What should I do if I experience spotting during pregnancy?

Management of Spotting During Pregnancy

If you experience spotting during pregnancy, immediately contact your healthcare provider for evaluation with transvaginal ultrasound and quantitative beta-hCG testing—do not undergo any digital pelvic examination until ultrasound excludes placenta previa or vasa previa, as examination before imaging can cause catastrophic hemorrhage. 1, 2

Immediate Actions and Safety Considerations

• Avoid digital pelvic examination until ultrasound imaging is completed, particularly in second and third trimester bleeding, as this can precipitate life-threatening hemorrhage if placenta previa or vasa previa is present 1, 2
• Assess your hemodynamic stability (dizziness, rapid heart rate, feeling faint) and seek emergency care if you experience heavy bleeding, severe pain, or signs of shock 1
• Determine exact gestational age, as management differs significantly between first trimester (before 13 weeks) and second/third trimester bleeding 1, 2

Essential Diagnostic Evaluation

• Transvaginal ultrasound is the primary diagnostic tool and must be performed before any internal examination, as it provides superior resolution for early pregnancy assessment 1, 2
• Obtain quantitative beta-hCG level regardless of ultrasound findings, as this helps distinguish normal from abnormal pregnancy 2
• If intrauterine pregnancy is confirmed on ultrasound, ectopic pregnancy is essentially ruled out (except rare heterotopic pregnancy) 1, 2

Understanding Your Prognosis

• Approximately 20-40% of pregnant women experience first trimester bleeding, and about half of these pregnancies continue successfully 3, 4
• If a live fetus with cardiac activity is seen on ultrasound, approximately 89% of pregnancies continue to viability, though the miscarriage rate is still 11% 5
• Heavy bleeding carries more than twice the risk of miscarriage compared to light spotting 5
• The presence of a subchorionic hemorrhage (blood collection) on ultrasound increases miscarriage risk 2.6-fold (23% vs 9% without hemorrhage) 5

Follow-Up Based on Initial Findings

If Viable Intrauterine Pregnancy is Confirmed:

• Schedule follow-up ultrasound in 1-2 weeks to confirm continued viability 2
• Expectant management with watchful waiting is appropriate if fetal heart activity is present and you are medically stable 6
• Bed rest does not improve outcomes and is not recommended 4

If Pregnancy of Unknown Location (No Intrauterine or Ectopic Pregnancy Seen):

• Serial beta-hCG measurements every 48 hours are mandatory, as 7-20% of these cases will be ectopic pregnancies 1, 2
• Repeat ultrasound when beta-hCG reaches 1,500-2,000 mIU/mL (the discriminatory threshold), at which point a normal intrauterine pregnancy must show a gestational sac 2, 4
• In normal pregnancy, beta-hCG levels increase by 80% every 48 hours 6
• Continue monitoring until definitive diagnosis is established 2

If Second or Third Trimester Bleeding:

• Approximately 50% of cases have no identifiable cause, but serious conditions like placenta previa (most common identified cause) and placental abruption (1% of pregnancies) must be excluded 1
• Ultrasound misses up to 50% of placental abruptions, so clinical correlation with pain, uterine tenderness, and contractions is essential 2
• Pathologic bleeding may require hospitalization and/or delivery 1

Specific Conditions to Discuss with Your Provider

• Ectopic pregnancy occurs in 1-2% of pregnancies and accounts for 6% of maternal deaths—requires immediate specialist consultation if suspected 4
• Threatened miscarriage is diagnosed when bleeding occurs with a closed cervix and viable pregnancy 3, 4
• Subchorionic hemorrhage with viable pregnancy requires follow-up ultrasound in 1-2 weeks 2

Critical Warning Signs Requiring Emergency Evaluation

• Heavy bleeding (soaking through a pad per hour) 5
• Severe abdominal or pelvic pain 4
• Dizziness, fainting, or signs of shock 1
• Shoulder pain (can indicate internal bleeding from ectopic pregnancy) 4

Common Pitfalls to Avoid

• Never allow digital pelvic examination before ultrasound in second/third trimester bleeding 1, 2
• Do not assume light spotting is always benign—ectopic pregnancy can present with minimal bleeding 4
• Do not delay follow-up if pregnancy location cannot be determined initially, as close monitoring is essential 2
• Ultrasound can miss ectopic pregnancy in 74% of initial scans, making serial beta-hCG monitoring critical when diagnosis is uncertain 2