How should a 24‑year‑old woman at 12 weeks gestation with three days of nausea and vomiting containing specks of blood and two days of bright‑red rectal bleeding, and stable vital signs, be evaluated and managed?

Evaluation and Management of a 24-Year-Old Woman at 12 Weeks Gestation with Nausea, Vomiting, Hematemesis, and Rectal Bleeding

This patient requires immediate evaluation with ultrasound to exclude life-threatening obstetric causes of vaginal bleeding (placenta previa, placental abruption, vasa previa), while simultaneously addressing her nausea and vomiting of pregnancy, which has likely caused a Mallory-Weiss tear (explaining the blood-specked vomitus) and hemorrhoidal bleeding (explaining the bright-red rectal blood on toilet paper). 1

Immediate Diagnostic Approach

Obstetric Evaluation (Priority #1)

• Perform transabdominal ultrasound immediately to exclude placenta previa, placental abruption, vasa previa, and other serious obstetric causes of second-trimester vaginal bleeding—digital pelvic examination must be avoided until these diagnoses are excluded. 1
• Ultrasound will also assess fetal viability, gestational age confirmation, and placental location. 1
• Approximately 50% of second and third trimester vaginal bleeding cases have no identifiable cause, but life-threatening conditions must be ruled out first. 1

Gastrointestinal Source Evaluation

• Blood-specked vomitus after three days of persistent vomiting strongly suggests a Mallory-Weiss tear (esophageal mucosal tear from forceful vomiting) rather than a primary GI bleed. 1
• Bright-red blood on toilet paper after wiping is the classic presentation of hemorrhoidal bleeding—the blood typically appears on toilet paper or drips into the bowl, not mixed with stool. 1
• Perform careful anorectal examination with anoscopy to visualize internal hemorrhoids and exclude anal fissure, perianal abscess, or other anorectal pathology—do not assume hemorrhoids without direct visualization. 1

Laboratory Assessment

• Check complete blood count to assess for anemia (though anemia from hemorrhoids alone is rare, occurring in only 0.5 per 100,000 population). 1
• Obtain comprehensive metabolic panel to evaluate for electrolyte abnormalities (hypokalemia, hyponatremia, hypochloremia, metabolic alkalosis), elevated BUN/creatinine ratio suggesting dehydration, and liver function tests (AST/ALT elevated in 40-50% of hyperemesis cases). 2, 3
• Urinalysis for ketonuria—presence indicates inadequate hydration and progression toward hyperemesis gravidarum. 2, 3
• Check thyroid function tests, as biochemical hyperthyroidism occurs commonly with hyperemesis but rarely requires treatment. 2, 3

Severity Assessment of Nausea and Vomiting

Use PUQE Score for Objective Measurement

• Calculate the Pregnancy-Unique Quantification of Emesis (PUQE) score based on the preceding 12 hours: total hours of nausea + number of vomiting episodes + number of retching episodes. 2, 4
• PUQE ≤6 = mild; 7-12 = moderate; ≥13 = severe requiring escalation of therapy. 2, 4

Red Flags Requiring Hospitalization

• Weight loss ≥5% of pre-pregnancy weight 2, 4
• Ketonuria with dehydration 2, 4
• Inability to tolerate any oral intake for >24 hours 2, 4
• Electrolyte abnormalities (particularly hypokalemia with hypomagnesemia, which prolongs QT interval and increases arrhythmia risk) 2

Management Algorithm

For Nausea and Vomiting (First Priority)

Immediate Pharmacologic Treatment:

• Start doxylamine 10 mg plus pyridoxine (vitamin B6) 10-25 mg every 8 hours immediately—this is the first-line, evidence-based treatment safe throughout pregnancy and breastfeeding. 2, 4, 5, 6
• Add thiamine 100 mg daily immediately if vomiting has persisted for more than 1-2 weeks, as thiamine stores deplete rapidly (within 7-8 weeks of persistent vomiting, potentially exhausted after only 20 days), and deficiency can cause Wernicke's encephalopathy. 2, 4, 3

If Symptoms Persist or Worsen (Second-Line):

• Escalate to metoclopramide 5-10 mg orally every 6-8 hours—this is the preferred second-line agent with extensive safety data showing no increased risk of major congenital defects in 33,000 first-trimester exposures (OR 1.14,99% CI 0.93-1.38). 2, 4
• Ondansetron 4-8 mg every 8 hours can be used at 12 weeks gestation (patient is past the critical 10-week window where concerns about congenital heart defects exist). 2, 4

Supportive Measures:

• Recommend small, frequent, bland meals (BRAT diet: bananas, rice, applesauce, toast), high-protein/low-fat foods, and avoidance of strong odors or known triggers. 2, 4
• Ginger 250 mg capsules four times daily may provide additional symptom relief. 2, 4

If Hospitalization Required:

• Initiate IV fluid resuscitation targeting urine output ≥1 L/day and resolution of ketonuria. 2
• Aggressively replace potassium and magnesium (hypokalemia with hypomagnesemia prolongs QT interval and raises arrhythmia risk). 2
• Switch to IV thiamine 200-300 mg daily if oral intake is impossible. 2

For Rectal Bleeding (Secondary Priority)

Conservative Management for Hemorrhoids:

• Medical therapy is appropriate for first-degree hemorrhoids (bleeding without prolapse)—the cornerstone is adequate fiber and water intake. 1
• Topical corticosteroids and analgesics are useful for managing perianal irritation, but prolonged use of potent corticosteroid preparations should be avoided. 1
• Sitz baths and stool softeners to prevent straining during defecation. 1

When to Escalate:

• If hemorrhoidal bleeding is atypical (dark blood, blood mixed in stool rather than on toilet paper), perform flexible sigmoidoscopy at minimum. 1
• Complete colonoscopy is indicated if no source is evident on anorectal examination or if the patient has significant risk factors for colorectal neoplasia (though unlikely at age 24). 1
• Hemorrhoids alone do not cause positive fecal occult blood testing—if stool guaiac is positive, the colon must be adequately evaluated. 1

For Blood-Specked Vomitus

• Mallory-Weiss tears typically heal spontaneously once vomiting is controlled with antiemetic therapy—no specific intervention is required beyond treating the underlying nausea and vomiting. 1
• If hematemesis persists or worsens despite antiemetic therapy, consider upper endoscopy to exclude other causes (peptic ulcer disease, esophagitis, varices). 1

Critical Pitfalls to Avoid

• Never perform digital pelvic examination before ultrasound excludes placenta previa, low-lying placenta, and vasa previa—digital examination can precipitate catastrophic hemorrhage in these conditions. 1
• Do not attribute all symptoms to "normal pregnancy"—three days of persistent vomiting with blood-specked vomitus and rectal bleeding requires systematic evaluation to exclude serious pathology. 1
• Do not delay antiemetic therapy—early treatment may prevent progression to hyperemesis gravidarum, which is associated with poor maternal and fetal outcomes including low birth weight, preterm delivery, and maternal Wernicke's encephalopathy. 2, 4, 5, 6
• Do not assume hemorrhoids without direct visualization—anal fissure, perianal abscess, and other anorectal pathology frequently cause similar symptoms. 1
• Do not withhold thiamine supplementation—if vomiting has been persistent for more than 1-2 weeks, thiamine stores are likely depleted and Wernicke's encephalopathy is a real risk. 2, 4, 3

Expected Clinical Course

• Nausea and vomiting of pregnancy typically begins at 4-6 weeks gestation, peaks at 8-12 weeks (where this patient is now), and resolves by week 16 in >50% of patients and by week 20 in 80%. 7, 2
• With appropriate antiemetic therapy, symptoms should improve within 24-48 hours—if no improvement occurs, escalate to second-line agents and consider hospitalization. 2, 4
• Hemorrhoidal bleeding should resolve with conservative management (fiber, fluids, stool softeners) within 1-2 weeks. 1
• Recurrence risk of hyperemesis in subsequent pregnancies is 40-92%. 2, 4