Management of Bright Red Vaginal Bleeding with Pain in a 28-Year-Old Pregnant Woman
This patient requires immediate ultrasound evaluation without digital pelvic examination to determine pregnancy location, viability, and exclude life-threatening causes such as ectopic pregnancy, placental abruption, or placenta previa. 1, 2, 3
Critical First Steps: What NOT to Do
- Never perform digital pelvic examination before ultrasound has definitively excluded placenta previa, low-lying placenta, and vasa previa, as examination can precipitate catastrophic hemorrhage 2, 3
- Obtain quantitative beta-hCG immediately regardless of reported last menstrual period or contraceptive use 3
- Assess hemodynamic status immediately: check vital signs, establish IV access, and initiate fluid resuscitation if tachycardia, hypotension, or altered mental status are present 1
Diagnostic Algorithm Based on Gestational Age
If First Trimester (Most Likely Given Age and Presentation)
Painful bleeding suggests threatened abortion, early pregnancy loss, or ectopic pregnancy rather than benign causes 3, 4, 5
- Pain and heavy bleeding are associated with increased risk of early pregnancy loss 5
- Ectopic pregnancy must be excluded immediately as it can rapidly progress to life-threatening hemorrhage 3
- Approximately one-fourth of pregnant women experience first trimester bleeding, with about half progressing to miscarriage 4
Key discriminatory criteria:
- When beta-hCG reaches 1,500-2,000 mIU/mL, a normal pregnancy should show a gestational sac on transvaginal ultrasound 4, 5
- When gestational sac >10 mm diameter, a yolk sac must be present 4
- When crown-rump length >5-7 mm, cardiac activity must be present 4, 5
- In normal pregnancy, beta-hCG increases by 80% every 48 hours 4
If intrauterine pregnancy confirmed with fetal cardiac activity:
- Guarded reassurance and watchful waiting are appropriate if patient is medically stable with no adnexal mass or signs of intraperitoneal bleeding 4
- Bed rest does not improve outcomes 5
If profuse bleeding with confirmed early pregnancy loss:
- Surgical evacuation (suction curettage or D&C) is the treatment of choice to control bleeding 1
- Medical management with misoprostol is contraindicated as it may worsen hemorrhage before achieving complete expulsion 1
- Expectant management should not be attempted with profuse bleeding as it risks severe hemorrhage and hemodynamic collapse 1
If ectopic pregnancy suspected:
- Absence of intrauterine pregnancy with beta-hCG above discriminatory level raises concern for ectopic pregnancy 4, 5
- Presence of adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise 4
- Transvaginal ultrasound may miss up to 74% of ectopic pregnancies initially 3
If Third Trimester (8 Months)
Painful bleeding suggests placental abruption rather than placenta previa (which is typically painless) 2, 3
- Placental abruption affects approximately 1% of pregnancies and presents with uterine tenderness, increased uterine tone, and potential hemodynamic instability 3
- Transabdominal ultrasound is mandatory first imaging study before any examination 2
- If placenta previa confirmed, planned cesarean delivery is required 2
Post-Procedure Management (If Surgical Intervention Required)
- Monitor for 2-4 hours minimum after surgical evacuation, observing for continued bleeding, vital sign stability, and adequate urine output 1
- Administer uterotonics (oxytocin infusion or methylergonovine) if uterine atony suspected 1
- Administer Rh immunoglobulin to Rh-negative patients within 72 hours 1
Common Pitfalls to Avoid
- Never attempt expectant management with profuse bleeding 1
- Never use misoprostol as first-line treatment for profuse bleeding 1
- Never perform digital examination before ultrasound 2, 3
- Do not assume contraception or reported menstrual history excludes pregnancy 3
- Transvaginal ultrasound is safe even with placenta previa 3