First-Trimester Bleeding – ED

First-Trimester Bleeding

1. In a patient with acute vaginal bleeding, look for and recognize early signs of shock (e.g., vital signs, orthostatic changes).

General Approach – ABC, O2, Monitor, O- blood, cross match

2. Given a patient with vaginal bleeding, consider pregnancy in the differential diagnosis and investigate appropriately to rule out an ectopic location when pregnancy is identified.


If negative, consider PALM COEIN

  • Causes: 1) structural 2) Coagulation 3) Ovulatory dysfunction
  • Structural: Polyps, Adenomyosis, Leimyoma (fibroid), Malignancy and hyperplasia
  • Non-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified

If positive, ensure IOP

  • bHCG doubles Q2d until week 10 for normal pregnancy then declines
  • US
    • 5wk – gestational sac,
    • 5wk+4 – yolk sac,
    • 6wk – fetal pole,
    • 8wk – CRL 16cm
  • Fetal demise if
    • CRL 7mm without FHR or
    • Mean gestation sac 25mm without a fetus;
    • 2wk after visual gestational sac w/o FHR or
    • 1wk + 4 d after visualized yolk sac
  • bHCG higher than expected – gestational trophoblastic disease
  • bHCG lower – ? ectopic – especially US didn’t show IUP but bHCG above discriminatory zone

3. In any patient with vaginal bleeding in the first trimester, perform an appropriate pelvic exam (both speculum and bi-manual).


  • implantation bleed, subchorionic hemorrhage,
  • threatened/ectopic/incomplete abortion,
  • PID/STD, cervical lesions, vaginal trauma,
  • trophoblastic disease, or
  • coagulation issues (vWD)


  • Hx – focus on ovulatory history and coagulation
  • O/E – look for structural causes of vaginal bleeding (speculum for vaginal/cervix and bimanual for endometrial) & opening of cervic
  • b/w to assess coagulopathy and Hgb (stable vs unstable)
  • US to assess structural causes

4. In the investigation of a pregnant patient with vaginal bleeding, recognize the limitations of quantitative beta-hCG and ultrasound testing (beta-hCG above discriminatory zone and no yolk sac in uterus) in ruling out ectopic pregnancy.

Negative US can’t rule out ectopic pregnancy. 

5. In pregnant patients with vaginal bleeding, determine maternal Rh status so as to offer prophylaxis for Rh sensitization.

RH 50mcg IM for GA <12 wk and 300mcg for GA >12wk

use Kleihauer test to quantify fetal blood exposure (not needed until around GA 16wk as fetal blook <30ml and rhogam 300mcg can neutralize up to 30ml of fetal blood)

6. In discharging a patient with a non-viable pregnancy, ensure appropriate arrangements for counselling, support, and follow-up.

Non-viable pregnancy

GA >13wk, hemorrhage, infection, unstable –> D&C

If stable and <12+6 wk

  • expectant management is an option
  • Misoprostol can be tried

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CCFP ExamApril 30, 2015
The big day is here.
September 2020
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