What is the management for vaginal bleeding at 8 weeks and 4 days of gestation with a recent ultrasound showing a viable fetus and a drop in hemoglobin levels from 107 to 96?

Management of First Trimester Vaginal Bleeding with Viable Fetus and Declining Hemoglobin

For vaginal bleeding at 8 weeks 4 days gestation with a recent viable ultrasound and hemoglobin drop from 107 to 96 g/L, the primary management is expectant with close monitoring, repeat ultrasound in 1-2 weeks, and assessment for ongoing hemorrhage requiring intervention. 1, 2

Immediate Assessment

Hemodynamic Stability

• Assess for signs of ongoing hemorrhage: orthostatic vital signs, tachycardia, and symptoms of hypovolemia (lightheadedness, syncope) 3
• The hemoglobin drop of 11 g/L (107→96) suggests moderate blood loss but does not necessarily indicate active hemorrhage requiring transfusion 4
• Determine if bleeding is ongoing or has resolved through patient history 3

Exclude Life-Threatening Diagnoses

• Do not perform digital pelvic examination until ultrasound excludes placenta previa and vasa previa (though rare at 8 weeks, examination can precipitate catastrophic hemorrhage) 1, 3
• Ectopic pregnancy is essentially ruled out since intrauterine pregnancy was confirmed 4 days ago, except in rare heterotopic pregnancy cases 1
• Perform speculum examination only to assess for cervical lesions, polyps, or inflammation as alternative bleeding sources 3

Diagnostic Workup

Repeat Ultrasound

• Schedule repeat transvaginal ultrasound in 1-2 weeks to confirm continued fetal viability 1, 2
• Transvaginal ultrasound provides superior resolution for early pregnancy assessment compared to transabdominal 1
• Approximately 50% of women with first trimester bleeding will continue to have viable pregnancies 2, 5

Laboratory Assessment

• Obtain quantitative beta-hCG level regardless of ultrasound findings to establish trend 1, 3
• Repeat complete blood count to monitor hemoglobin trajectory and assess need for iron supplementation 4
• Consider coagulation studies only if there is concern for underlying bleeding disorder (heavy bleeding, family history) 4

Management Strategy

Expectant Management

• Threatened abortion is managed expectantly with observation 2
• Bed rest does not improve outcomes and should not be routinely recommended 2
• There is insufficient evidence supporting routine use of progestins for threatened abortion 2

Patient Counseling

• Pain and heavy bleeding are associated with increased risk of early pregnancy loss 2
• The viable pregnancy rate at 6-8 weeks gestation in patients with bleeding is approximately 61% 6
• First trimester bleeding is associated with increased risk of preterm delivery, placental abruption later in pregnancy, and small for gestational age infants 1

Follow-Up Protocol

• Repeat ultrasound in 1-2 weeks to confirm fetal viability 1, 2
• If bleeding persists or worsens, consider earlier ultrasound evaluation 5
• Serial beta-hCG measurements every 48 hours are indicated only if ultrasound findings become inconclusive 1, 3

Red Flags Requiring Urgent Re-evaluation

• Severe abdominal pain suggesting ectopic pregnancy or other complications 2
• Heavy bleeding (soaking more than 2 pads per hour) 2
• Hemodynamic instability (orthostatic hypotension, tachycardia) 3
• Fever suggesting infection 5
• Passage of tissue (may indicate pregnancy loss) 5

Special Considerations

Subchorionic Hemorrhage

• If subchorionic hemorrhage is identified on ultrasound with viable pregnancy, schedule follow-up ultrasound in 1-2 weeks 1
• This is a common finding in first trimester bleeding and often resolves spontaneously 5

Anemia Management

• Consider oral iron supplementation given hemoglobin drop to 96 g/L 4
• Transfusion is not indicated at this hemoglobin level unless patient is symptomatic or actively hemorrhaging 4

Common Pitfalls

• Never perform digital pelvic examination before ultrasound in pregnant patients with vaginal bleeding 1, 3
• Do not assume bleeding automatically indicates pregnancy loss—37% of patients with first trimester bleeding have viable pregnancies on ultrasound 6
• Ultrasound interpretation requires experienced operators; early "intrauterine" pregnancies can be misdiagnosed 7
• Do not delay repeat ultrasound beyond 2 weeks if bleeding continues, as timely diagnosis allows appropriate counseling and management 1, 2