What should be done for a 9-week pregnant patient experiencing heavy bleeding?

Management of Heavy Bleeding at 9 Weeks Gestation

Immediate ultrasound evaluation is the absolute first priority to distinguish between viable intrauterine pregnancy, early pregnancy loss, and ectopic pregnancy, as digital examination is contraindicated until placental location is confirmed and management depends entirely on pregnancy viability status. 1

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Assess vital signs immediately, focusing on heart rate, blood pressure, capillary refill, and conscious level to determine if the patient is compensating despite blood loss 2
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate even if formal measurement is low 2
• Establish two large-bore (14-16 gauge) intravenous lines if bleeding is heavy or patient shows signs of hemodynamic compromise 3

Critical Safety Rule

• Do NOT perform digital vaginal examination until ultrasound definitively excludes placenta previa, low-lying placenta, and vasa previa, as examination before imaging can precipitate catastrophic hemorrhage 1, 3
• Speculum examination may be performed to assess for cervical lesions, polyps, or cervical dilation if ultrasound has excluded placental causes 1

Diagnostic Workup

Transvaginal Ultrasound (First Priority)

• Transvaginal ultrasound provides superior resolution for early pregnancy evaluation and is the primary diagnostic tool 1
• At 9 weeks gestation, a viable intrauterine pregnancy must demonstrate:
  • Gestational sac with yolk sac present
  • Embryo with cardiac activity when crown-rump length exceeds 5 mm 4
  • Mean gestational sac diameter correlating with gestational age 5

Laboratory Testing

• Obtain baseline labs: complete blood count, Rh factor, coagulation panel including fibrinogen, and type and cross-match 2, 3
• Quantitative beta-hCG level should be obtained regardless of ultrasound findings 1
• Note: Serial beta-hCG levels are of minimal clinical utility once intrauterine pregnancy is visualized on ultrasound 6

Management Based on Ultrasound Findings

Viable Intrauterine Pregnancy with Subchorionic Hemorrhage

• Provide reassurance, as approximately 50% of women with first trimester bleeding will continue pregnancy successfully 4
• Schedule follow-up ultrasound in 1-2 weeks 1
• Bed rest does NOT improve outcomes and should not be recommended 5
• Progesterone supplementation has insufficient evidence for benefit in women without history of recurrent miscarriage 5, 6
• Pelvic rest (no intercourse, no tampons) is reasonable though evidence is limited 5

Early Pregnancy Loss (Nonviable Intrauterine Pregnancy)

Diagnostic criteria for early pregnancy loss include 5:

• Mean gestational sac diameter ≥25 mm with no embryo, OR
• Crown-rump length ≥7 mm with no fetal cardiac activity

Three management options exist, all with similar long-term outcomes 5, 6:

1. Expectant Management

   • Appropriate if patient is hemodynamically stable and desires this approach 5
   • Success rate approximately 80% within 2-4 weeks 5
   • Patient must understand warning signs requiring immediate evaluation: soaking more than 2 pads per hour for 2 consecutive hours, fever, severe pain 5

2. Medical Management

   • Misoprostol 800 mcg vaginally, may repeat once after 24-48 hours if needed 5
   • Success rate 84-93% 5
   • More predictable timing than expectant management 5
   • Exception: Gestational trophoblastic disease must be surgically evacuated, never medically managed 4

3. Surgical Management (Uterine Aspiration)

   • Most rapid and definitive treatment 5
   • Indicated if patient is hemodynamically unstable, has severe bleeding, or prefers immediate resolution 5
   • Consider thromboprophylaxis assessment: LMWH prophylaxis for 7-10 days if surgical procedure performed with additional VTE risk factors 7

Pregnancy of Unknown Location

If no intrauterine or ectopic pregnancy is visualized:

• Obtain serial beta-hCG measurements 48 hours apart 1
• In normal pregnancy, beta-hCG increases by 80% every 48 hours 4
• Repeat ultrasound when beta-hCG reaches discriminatory threshold of 1,500-2,000 mIU/mL 1, 4, 5
• Approximately 7-20% of pregnancies of unknown location will ultimately be diagnosed as ectopic pregnancy 1

Ectopic Pregnancy

If adnexal mass is present or free pelvic fluid is identified:

• Ectopic pregnancy until proven otherwise 4
• Management options depend on hemodynamic stability, beta-hCG level, mass size, and presence of cardiac activity 5
• Surgical management via laparoscopy if unstable, ruptured, or high beta-hCG 5
• Medical management with methotrexate if stable with specific criteria met 5

Resuscitation for Heavy Bleeding

Fluid Resuscitation

• In massive hemorrhage, use warmed blood and blood components rather than crystalloid 2
• Blood group O-negative should be transfused when needed until cross-matched blood becomes available to avoid Rh alloimmunization 3
• Actively warm the patient and all transfused fluids 2

Transfusion Thresholds

• Red cell transfusion for hemoglobin <70 g/L or hemodynamic instability 7
• Platelet transfusion if count <50,000/mm³ with ongoing bleeding 8
• Fresh frozen plasma if PT/aPTT prolonged or fibrinogen <2 g/L 8

Hemostatic Agents

• Tranexamic acid should be administered within 3 hours if bleeding meets criteria for postpartum hemorrhage (>500 mL), as effectiveness drops 10% every 15 minutes and administration beyond 3 hours may be harmful 7
• Oxytocin 10 units in 500 mL physiologic saline infused at 20-40 drops/minute for uterine atony after surgical evacuation 7

Rh Status Management

• All Rh-negative pregnant trauma/bleeding patients must receive anti-D immunoglobulin 3
• Administer 300 mcg (standard dose) for first trimester bleeding 3
• Kleihauer-Betke testing to quantify maternal-fetal hemorrhage is typically not necessary in first trimester but should be performed if bleeding is massive 3

Follow-Up Care

• Repeat complete blood count to monitor hemoglobin trajectory and assess need for iron supplementation if hemoglobin has dropped 8
• Oral iron supplementation for hemoglobin <100 g/L 8
• Psychological support and counseling regarding future pregnancy planning and contraception 4
• Document all findings carefully, especially if domestic violence is suspected 3

Critical Pitfalls to Avoid

• Never perform digital vaginal examination before ultrasound excludes placental causes of bleeding 1, 3
• Never delay tranexamic acid beyond 3 hours if hemorrhage criteria are met 7
• Never use progesterone for threatened abortion without history of recurrent miscarriage 5, 6
• Never recommend bed rest, as it does not improve outcomes 5
• Never surgically evacuate suspected gestational trophoblastic disease without tissue diagnosis, but never use medical management for confirmed GTD 4
• Never assume normal vital signs exclude significant pathology—patients can compensate well despite significant blood loss 2