.
Ectopic pregnancy
Ectopic pregnancies occur in about 1.4% of pregnancies. Patients may be asymptomatic or may present with mild to severe pain. If there is rupture, they might range from having mild peritoneal irritation from blood to having severe hemorrhagic shock. Most patients are asymptomatic or mildly symptomatic when diagnosed. Patients with previous pelvic infections or previous tubal disease or tubal surgery have an increased risk. Women using birth control are at an increased risk. A woman with a previous tubal ligation has 1 in 3 risk of an ectopic if she becomes pregnant, while a woman with an IUD has a 1 in 6 risk of an ectopic with pregnancy. The diagnosis is clinical and should be presumed in any woman with severe pain and shock and a positive pregnancy test or when there is evidence of no intrauterine pregnancy and an HCG level greater than 3500. Some women can have both an intrauterine pregnancy and an ectopic pregnancy concurrently (heterotopic pregnancy).
.
Miscarriage
Miscarriage occurs in about 15-20% of pregnancies with 80% of miscarriages occurring in the first trimester. The biggest causal factor of miscarriage in the first trimester is chromosomal abnormalities, accounting for about 50% of miscarriages. Once a heartbeat is heard patients’ risk of miscarriage, if they present with bleeding, is ≤10%. If they are asymptomatic and a heartbeat has been heard their risk at 6 weeks is ≤9% and ≤0.5% at 9 weeks. Patients will present with mild bleeding at first that may or may not progress into cramping abdominal pain anywhere from hours to days after the initial onset of bleeding. They may have a feeling of pelvic pressure or discomfort and notice a passage of tissue or products. Hemorrhage can occur. The severity of symptoms depends upon the gestational age at which the miscarriage occurs and the type of miscarriage (complete, incomplete, missed). Some risk factors associated with miscarriage are: advanced maternal age, smoking, cocaine or alcohol use, maternal thrombophilias, maternal uterine defects, and uncontrolled chronic maternal conditions such as diabetes or thyroid conditions. Miscarriage is diagnosed by ultrasound findings that show an anembryonic gestation, no embryonic cardiac activity or growth appropriate for gestational age, empty uterus or uterus with echogenic material only.
.
Subchorionic Hematoma
Subchorionic hematomas are responsible for about 18-22% of vaginal bleeding cases in pregnancy. A subchorionic hematoma is seen as a collection of blood between the chorion and uterine wall on ultrasound. Patients typically present with painless vaginal bleeding before 20 weeks gestation and the amount of bleeding can be anywhere from spotting to brisk bleeding. If a woman has ultrasonographic findings of a subchorionic hematoma with normal fetal cardiac activity, her risk of miscarriage is 9%. This risk increases with increasing size of hematoma, and age of the mother ≥35. Subchorionic hemorrhages can be incidental findings on ultrasound and may be asymptomatic.
.
Gestational Trophoblastic Disease: Molar Pregnancies
Molar pregnancies occur at a rate of 1-2 per 1,000 with adolescents and women age 36-40y/o at a twofold increased risk and women ≥40 years at a tenfold increased risk. Having a single molar pregnancy increases a woman’s risk of having a repeat mole by 1.3% and two prior moles can increase the risk up to 23%. Having a previous miscarriage increases the risk as much as twofold. Women present with amenorrhea for 1-2 months and then irregular bleeding which prompts a pregnancy test that will be positive and followed up by US. They can have normal first trimester pregnancy symptoms of nausea, fatigue, and uterine growth that rapidly progress. The first symptom they may notice is the uterine bleeding that can be anywhere from spotting to profuse hemorrhage. β-hcg levels will be higher than expected based on LMP and <100,000mlU/mL in partial or >100,000mlU/mL in complete mole. Ultrasound for a complete mole will show echogenic uterine mass with numerous anechoic cystic spaces described as a snowstorm pattern while partial moles have a thickened multicystic placenta +/- fetal tissue and possible cardiac activity.
.
Vanishing Twins
In twin pregnancies evaluated by first trimester ultrasound, approximately 10-40% will show one twin vanishing before the second trimester. Women may be completely asymptomatic and only know this occurred after repeat ultrasounds show only one fetus, or they may have some mild bleeding that prompts an earlier repeat ultrasound, at which time the vanishing twin is diagnosed.
.
Vulvar Varicose Veins
Varicose veins are common in pregnancy occurring in about 20% of pregnant women. They can be anywhere from asymptomatic to large, bulging, and bleeding. They usually present with mild discomfort, worse with tight clothing. These varicosities will get progressively worse throughout pregnancy, as weight increases, and if the patient stands for prolonged periods of time. If the varicosities are bulging and large there is the possibility for rupture and profuse hemorrhage, however this is rare. Vaginal delivery may also result in rupture and mild to heavy bleeding from varicose sites.
.
Cervical Bleeding
Bleeding from the cervix can occur at any time in the pregnancy and is common. There are a multitude of reasons the cervix may bleed ranging anywhere from infection or inflammation of the cervix, bleeding due to ectropion, or bleeding due to cervical dilation and effacement with shearing of small vessels during any phase of labor. Cervical bleeding due to ectropion or cervicitis will be light spotting to very mild bleeding that can increase with any trauma to the cervix (swabs used for testing, intercourse, etc.). Cervical bleeding due to dilation and effacement usually looks like pink tinged mucus at first and as it progressively dilates there may be visible bleeding from the vagina in small amounts, enough to be noticed on cervical checks and with any interventions (foley or placement of internal monitors) but, if it is steady moderate flow, other diagnoses should be investigated such as fissures, lacerations, or uterine/placental causes.
.
Placental Abruption
The rate of placental abruption averages across databases to be about 0.5-1 in 200 deliveries. It can present as a total or partial abruption depending on how much of the placenta separates from the uterus, and it can result in external hemorrhage or concealed hemorrhage in which the blood is trapped between the placenta and uterus and does not appear on physical exam. Women with placental abruption can vary in presentation dramatically. The most common symptoms are vaginal bleeding (78%), uterine tenderness or back pain (66%), and fetal distress (60%) [taken from Williams]. Other accompanying symptoms may be uterine contractions and a hypertonic tight uterus. The bleeding can be anywhere from mild to a profuse hemorrhage, and in some cases it may progressively get worse as the separation gets worse. Severe back pain or abdominal pain without bleeding should also be a warning sign that prompts you to think about possible concealed hemorrhage. Patients with advanced maternal age, hypertensive disease, higher parity, previous abruption, PROM, thrombophilias, cocaine use, and low birth weight are all at increased risk of placental abruption.
.
Placenta Previa/Vasa Previa
Previas occur in about 1 per 250-400 pregnancies. Previas will usually present with painless vaginal bleeding in the second or third trimester. There is usually a sentinel mild bleed that will resolve and then recur later on. 10% of women with placenta previa will not have bleeding until the onset of labor at which time it may mimic placental abruption. Copious hemorrhage can be associated with any cervical dilation that occurs. If someone presents with vaginal bleeding a speculum exam should be performed prior to a digital exam. Risk factors for previas are advanced maternal age, multiparity, prior cesarean delivery, cigarette smoking, multifetal gestation.
.
Placenta Accreta Spectrum (PAS)
Placenta accreta spectrum occurs in about 1 in 272 women with a hospital birth. 80% of patients with PAS will have a concomitant placenta previa. These two things combined put the patient at risk for bleeding in pregnancy. Women may present with anywhere from painless mild bleeding to severe hemorrhage from their vagina. If placenta percreta is present it may invade the bladder at which time blood tinged urine may be present. PAS is usually diagnosed by second or third trimester ultrasound. The greatest risk factor for PAS is prior cesarean delivery, and the increasing cesarean rate is the reason PAS incidence has skyrocketed.
.
Anal Causes: (GI Rule Out)
Please refer to surgerystudent.com for more in depth descriptions of these conditions.
- Hemorrhoids (internal), Hemorrhoids (external)
- Fissures
- Anorectal carcinoma
- Ulcerative Colitis
- Crohn Syndrome
- Rectal polyp