Vaginal Bleeding - Causes, Pregnancy Evaluation, Ectopic Risk, Miscarriage Types, Diagnosis & Emergency Management

Vaginal bleeding is a common emergency complaint in reproductive-age individuals.
The clinical approach focuses on two initial questions:

1. Is the patient pregnant or not?

2. Is the bleeding stable, dangerous, or suggestive of pregnancy complications?

Your uploaded chart provides an excellent framework, expanded here into a clear academic article.

Red Flags in Vaginal Bleeding

These features indicate potential emergency conditions:

Major Red Flags

• Passing large clots
• Heavy bleeding (saturating >1 pad/hour)
• Severe abdominal or pelvic pain
• Dizziness or fainting
• Known ectopic pregnancy risk
• Prior need for Rhogam
• Vaginal discharge suggesting infection
• Post-intercourse bleeding
• Fever
• Abnormal pelvic exam findings

Any unstable patient requires immediate resuscitation and OB/GYN consultation.

Step 1: Immediate Pregnancy Test (UPreg)

The urine pregnancy test determines the diagnostic pathway:

If UPreg (Pregnancy Test) is Negative

✔ Stable?

If the patient is:

• Not anemic
• Bleeding < 1 pad per hour
• Has no concerning pelvic exam features

→ She may be discharged with follow-up.

✔ Consider causes such as:

• Anovulatory cycle
• Hormonal imbalance
• Fibroids
• Infection
• Vaginal or cervical lesions

If UPreg is Positive

This is where the algorithm becomes focused and structured.

Initial Workup:

• CBC
• Quantitative hCG
• Type & Screen
• Ultrasound (transvaginal if <8 weeks pregnant)

Why transvaginal?
Because it allows early detection of an intrauterine pregnancy (IUP) or ectopic pregnancy.

Ultrasound + hCG + Cervical Os = The Diagnostic Triangle

Management depends on:

1. IUP present or not?

2. hCG level (<1500 vs >1500)

3. Cervical os open or closed?

Let’s break down the scenarios from your chart.

Case Breakdown (From Chart Table)

1. No IUP, hCG < 1500, Os CLOSED

Likely very early pregnancy.

Differential:

• Early normal pregnancy
• Complete miscarriage
• Ectopic pregnancy still possible

Plan:

• Repeat hCG in 48 hours
• Follow-up ultrasound

2. No IUP, hCG < 1500, Os OPEN

Suggests miscarriage.

Differential:

• Early pregnancy loss
• Incomplete miscarriage
• Ectopic risk still present

Plan:

• Repeat hCG
• OB follow-up

3. No IUP, hCG > 1500

At this level, an IUP should be visible.

Concern:

Ectopic pregnancy until proven otherwise

Workup:

• OB consult
• Repeat hCG
• Ultrasound

4. IUP Present, Os CLOSED

Condition:

Threatened abortion

Symptoms:

• Vaginal bleeding
• Viable pregnancy on US
• Os remains closed

Plan:

• Discharge with precautions
• Repeat ultrasound next day
• OB follow-up

5. IUP Present, Os OPEN

Condition:

Inevitable abortion

Os dilation = pregnancy will not continue.

Plan:

• OB consultation
• Next-day ultrasound
• Outpatient follow-up if stable

Important Notes & Pitfalls

✔ Always confirm actual vaginal bleeding

Rectal or urologic sources may be mistaken for vaginal bleeding.

✔ Don’t call an os “open” unless absolutely certain

If unsure → chart as closed and arrange OB/GYN follow-up.

✔ Rh-Negative + Pregnant → Give Rhogam

Prevents alloimmunization.

✔ Gestational sac + yolk sac

Both are required to confirm a true IUP.

✔ Ectopic pregnancy can occur even with bleeding and low hCG

Workup Summary

Blood tests

• CBC → evaluate anemia
• hCG (quantitative) → trend over 48 hours
• Type & Screen → determine Rh status

Ultrasound

Transvaginal preferred in early pregnancy

Look for:

• Gestational sac
• Yolk sac
• Fetal heart if >6 weeks

Pelvic Exam

Check for:

• Os status (open/closed)
• Clots
• Active bleeding
• Adnexal tenderness or masses

Indications for OB/GYN Consultation

• Suspected ectopic pregnancy
• Hemodynamic instability
• Heavy bleeding
• Inevitable or incomplete miscarriage
• Missed abortion
• Significant pelvic pain
• Ultrasound findings unclear

Documentation Essentials

HPI

• Last menstrual period (LMP)
• Bleeding amount and duration
• Pain
• Pregnancy symptoms

Pelvic Exam

• Os closed
• Blood present in vault
• No adnexal masses
• No cervical motion tenderness

Skin

No pallor (assesses anemia)

Quick Summary Table

Status	Os	hCG	Diagnosis	Plan
No IUP	Closed	<1500	Early vs resolved pregnancy	Repeat hCG, US
No IUP	Open	<1500	Early miscarriage	Repeat hCG
No IUP	Either	>1500	Rule out ectopic	OB consult
IUP	Closed	—	Threatened AB	D/C home
IUP	Open	—	Inevitable AB	OB consult

FAQs About Vaginal Bleeding

1. When should a pregnant patient go to the ER?

If bleeding is heavy, painful, or accompanied by dizziness or fainting.

2. What hCG rise is normal?

A normal pregnancy doubles hCG every 48 hours.

3. Can you have an ectopic pregnancy with low hCG?

Yes—dangerous cases may have low or slowly rising levels.

4. When is Rhogam needed?

For all Rh-negative pregnant patients with bleeding.