What are the management and evaluation steps for a pregnant female experiencing spotting, particularly if she has a history of bleeding disorders or is taking anticoagulant medications?

Management of Spotting in Pregnancy

For pregnant women experiencing spotting, immediate assessment of hemodynamic stability and ultrasound evaluation to exclude placenta previa, vasa previa, and ectopic pregnancy must be performed before any digital pelvic examination, with management tailored to trimester, bleeding severity, and underlying conditions such as thrombophilia or anticoagulation use. 1

Initial Evaluation and Stabilization

Immediate Assessment

• Check vital signs immediately to determine hemodynamic stability and assess for shock using shock index and patient physiology 1
• Avoid digital pelvic examination until ultrasound has excluded placenta previa, low-lying placenta, and vasa previa in second and third trimester bleeding 1
• Ultrasound is the diagnostic mainstay before performing any digital examination in pregnant patients with vaginal bleeding 1

First Trimester Spotting (Most Common Presentation)

• Perform both transabdominal and transvaginal ultrasound with Doppler to assess for intrauterine pregnancy, ectopic pregnancy, or nonviable pregnancy 1
• Ultrasound is required for definitive diagnosis, as clinical assessment alone shows only 38.8% concordance with actual diagnosis 2
• Use quantitative β-hCG levels in conjunction with ultrasound findings; the discriminatory level (1,500-3,000 mIU/mL) is the threshold above which an intrauterine pregnancy should be visible on transvaginal ultrasound 3
• Ectopic pregnancy must be ruled out, particularly after 7 weeks of amenorrhea, as failure to diagnose carries life-threatening consequences 4, 5

Management in Women with Bleeding Disorders

Active Bleeding with Known Bleeding Disorder

• Target fibrinogen levels ≥1.5 g/L in women with bleeding disorders experiencing first trimester vaginal bleeding 1
• Consider early fibrinogen replacement if levels are inadequate 1
• Schedule delivery with laboratory and blood bank support if fibrinogen levels are <1 g/L in the third trimester 1
• Maintain fibrinogen ≥1.5 g/L for neuraxial anesthesia and cesarean section 1

Postpartum Monitoring

• Continue clinical monitoring for 72 hours postpartum in women with bleeding disorders 1
• Consider early use of fibrinogen replacement and tranexamic acid if postpartum bleeding occurs 1

Management in Women on Anticoagulation

Pregnant Women Receiving Long-Term Vitamin K Antagonists

• Switch to adjusted-dose LMWH or 75% of therapeutic dose LMWH throughout pregnancy, then resume long-term anticoagulants postpartum 6
• Subcutaneous LMWH or UFH is favored over oral anticoagulation during pregnancy 1

Women with Mechanical Heart Valves (High-Risk Scenario)

• Use adjusted-dose bid LMWH throughout pregnancy with doses adjusted to achieve manufacturer's peak anti-Xa LMWH 4 hours post-injection, OR adjusted-dose UFH subcutaneously every 12 hours 6
• Consider adding low-dose aspirin 75-100 mg/day in women at high risk of thromboembolism 1

Women with Thrombophilia

• For homozygous Factor V Leiden or prothrombin 20210A mutation with positive family history of VTE: use antepartum prophylaxis with prophylactic- or intermediate-dose LMWH 6
• For other thrombophilias with positive family history of VTE: clinical vigilance during pregnancy with postpartum prophylaxis 6
• Do NOT use antithrombotic prophylaxis for women with inherited thrombophilia and history of pregnancy complications alone without VTE history 6

Specific Clinical Scenarios

Threatened Abortion

• Expectant management is appropriate for threatened abortion 3
• Bed rest does not improve outcomes 3
• Pain and heavy bleeding are associated with increased risk of early pregnancy loss 3

Confirmed Early Pregnancy Loss

• Ultrasound findings diagnostic of early pregnancy loss include mean gestational sac diameter ≥25 mm with no embryo, or no fetal cardiac activity when crown-rump length is ≥7 mm 3
• Treatment options include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration 3

Women with Portal Hypertension/Varices

• Consider non-selective beta-blockers (propranolol preferred) for prophylaxis of variceal bleeding 1
• For active variceal hemorrhage: immediate resuscitation, emergent endoscopic therapy, octreotide (avoid terlipressin due to uterine contraction risk), and cephalosporin antibiotic prophylaxis 1
• Monitor for postpartum hemorrhage, which occurs in 5-45% of women with cirrhosis 1

Critical Pitfalls to Avoid

• Never perform digital examination before ultrasound in second/third trimester bleeding to avoid catastrophic hemorrhage from placenta previa 1
• Do not rely on clinical diagnosis alone—ultrasound is essential as clinical assessment has low concordance (38.8%) with actual diagnosis 2
• Do not miss ectopic pregnancy—maintain high suspicion with abdominal pain and bleeding after 7 weeks amenorrhea 4, 5
• Do not continue vitamin K antagonists during pregnancy—switch to LMWH to avoid fetal complications 6
• Do not screen for inherited thrombophilia based on pregnancy complications alone without VTE history 6