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Evaluation of Vaginal Bleeding in Second Trimester
- > 20 weeks: we generally do not see the patients except for severe illness or trauma.
Differential Diagnosis:
- Ectopic pregnancy is exceedingly rare, but is possible. Usually presents in 1st
- Miscarriage
- Cervical insufficiency
- Vaginal/cervical pathology
- Abuptio placenta
After 20 weeks also consider:
- Placenta previa: *** do not digitally examine patients.
- Uterine rupture
- Vasa previa
Bleeding associated with cramping or pelvic pressure is an indicator of miscarriage. Small amount of painless vaginal bleeding is more typical of cervical insufficiency.
What do you do?
1) Stabilize: IV, oxygen, monitor, give fluids
2) Send labs: CBC, Type and Screen
3) Examine the patient
- 16 weeks: Fundus is half way between the pelvic brim and the umbilicus.
- 20 weeks: Fundus is at umbilicus.
- Vagina: look for fresh blood, pooling of blood, polyps/lacerations/lesions.
- Cervix: look for bulging membranes, bloody show, mass/lesions.
- Digital Exam: determine if the os is open/closed, if there is effacement of the cervix.
- U/S to determine if the fetus is alive.
A few words about cerclage: elective, historical indication, cervix <25mm by TVUS.
From the literature:
2004, Journal of Epidemiology: observational study of 166 patients with second trimester bleeding had NO significant increased risk of preterm labor or PPROM.
2011, Journal of Royal Society of Meidicine, retrospective, 177 patients had cerclage, 116 were ultrasound or historically indicated, 61 were emergency. Significantly higher complication risks and worse outcome seen with emergency cerclage (birth at 26 weeks vs 32 weeks).
Consult GYNECOLOGY and admit the patient to their service.
Jay Khadpe MD
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