What to do after vaginal bleeding during pregnancy has stopped?

Management After Vaginal Bleeding in Pregnancy Has Stopped

After vaginal bleeding during pregnancy has stopped, patients should undergo ultrasound evaluation to determine the cause of bleeding and receive appropriate monitoring based on the identified etiology. 1

Initial Assessment

• Ultrasound imaging is the mainstay for accurate diagnosis and management guidance after vaginal bleeding has stopped, as digital pelvic examination should be avoided until diagnoses such as placenta previa, low-lying placenta, and vasa previa have been excluded 1
• Both transabdominal and transvaginal ultrasound should be considered, with transvaginal ultrasound being particularly helpful for cervical-related causes of bleeding 1
• Laboratory assessment should include complete blood count and coagulation panel including fibrinogen levels 2

Management Based on Gestational Age and Findings

For Viable Pregnancies (≥23 weeks)

• All pregnant patients with a viable pregnancy who experienced bleeding should undergo electronic fetal monitoring for at least 4 hours, even after bleeding has stopped 2
• Patients with adverse factors including uterine tenderness, significant abdominal pain, history of vaginal bleeding, sustained contractions (>1/10 min), rupture of membranes, atypical or abnormal fetal heart rate pattern, high-risk mechanism of injury, or serum fibrinogen <200 mg/dL should be admitted for observation for 24 hours 2
• An obstetrical ultrasound should be performed prior to discharge for all patients admitted for monitoring 2

For Specific Diagnoses

1. Placenta Previa:

   • If asymptomatic previa is diagnosed and bleeding has stopped, patients can continue normal activities with repeat ultrasound evaluation at 28 weeks 3
   • Persistent previa in the third trimester requires pelvic rest and hospitalization if significant bleeding recurs 3

2. Placental Abruption:

   • Management should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for diagnosis 2
   • Close monitoring is essential as abruption may require rapid operative delivery to prevent neonatal morbidity and mortality 3

3. Congenital Fibrinogen Disorders:

   • For patients with diagnosed fibrinogen disorders who experienced vaginal bleeding, fibrinogen replacement should be continued until fibrinogen level reaches ≥1.5 g/L even after bleeding has stopped 1

Follow-up Care

• Schedule a follow-up appointment within 1-2 weeks to reassess maternal and fetal well-being 1
• For Rh-negative patients, anti-D immunoglobulin should be administered after bleeding episodes 2
• Quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done in Rh-negative patients to determine if additional doses of anti-D immunoglobulin are needed 2

Warning Signs for Immediate Return

Instruct patients to return immediately if they experience:

• Recurrence of bleeding 1
• Decreased fetal movement 1
• Severe abdominal pain 2
• Fever or signs of infection 2

Common Pitfalls and Caveats

• Approximately half of patients with vaginal bleeding during pregnancy have no identifiable cause, but this remains a diagnosis of exclusion 1
• Placental abruption may be difficult to diagnose by ultrasound, with detection rates of 50% or less, so clinical vigilance is essential even when imaging appears normal 1
• Digital pelvic examination should be deferred in cases of bleeding at or after 23 weeks until placenta previa is excluded by ultrasound 2
• Radiographic studies indicated for maternal evaluation should not be deferred due to concerns regarding fetal radiation exposure if they are clinically necessary 2