Vaginal Bleeding during Pregnancy

BASICS

DESCRIPTION

  • Vaginal bleeding during pregnancy has many causes and ranges in severity from benign, with normal pregnancy outcome to life-threatening for both infant and mother.
  • Origin of blood can be from the vagina, cervix, uterus, fetus, or placenta. The differential diagnosis is guided by the gestational age of the fetus.

EPIDEMIOLOGY

Prevalence

  • In early pregnancy: 7–25% of patients
  • In late pregnancy: 0.3–2% of patients

ETIOLOGY AND PATHOPHYSIOLOGY

  • Many times, the cause is unknown.
  • Anytime in pregnancy:
    • Cervicitis (infectious or noninfectious)
    • Vaginitis (infectious or noninfectious)
    • Vaginal or cervical trauma (including postcoital)
    • Cervical lesion (including polyps or warts) or neoplasia
    • Hyperemia of cervix (increased blood flow from pregnancy)
  • Early pregnancy:
    • For up to 50% of early pregnancy bleeding, no cause is ever found; bleeding in the 1st trimester is a risk factor for multiple adverse pregnancy outcomes (1)[A]
    • Ectopic pregnancy: leading cause of 1st-trimester maternal death in the United States—must be excluded in every pregnant patient with bleeding.
    • Spontaneous abortion: occurs in 10–15% of clinically recognized early pregnancies.
    • Loss of one fetus from a multiple gestation (“vanishing twin”)
    • Implantation bleeding: benign, about 6 days after fertilization
    • Uterine fibroids
    • Subchorionic bleeding (or hematoma): in late 1st trimester
    • Low-lying placenta
    • Gestational trophoblastic disease: hydatidiform mole (most common), choriocarcinoma, or placental-site trophoblastic tumors
  • Late pregnancy:
    • Cervical change
    • Placenta previa: painless bleeding; prevalence of 2.9% in North America; however, prevalence varies by geographical region; occurs in 0.5% of pregnancies in the United States
    • Placental abruption: (typically) painful bleeding; occurs in 1–2% deliveries in the United States.
    • Vasa previa: minimal bleeding with fetal distress; rare (1:2,500 deliveries)
    • Placenta accreta, increta, percreta
    • Uterine rupture: typically presents with vaginal bleeding, abnormal fetal heart rate, and disordered or hypertonic uterine contractions with or without pain

Genetics

No genetic risk factors have been determined to increase the risk of bleeding during pregnancy

RISK FACTORS

See specific etiologies in earlier discussion.

GENERAL PREVENTION

  • Address modifiable risk factors such as domestic violence and tobacco and drug use.
  • If placenta or vasa previa, nothing per vagina

COMMONLY ASSOCIATED CONDITIONS

See specific risk factors in earlier discussion.

DIAGNOSIS

HISTORY

  • Anytime in pregnancy: quality of pregnancy dating, context (e.g., following bowel movement, during voiding, after intercourse, drug use, or trauma including domestic violence), amount of bleeding, obstetrical history, personal or family history of inherited bleeding disorders
  • Early pregnancy: severe nausea/vomiting (can be associated with molar pregnancy); amount of bleeding, pelvic pain, or suprapubic cramping (e.g., spontaneous abortion, ectopic) complications in previous pregnancies (e.g., spontaneous abortion, abruption, 1st-trimester vaginal bleeding)
  • Late pregnancy: contractions (labor), abdominal pain especially between contractions (abruption, uterine rupture), presence or absence of fetal movement, rupture of membranes
  • See “Etiology and Pathophysiology” for additional pertinent history.

PHYSICAL EXAM

  • Vital signs: When present, signs of hemodynamic instability include tachycardia and tachypnea, hypotension and thready pulse.
  • Abdomen: uterine tenderness, fundal height (increasing fundal height may be associated with placental abruption)
  • Speculum: Visualize cervix and identify source of bleeding (from cervical os or from within vagina).
  • Cervix: digital exam to assess for dilation; required to assess for labor but should not be performed until placenta previa ruled out via ultrasound and may be done visually on speculum exam
  • Fetal monitoring: Doppler heart tones in early pregnancy; external fetal monitoring for gestational age of >26 weeks

DIFFERENTIAL DIAGNOSIS

  • Hematuria (UTI, kidney stones)
  • Rectal bleeding

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • CBC
  • Blood type and screen if more than minimal bleeding; if significant hemorrhage, type and crossmatch. The World Health Organization does not recommend giving RhoGAM until 12 weeks’ gestation and later (2) while the Society for Maternal-Fetal Medicine recommends screening for Rh-negative status and administering RhoGAM to all Rh-negative patients with vaginal bleeding under 12 weeks’ gestation (3).
  • Quantitative β-human chorionic gonadotropin (β-hCG):
    • Prior to 12 weeks, levels can be followed serially every 48 to 72 hours with characteristic trends:
      • Although many texts cite at least 66% rise in 48 hours in normal pregnancy, when initial β-hCG levels is <1,500 mIU/mL, between 1,500 to 3,000 mIU/mL, or >3,000 mIU/mL, subsequent level is expected to increase by at least 49%, 40%, and 33%, respectively over 48 hours.
      • Falls by ~50% every 48 to 72 hours in spontaneous abortion
      • Rises gradually (<50% in 48 hours) or plateaus in ectopic pregnancy
      • Extremely high in molar pregnancy
  • Transabdominal or transvaginal ultrasound should be used to confirm an intrauterine pregnancy (IUP) when the quantitative β-hCG >2,000.
  • Other lab tests based on clinical scenario:
    • Wet mount, gonorrhea/chlamydia/trichomoniasis, Pap smear
    • Progesterone level occasionally used to determine viability in threatened abortion (<5 indicates not viable, >25 indicates viability, 5 to 25 is equivocal)
    • Prothrombin time with international normalized ratio (INR), partial thromboplastin time, fibrinogen, and fibrin split products: if suspect coagulopathy or abruption
    • Kleihauer-Betke: assesses for fetal–maternal hemorrhage; low sensitivity and specificity for abruption; helpful for dosing RhoGAM
  • Transvaginal ultrasound is the preferred imaging modality if evaluating for possible ectopic pregnancy.
    • Early pregnancy:
      • Gestational sac seen at 5 to 6 weeks; fetal heartbeat observed by ≥6 weeks
      • Diagnostic of ectopic with nearly 100% sensitivity when β-hCG level is 1,500 to 2,000 mIU/mL; if no IUP is present and ultrasound does not confirm ectopic pregnancy, serial quantitative β-hCG values should be followed.
    • Late pregnancy:
      • Proceed to rule out placenta previa with ultrasound, labor with serial cervical exams, and abruption with external fetal monitoring.
ALERT

Confirm fetal presentation and placental position prior to cervical exam (to avoid complications in placenta previa).

Diagnostic Procedures/Other

Ultrasound: Can be used to follow the size of a hematoma or to follow the progression of a pregnancy in early 1st trimester bleeding.

TREATMENT

GENERAL MEASURES

Treat the underlying cause of the bleeding if identified.

MEDICATION

First Line

  • If the mother is Rh-negative, give RhoGAM to prevent autoimmunization. In late pregnancy, dose according to the amount of estimated fetal–maternal hemorrhage.
  • If cause of bleeding is preterm labor, consider steroid administration for fetal lung maturity if <36 weeks’ gestation. Tocolytics may be used to prolong pregnancy to allow for course of steroids.
  • If threatened abortion and patient with shortened cervix on transvaginal ultrasound: Consider progesterone vaginally; shown to improve live birth outcomes in subgroups of women with history of three or more spontaneous abortions; no benefit is seen on patients without a history of spontaneous abortion.
  • If mother has an inherited bleeding disorder or if bleeding is severe, consider recombinant or donor blood products.
  • If early pregnancy loss is determined to be the cause, consider expectant managementor medication management by using the combination of mifepristone and misoprostol to accelerate return to prepregnant state.

ISSUES FOR REFERRAL

If bleeding ectopic pregnancy is found, immediate referral to OB-GYN for management.

SURGERY/OTHER PROCEDURES

  • Cesarean section may be indicated for recurrent or uncontrolled bleeding with placenta previa or vasa previa.
  • If ectopic is diagnosed, immediate surgical treatment may be needed. Some early ectopic pregnancies can be treated medically if certain criteria are met.
  • Surgical uterine evacuation is necessary for molar pregnancy due to malignant potential.
  • Incomplete or inevitable spontaneous abortion: Management is patient centered and should include psychological support. In the absence of infection, patient may elect expectant, medical, or surgical management.
  • If history of cervical insufficiency resulting in preterm delivery, can consider cerclage placement in the 2nd trimester.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Acupuncture: may increase blood flow to the uterine lining to help prevent threatened miscarriage.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • In early pregnancy: based on quantity of bleeding, need for surgical treatment for ectopic pregnancy, or presence of infection in case of spontaneous abortion
  • In late pregnancy, consider admission if significant bleeding and/or presence of maternal or fetal compromise; consider admission with trauma if ≥2 contractions per 10 minutes
  • In late pregnancy, may discharge when bleeding has stopped; labor, previa, and abruption have been ruled out; and fetal heart tracing is normal.
  • After trauma in late pregnancy, may discharge home if normal fetal heart tracing for ≥4 hours with <2 contractions per 10 minutes (Consider mechanism of injury when deciding on duration of observation.)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Patient should be instructed to report any increase in the amount or frequency of bleeding and to seek immediate care if experiencing fever, dizziness, abdominal pain, or sudden increased bleeding and to seek immediate care if experiencing fever, dizziness, abdominal pain, or sudden increase in bleeding. Patient should save any tissue passed vaginally for examination.
  • Frequency of outpatient follow-up as indicated based on etiology of bleeding

PATIENT EDUCATION

PROGNOSIS

  • Prognosis depends on the etiology of vaginal bleeding, severity of bleeding, and rapidity of diagnosis; ectopic pregnancies result in 9–14% of maternal mortality in the 1st trimester and 5–10% of all pregnancy related deaths
  • Approximately half of patients with early pregnancy bleeding will continue with a normal pregnancy; if fetal heart activity (ultrasound) present during the episode of 1st-trimester bleeding, there is a <10% chance of pregnancy loss.
  • Heavy bleeding in early pregnancy, particularly when accompanied by pain, is associated with higher risk of spontaneous abortion.
  • Subchorionic bleeding has about 2- to 3-fold increased risk of spontaneous abortion. Smaller hemorrhage and presence of viable fetal heart rate confer lower risk of loss; most resolve spontaneously.
  • Bed rest has not been shown to affect the outcome of bleeding in early pregnancy but may be indicated for bleeding in late pregnancy with placenta or vasa previa or with maternal hypertension.

COMPLICATIONS

  • Pregnancy loss
  • Preterm labor
  • Hemorrhage
  • Increased rates of cesarean delivery when the cause of bleeding (i.e. placental) leads to fetal distress

Authors

Kristina Gracey, MD, MPH
Vernon L. Wheeler, MD
Olukorede Opeoluwa, MD
Anne M. Knierim, MD

REFERENCES

  1. Karimi A, Sayehmiri K, Vaismoradi M, et al. Vaginal bleeding in pregnancy and adverse clinical outcomes: a systematic review and meta-analysis. J Obstet Gynaecol. 2024;44(1):2288224.  [PMID:38305047]
  2. World Health Organization. Abortion care guideline. 2022. https://iris.who.int/bitstream/handle/10665/349316/9789240039483-eng.pdf
  3. Society for Maternal-Fetal Medicine; Prabhu M, Louis JM, Kuller JA; SMFM Publications Committee. Society for Maternal–Fetal Medicine Statement: RhD immune globulin after spontaneous or induced at less than 12 weeks gestation. Am J Obstet Gynecolol. 2024;230(5):B2–B5.  [PMID:38417536]

CODES

ICD10

  • O20.9 Hemorrhage in early pregnancy, unspecified
  • O46.90 Antepartum hemorrhage, unspecified, unspecified trimester
  • O20.0 Threatened abortion
  • O26.859 Spotting complicating pregnancy, unspecified trimester
  • O46.8X2 Other antepartum hemorrhage, second trimester
  • O46.8X9 Other antepartum hemorrhage, unspecified trimester
  • O26.853 Spotting complicating pregnancy, third trimester
  • O46.92 Antepartum hemorrhage, unspecified, second trimester
  • O46.8X1 Other antepartum hemorrhage, first trimester
  • O44.11 Placenta previa with hemorrhage, first trimester
  • O20.8 Other hemorrhage in early pregnancy
  • O44.12 Placenta previa with hemorrhage, second trimester
  • O44.13 Placenta previa with hemorrhage, third trimester
  • O46.91 Antepartum hemorrhage, unspecified, first trimester
  • O44.10 Placenta previa with hemorrhage, unspecified trimester
  • O46.93 Antepartum hemorrhage, unspecified, third trimester
  • O26.852 Spotting complicating pregnancy, second trimester
  • O26.851 Spotting complicating pregnancy, first trimester
  • O46.8X3 Other antepartum hemorrhage, third trimester

SNOMED

  • 106004004 Hemorrhagic complication of pregnancy (disorder)
  • 34842007 Antepartum hemorrhage (disorder)
  • 54048003 Threatened abortion (disorder)
  • 284075002 Spotting per vagina in pregnancy (finding)
  • 38010008 Intrapartum hemorrhage (disorder)
  • 75836008 Ante AND/OR intrapartum hemorrhage associated with trauma (disorder)
  • 198903000 Placenta previa with hemorrhage
  • 26840006 Ante AND/OR intrapartum hemorrhage associated with leiomyoma (disorder)
  • 25825004 hemorrhage in early pregnancy (disorder)

CLINICAL PEARLS

Last Updated: 2026

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