Vaginal Bleeding – Early Pregnancy

Some medical problems may appear only once in a career; alligator bites in SLO for example. Then there are the bread of butter problems of emergency medicine that arrive every 2nd or 3rd shift. Vaginal bleeding in early pregnancy is one of them.

Personally, I find this problem to be a bit fatiguing; not because I’m a burned out ER doc lacking empathy, but because I know that an OB office is such a more comfortable place for these patients. “If you have bleeding, then go to the ER” is the message many pregnant women hear, but I think they often don’t realize the reasons. Patients arrive hoping we may be able to save a fetus. But in the first trimester, we in the emergency department mainly strive to save mom.

Red Flags:

• Syncope
• Lightheadedness
• Abdominal pain
• Fever, vomiting, dehydration
• Underlying anemia
• Excessive bleeding (I get interested after a couple soaked pads an hour for 4+ hours. More interesting is a statement of increasing, rather than decreasing bright red bleeding.)
• Past ectopic pregnancy
• “I’m Rh negative.”

Happy Words

• “I noticed a little spotting so the hotline nurse told me I should come get checked.”
• “I’ve already had an ultrasound that showed a normal fetal heartbeat and I’m Rh+.”
• “My next OB appointment is tomorrow at noon.”
• “I didn’t know I was pregnant and don’t really want to be.”
• “I’m not bleeding anymore, but would just like an ultrasound to be sure.”

There’s very little variability or creativity when caring for these patients. We check Mom’s hematocrit to look for anemia. We check her blood type to see if she is Rh negative or positive. If negative, she gets a dose of Rhogam which hopefully limits sensitization by a potentially Rh positive fetus… and theoretically limits rejection of a future Rh positive fetus. (Look up “erythroblastosis fetalis” if you want to dig deeper.)
We check a “quantitative HCG” which helps to assess how far along the pregnancy may be in the first trimester. It’s frequently rechecked in about 48 hours to see that it is increasing appropriately. If it’s going down rather than up, we suspect something’s amiss, but rarely do we get that follow up in the ER. We’ll also do a pelvic exam to gauge the level of bleeding, and to see if any fetal tissue may be present.
What matters most, however, is the ultrasound. Walking in with vaginal bleeding in early pregnancy and no previous ultrasound, your chance for miscarriage is about 50/50. Walking out following an ultrasound that shows a moving fetus with beating heart, your chance for miscarriage drops dramatically to sub 5-10%.

“Am I having a miscarriage,” is mom’s main question and we do what we can to answer that. However, we do essentially nothing to prevent it, other than possibly IV fluids if we suspect dehydration. Miscarriage is a frequent occurrence unfortunately, but it prevents quite a bit of future suffering.

As an ER doc my main task is to rule out an ectopic pregnancy, or pregnancy that lands outside of the uterus, generally in the Fallopian tubes. Tasks #2,3 and 4 are to comfort mom.

As for Pre-R, sadly nobody has donated an ultrasound to us as yet. But we’re happy to order one for you through Selma Carlson Diagnostic Center if you like. Their charge for a pelvic ultrasound is $270, and transabdominal is $135. Pretty reasonable.

In summary for vaginal bleeding in early pregnancy, aka “threatened abortion,” or “threatened miscarriage”:

  • If you’re pregnant with no prenatal care and feeling sick and/or terrified, then head to the ER.
  • If you have some questions, or would like an outpatient ultrasound or lab work, feel free to call Pre-R.
  • If you have prenatal care, if you know your baby is in your uterus, if you know your blood type is Rh+, if the bleeding isn’t severe, then consider waiting to see your OB. I don’t want to be spanked by my ER, FP or OB friends here. Of course the ER is always an option, but just realize you’re getting the OB JV team… and we may use a bedpan to prop up your bottom if the special “pelvic bed” is taken. Apologies in advance.

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