Should a patient with a single drop of vaginal bleeding during the late first trimester, without pain or other symptoms, go to the Emergency Department (ED)?

From the Guidelines

A single drop of vaginal bleeding during the late first trimester, without pain or other symptoms, does not necessitate an immediate visit to the Emergency Department (ED), and the patient should instead contact their obstetrician or midwife to report the spotting. This approach is supported by the fact that bleeding in the first trimester occurs in 7% to 27% of pregnancies, with an overall risk of miscarriage of approximately 12% 1. The primary imaging modality for evaluating patients with vaginal bleeding in the first trimester is ultrasound (US), which can usually differentiate causes of first-trimester bleeding, including normal intrauterine pregnancy (IUP) with or without a subchorionic hematoma, nonviable IUP, gestational trophoblastic disease (GTD), and ectopic pregnancy 1.

Key Considerations

• Light spotting or minimal bleeding can occur normally during pregnancy due to increased blood flow to the cervix or after sexual intercourse.
• Patients should monitor for any increase in bleeding, development of pain, cramping, fever, or passage of tissue, as these would warrant immediate medical attention.
• The distinction between normal spotting and concerning bleeding is important, as approximately 20-30% of pregnancies experience some spotting, but only a portion of these represent complications requiring urgent intervention.
• It is crucial to document the episode and inform the healthcare provider at the next scheduled prenatal visit.

Recommendations

• Contact the obstetrician or midwife to report the spotting and receive guidance on next steps.
• Monitor for any increase in bleeding or development of symptoms such as pain, cramping, fever, or passage of tissue.
• Seek emergency care if bleeding increases or additional symptoms develop before speaking with a provider.

From the Research

Vaginal Bleeding in the First Trimester

• A single drop of vaginal bleeding during the late first trimester, without pain or other symptoms, may not necessarily require emergency care 2.
• However, it is essential to consider the individual's overall health and any potential underlying conditions that may increase the risk of complications.

Emergency Department Visits for Nonurgent Conditions

• A significant proportion of emergency department visits are for nonurgent conditions, which can lead to excessive healthcare spending and unnecessary testing and treatment 3.
• Factors influencing an individual's decision to visit an ED for a nonurgent condition include convenience, referral by a physician, and negative perceptions about alternative care options 3.

Patient Decision-Making

• Patients may choose to visit the emergency department over primary care due to various reasons, including the acuity of their condition, barriers to accessing primary care, advantages associated with ED care, and fulfillment of medical needs 4.
• A qualitative metasynthesis identified eleven themes under four domains that influence patient decision-making, including pain, concern for severe illness, difficulty accessing primary care, and perceived expertise of ED healthcare providers 4.

Hospitalization Risk and Emergency Department Visits

• Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits 2.
• A study using National Hospital Ambulatory Medical Care Survey data found that 97 reasons for visit had admission percentages less than 2%, and another 52 had hospital admissions estimated between 2% and 4% 2.