What is the management of spotting in pregnancy?

From the Guidelines

Spotting in pregnancy should be evaluated by a healthcare provider, who will likely perform a physical examination and possibly an ultrasound to assess the pregnancy's viability and identify any potential causes of the bleeding, as recommended by the American College of Radiology Appropriateness Criteria 1. The management of spotting in pregnancy primarily involves monitoring and supportive care, as spotting is common and often resolves without intervention. If you experience spotting, contact your healthcare provider for evaluation, but try to remain calm as approximately 20-30% of pregnant women experience some bleeding in early pregnancy.

Key Considerations

• Your provider will likely perform a physical examination, possibly an ultrasound, and may check hormone levels to assess the pregnancy's viability.
• While waiting for evaluation, avoid sexual intercourse, douching, and tampons.
• No specific medications are typically prescribed for spotting itself, though if a specific cause is identified (such as a vaginal infection), appropriate treatment will be provided.
• In some cases where there is concern about progesterone levels, supplementation may be recommended, typically as vaginal suppositories (100-200mg twice daily) or oral micronized progesterone (200mg daily), though evidence for this practice is mixed, as noted in the guidelines for second and third trimester vaginal bleeding 1.

Importance of Ultrasound

• Transabdominal US is the mainstay of obstetrical imaging, but transvaginal US is particularly helpful for evaluating cervical-related causes of second and third trimester vaginal bleeding, as it provides accurate and safe diagnosis of placenta previa 1.
• Transperineal US (or translabial US) may also be useful for evaluating the cervix, but optimal visualization of the cervix occurs with closer approximation of the cervix, such as with real-time evaluation using transvaginal US 1.

Potential Causes of Spotting

• Spotting can result from normal implantation bleeding, cervical changes, vaginal infections, or sometimes more serious conditions like ectopic pregnancy or threatened miscarriage, which is why professional evaluation is important.
• The outcome of pregnancies with vaginal bleeding in the second and third trimesters depends on the precise etiology for the bleeding, and imaging, particularly with ultrasound (US), is the mainstay for making accurate diagnoses and for emergent guidance of management 1. It is essential to prioritize the health and well-being of both the mother and the fetus, and any concerns about spotting or vaginal bleeding during pregnancy should be promptly evaluated by a healthcare provider, as recommended by the American College of Radiology Appropriateness Criteria 1.

From the Research

Management of Spotting in Pregnancy

The management of spotting in pregnancy can be complex and depends on the underlying cause.

• Spotting can be caused by various factors, including cervical polyps, which can be diagnosed and managed using ultrasound 2.
• Ultrasound can aid in creating a treatment plan by assessing the type of polyp and source of symptomatology, and can help localize the source of symptomatology to polyps versus placental pathology 2.
• The removal of all cervical polyps with subsequent histologic review is recommended, as premalignant and malignant lesions can be found in cervical polyps 3, 4.
• Imaging studies, such as transvaginal ultrasound and saline infusion sonography, can be used to detect endometrial pathology, but may not be as accurate as hysteroscopy-guided biopsy 5.
• In cases of cervical insufficiency, cerclage may be used as a management option, but the diagnosis and management of other cervical issues during pregnancy are discussed in more detail in other publications 6.

Diagnostic Approaches

• Ultrasound can be used to diagnose cervical polyps and other cervical issues during pregnancy 2.
• Histologic evaluation of cervical polyps is necessary to determine the presence of significant histologic and concurrent cytologic findings 3, 4.
• Imaging studies, such as transvaginal ultrasound and saline infusion sonography, can be used to detect endometrial pathology, but may not be as accurate as hysteroscopy-guided biopsy 5.

Treatment Options

• The removal of all cervical polyps with subsequent histologic review is recommended 3, 4.
• Polypectomies can be performed with no complications, and patients can subsequently have uncomplicated normal spontaneous vaginal deliveries at term 2.
• Cerclage may be used as a management option for cervical insufficiency 6.