Does a patient with spotting at 28 weeks gestation after intercourse and a history of miscarriage (spontaneous abortion) at 13 weeks require hospital admission?

Management of Spotting at 28 Weeks Gestation After Intercourse

A patient with spotting at 28 weeks gestation after intercourse with a history of miscarriage at 13 weeks does not require hospital admission if the bleeding is minimal and there are no other concerning symptoms.

Initial Assessment

When evaluating vaginal bleeding in the second and third trimester, it's crucial to distinguish between benign causes and potentially serious complications:

• Post-coital bleeding: Often benign and related to increased cervical vascularity during pregnancy
• Concerning features requiring immediate evaluation:
  • Heavy bleeding (more than spotting)
  • Abdominal pain or uterine contractions
  • Rupture of membranes
  • Decreased fetal movement

Diagnostic Approach

The American College of Radiology (ACR) recommends the following approach 1, 2:

1. Ultrasound evaluation before digital examination

   • Transabdominal ultrasound to evaluate placental location
   • Transvaginal ultrasound if needed for better cervical visualization
   • Rule out placenta previa, vasa previa, or low-lying placenta

2. Physical examination (after ultrasound confirms no placenta previa)

   • Visual inspection of the cervix with a speculum
   • Avoid digital examination until placental location is confirmed

Risk Assessment

Several factors affect the risk assessment:

• History of prior miscarriage: While concerning, a previous first-trimester loss (13 weeks) doesn't significantly increase the risk for third-trimester complications
• Timing of bleeding: Post-coital spotting is often related to cervical friability rather than placental or membrane issues
• Amount of bleeding: Spotting carries a better prognosis than heavy bleeding 3

Management Algorithm

For minimal spotting after intercourse at 28 weeks:

1. Outpatient management is appropriate if:

   • Spotting only (not heavy bleeding)
   • No abdominal pain or contractions
   • Normal fetal movement
   • No signs of infection or rupture of membranes
   • Ultrasound shows no placenta previa or abruption

2. Patient education:

   • Pelvic rest (no intercourse) for 1-2 weeks
   • Monitor for increased bleeding, contractions, or decreased fetal movement
   • Return precautions: heavy bleeding, pain, contractions, rupture of membranes

Indications for hospital admission:

1. Heavy bleeding beyond spotting
2. Signs of preterm labor (contractions, cervical change)
3. Placental abnormalities on ultrasound
4. Rupture of membranes
5. Signs of maternal infection

Follow-up Recommendations

• Schedule follow-up within 1 week for reassessment
• Consider antenatal corticosteroids if risk factors for preterm delivery develop
• Monitor for recurrent bleeding episodes

Important Considerations

• The Society for Maternal-Fetal Medicine notes that hospital readmission should occur if there are contraindications to continued outpatient management, such as hemorrhage, infection, or fetal concerns 1
• Post-coital bleeding is common (0.7-9% of menstruating women) and is usually benign, especially when it presents as spotting 4
• Ultrasound evaluation is essential before performing any digital examination to rule out placenta previa or other placental abnormalities 1, 2

Remember that while a history of first-trimester miscarriage is concerning, it doesn't necessarily increase the risk of complications with post-coital spotting at 28 weeks if the current pregnancy has been otherwise uncomplicated.