardic and remain hypotensive despite aggressive fluid resuscitation.

I generally have to have a really good reason to perform a speculum examination in the ED and this would be one of those times. These patients can arrest, the treatment is relatively simple and can be done before gynaecology arrive, making you look like a hero. Move the patient to resus, give atropine (600mcg) if very bradycardic, call gynaecology and then insert the speculum and make sure you have a pair of long handled sterile forceps / gauze to hand. Visualise the cervical os and remove anything lodged in it (if it’s small, sweep with gauze on the end of forceps. For larger products, insert the forceps closed, open, grasp the contents, rotate and remove). This will remove the vagal stimulus and the patient should make a rapid recovery.

What about the patients who are haemodynamically stable, I hear you cry. These patients often seem more complex to manage. How you manage these patients depends on your departmental policy – many say refer to gynaecology if the patient is haemodynamically unstable or requiring more than simple analgesia. If the patient is stable, and their pain is controlled with paracetamol, send them home with safety net advice, and arrange an early pregnancy scan. It is worth thinking about referring some stable patients for inpatient management:

–          Late first trimester (10-12 weeks) as they carry a greater risk of substantial haemorrhage

–          Previous adverse or traumatic pregnancy experience (e.g. stillbirth)

–          Coagulopathies or other disorders that increase the likelihood of significant haemorrhage

–          Any evidence of infection (e.g. septic miscarriage)

If the woman is under 6 weeks pregnant, not in pain and stable, NICE recommend that they can be discharged to repeat a home pregnancy test in 7-10 days. If the repeat home pregnancy test is negative, then they have miscarried. If it is positive, they should attend either their GP or an EPAU or early pregnancy unit (if one is available). They should also represent if their symptoms continue or get worse.

Remember to be sensitive in how you approach these patients. The psychological trauma of miscarriage is often forgotten in the busy ED but many of the women will go on the have long-term mental health sequelae. It’s useful to have a “spiel” that you say – something like:

“Vaginal bleeding and pain in pregnancy is common, and everyone always assumes they are miscarrying the fetus. This may be true, but isn’t always. If this is what’s happening, there’s nothing you can do to change that, and nothing you’ve done to cause it. There’s nothing me, or any of my gynae collegues can do to change the outcome. The scan is important so that you know what is happening, but it doesn’t change our management.”

A Final Note

To PV or not PV, that is the question. In bleeding in later pregnancy, PV examination is actively discouraged due to the risk of precipitating a massive haemorrhage in those with undiagnosed placenta praevia. However, in early pregnancy, whether os is closed or open will change the diagnosis given to the woman. Honestly, I tend leave this decision up to my gynaecology colleagues as I’m going to make the referral either way. (This BestBet might help)

Further Reading

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