Early pregnancy bleeding

• 20 - 40 % of pregnant women will experience bleeding during the first trimester of pregnancy
• Major causes are miscarriage (10-20%) and ectopic pregnancy (1-2%)
• Establishing the site of the pregnancy is vital, as failure to correctly diagnose an ectopic can have potentially life threatening consequences
• Initial assessment is haemodynamic stability. Unstable patients need to be transferred to the emergency department
• History
• gestational age of the pregnancy
• the amount of blood loss
• any associated pain symptoms 
• the presence of syncope, chest pain and shortness of breath may point to anaemia from significant blood loss, and shoulder tip pain may be associated with intra-abdominal bleeding 
• Examination 
• Assess for haemodynamic instability 
• abdominal examination 
• speculum examination to assess the amount and origin of ongoing bleeding
• bimanual examination allows assessment of uterine size, dilatation of the cervical os, pelvic tenderness and cervical motion tenderness
• Investigation 
• Beta HCG (Serum HCG levels rise exponentially up to six to seven weeks of gestation, increasing by at least 66 % every 48 hours)
• Ultrasound assessment
• Testing for maternal blood group and antibody status will determine the need for RhD immunoglobulin administration 
• On TVS, a gestational sac will usually be visible from 4 weeks and 3 days after the last menstrual period
• Management 
• Rh D immunoglobulin is indicated for the prevention of Rh D sensitisation in Rh D negative women. This should be given within 72 hours of the sensitising event.

References:

http://www.racgp.org.au/afp/2016/may/early-pregnancy-bleeding/