The parental source may be a disruption in the vessels of the decidua or a lesion in the cervix or vagina. In the earlier stages of pregnancy, the cervix can be vulnerable to bleeding as new blood vessels are being grown. Vasa praevia is a rare condition that can result in bleeding from the fetoplacental circulation. Vasa praevia happens most often when the umbilical cord grows in a way that it directly enters the membrane, and therefore blood vessels that are unprotected by the umbilical cord or placental tissue can rupture and lead to bleeding. Another common source of bleeding can be due to abnormal development of the embryo. The most common early fetal abnormality is abnormal number of chromosomes causing loss of the pregnancy and bleeding. Diagnostic approach
The initial assessment of vaginal bleeding in early pregnancy must first consider hemodynamic stability and the degree of pain or bleeding. A hemodynamically unstable patient would necessitate an immediate transfer to the emergency department . It is important to recognize that patients may suffer significant blood loss before any signs of hemodynamic instability are evident.The initial evaluation of early pregnancy bleeding involves a history and physical examination. The relevant history includes determining the gestational age of fetus and characterizing the bleeding. Bleeding that is at least as heavy as menstrual bleeding or associated with clots, tissue, lightheadedness, or pelvic discomfort is associated with increased risks of ectopic pregnancy and spontaneous abortion.
If the viability of an intrauterine pregnancy is uncertain, repeat ultrasonography coupled with laboratory measurement of progesterone and/or serial hCG can be helpful. The absence of either intrauterine or ectopic pregnancy on imaging is suggestive of a complete early pregnancy loss (if the pregnancy was previously seen on imaging) or a pregnancy of unknown location (if the pregnancy was not previously seen on imaging). Management
The management of early pregnancy bleeding depends on its severity and cause.Patients with significant first-trimester bleeding (more than spotting) should have a red blood cell antibody screen. Patients who are Rh-negative are usually given anti-D immune globulin to prevent RhD isoimmunization. People with significant blood loss who become hemodynamically unstable require rapid intervention. Early pregnancy loss can be treated with watchful waiting, medication, or uterine aspiration based on shared decision-making between the patient and provider. For those with incomplete abortion, watchful waiting is the recommended method as more than 90% of these patients will complete the process spontaneously within four week. Patients who decide on expectant management may experience more days of bleeding and longer completion time as compared to surgical management. Serious complications of watchful waiting are rare. Effective medical management entails 200 mg of oral mifepristone (Mifeprex) followed 24 hours later by 800 mcg of vaginally administered misoprostol. Bed rest and progesterone therapy have not been shown to increase the likelihood of a viable outcome.Ectopic pregnancy is treated with methotrexate therapy or surgery.