From the Guidelines
For a pregnant patient with new onset rectal bleeding, you should consult obstetrics/gynecology (OB/GYN) as part of your management plan. Begin with a focused history and physical examination, including a gentle digital rectal exam to assess for hemorrhoids or anal fissures, which are common causes of rectal bleeding during pregnancy 1. Laboratory tests should include complete blood count to assess for anemia, coagulation studies, and comprehensive metabolic panel. Determine the gestational age through last menstrual period or ultrasound if not already known. Fetal heart monitoring is appropriate depending on gestational age. For imaging, consider a limited abdominal ultrasound if needed, as it poses minimal risk to the fetus. Avoid CT scans due to radiation exposure. If endoscopy is necessary, flexible sigmoidoscopy without sedation is preferred in the second trimester if possible. The OB/GYN consultation is crucial because pregnancy alters normal physiology, may contraindicate certain medications and procedures, and requires monitoring of both maternal and fetal well-being. Management decisions must balance treating the bleeding source while minimizing risks to the pregnancy, which necessitates a multidisciplinary approach.
Some key points to consider in the management of rectal bleeding in pregnancy include:
- Assessing the severity of bleeding and stabilizing the patient if necessary 1
- Evaluating for other causes of lower gastrointestinal bleeding, such as anorectal varices 1
- Considering the risks and benefits of imaging studies, such as ultrasound and endoscopy, in the pregnant patient 1
- Consulting with OB/GYN to ensure that management decisions are made with consideration of both maternal and fetal well-being.
In terms of specific tests and procedures, the following may be considered:
- Complete blood count to assess for anemia
- Coagulation studies to evaluate for bleeding disorders
- Comprehensive metabolic panel to assess for electrolyte imbalances
- Ultrasound to evaluate for placenta previa or other obstetric complications
- Flexible sigmoidoscopy without sedation if endoscopy is necessary.
It is essential to prioritize the health and well-being of both the mother and the fetus in the management of rectal bleeding during pregnancy. Consultation with OB/GYN is crucial to ensure that management decisions are made with consideration of both maternal and fetal well-being.
From the FDA Drug Label
If pregnant or breast-feeding, ask a health professional before use. The FDA drug label does not answer the question.
From the Research
Evaluation and Management of Rectal Bleeding in Pregnancy
- Rectal bleeding is a common symptom experienced by pregnant women, with approximately 40% of pregnant women experiencing it 2.
- The majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, but other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked 3, 2.
Consultation with OB-GYN
- A multidisciplinary team approach is essential in the management of rectal bleeding during pregnancy, suggesting the need for consultation with an OB-GYN 3.
- Providers must be mindful of the changes in normal ranges for common haematological and biochemical parameters in pregnancy compared with the non-pregnant state 2.
Additional Workup and Tests
- Imaging investigations or flexible sigmoidoscopy may be warranted in the evaluation of rectal bleeding in pregnancy 2.
- Faecal calprotectin is an established tool for identification of intestinal inflammation and is valid in pregnancy, with an elevated level (≥ 50 µg/g) signifying a need for further diagnostic evaluation 2.
- Women with evidence of haemodynamic compromise, elevated inflammatory markers, significant anaemia, signs of intestinal obstruction or compromise to the fetus should be evaluated urgently 2.
- Colonoscopy may be considered in older patients, but its necessity in pregnant women is not explicitly stated in the provided studies 4.