Vaginal bleeding in the first half of pregnancy is common. Causes range from harmless (implantation bleeding, cervical irritation after intercourse) to life-threatening (ruptured ectopic pregnancy). The three key diagnoses are pregnancy loss (spontaneous abortion), ectopic pregnancy, and gestational trophoblastic disease (molar pregnancy).

Spontaneous abortion (early pregnancy loss)

• Loss of an intrauterine pregnancy before viability; early pregnancy loss = before 13 0/7 weeks — about 10% of clinically recognized pregnancies
• About half are caused by fetal chromosomal abnormalities; other factors: advanced maternal age, uterine anomalies, uncontrolled diabetes, thyroid disease, antiphospholipid syndrome, smoking, alcohol
• Everyday activity, exercise, intercourse, and minor falls do not cause early loss — important for reducing guilt

Ectopic pregnancy

• Implantation outside the uterine cavity — most often in the fallopian tube (mainly the ampulla); also ovary, cervix, cesarean scar, abdomen
• Risk factors: previous ectopic pregnancy, tubal damage from PID (chlamydia, gonorrhea), tubal surgery or sterilization, pregnancy with an IUD in place, assisted reproduction (IVF), smoking, endometriosis
• The growing pregnancy stretches and can rupture the tube → intra-abdominal hemorrhage and hypovolemic shock — a leading cause of first-trimester maternal death

Gestational trophoblastic disease (hydatidiform mole) — abnormal fertilization produces swollen, fluid-filled villi instead of (complete mole) or alongside (partial mole) a normal embryo; can progress to gestational trophoblastic neoplasia. Details are in the Gestational Trophoblastic Disease topic.

All clients

• Amount (pad count; 1 g pad weight ≈ 1 mL blood), color, clots, passage of tissue (save it for examination)
• Pain: location, character, onset; shoulder pain
• Vital signs — tachycardia and falling BP signal hemorrhage; pallor, dizziness, syncope
• Last menstrual period, blood type and Rh, pregnancy intentions and emotional response

Ectopic pregnancy

• Classic triad: missed period, abdominal/pelvic pain, vaginal bleeding (usually 6–8 weeks after LMP)
• Unilateral lower abdominal pain; adnexal tenderness or mass
• Rupture: sudden, severe, sharp pain, referred shoulder pain (blood irritating the diaphragm), rigid abdomen with rebound tenderness, dizziness or fainting, hypotension and tachycardia; bluish discoloration around the umbilicus (Cullen sign) is a rare late sign

Molar pregnancy

• Dark brown to bright red bleeding in the first trimester, uterus larger than dates, no fetal heart activity (complete mole)
• Very high hCG, hyperemesis, preeclampsia before 20 weeks, hyperthyroidism, theca lutein ovarian cysts; passage of grape-like vesicles

• Quantitative serum hCG, often repeated in 48 hours: a viable intrauterine pregnancy usually rises by at least about 35–50% in 48 hours early on; a slow rise or plateau suggests ectopic or failing pregnancy; hCG alone never confirms location
• Transvaginal ultrasound: intrauterine gestational sac, yolk sac, embryo, and cardiac activity; no intrauterine pregnancy with an hCG above the level where one should be seen (about 3,500 mIU/mL in many protocols) suggests ectopic; adnexal mass; free fluid in the pelvis
• CBC, hemoglobin and hematocrit (urgent if rupture suspected), blood type, Rh, and antibody screen, type and crossmatch when bleeding is heavy
• Molar pregnancy: ultrasound pattern of multiple small cystic spaces ("snowstorm"); hCG; chest imaging and TSH as indicated
• Before methotrexate: CBC, liver enzymes, creatinine, blood type

Early pregnancy loss (inevitable, incomplete, missed) — options chosen with the client:

• Expectant management — waiting for spontaneous passage
• Medication: mifepristone 200 mg orally followed 24 hours later by misoprostol 800 mcg vaginally (more effective than misoprostol alone). Misoprostol causes cramping, heavy bleeding, diarrhea, fever/chills
• Uterine aspiration (manual or electric vacuum) — fastest; preferred with hemorrhage, instability, or infection
• Rh immune globulin: ACOG (2024) states that Rh testing and RhIG may be forgone for abortion or pregnancy loss before 12 0/7 weeks; at or after 12 weeks, give RhIG to Rh-negative unsensitized clients. For ectopic and molar pregnancy, follow the institutional protocol

Ectopic pregnancy

• Ruptured or hemodynamically unstable → emergency surgery (laparoscopic or open salpingectomy) with fluid resuscitation and transfusion
• Methotrexate (folic acid antagonist that stops trophoblast growth) for stable, unruptured ectopic pregnancy with reliable follow-up
  • Common regimen: single IM dose of 50 mg/m² (body surface area)
  • Contraindications: intrauterine pregnancy, hemodynamic instability or rupture, breastfeeding, immunodeficiency, moderate–severe anemia, leukopenia or thrombocytopenia, active lung or peptic ulcer disease, significant liver or kidney disease, hypersensitivity, inability to follow up. Higher failure risk with high hCG (e.g., above 5,000 mIU/mL), fetal cardiac activity, or a large mass
  • Adverse effects: nausea, vomiting, stomatitis, diarrhea, abdominal pain in the first few days ("separation pain"), raised liver enzymes, bone marrow suppression; photosensitivity
  • Follow-up: hCG on day 4 and day 7 — a fall of at least 15% between them indicates response; then weekly until undetectable (may take several weeks); a second dose or surgery if not falling
• Laparoscopic salpingostomy or salpingectomy when methotrexate is not suitable

Molar pregnancy — suction evacuation; serial hCG until undetectable, then continued surveillance; reliable contraception during follow-up (hormonal methods are safe; an IUD is not placed until hCG is normal); chemotherapy for persistent or rising hCG.

Listed in priority order.

1. Hemodynamic stability
   • Vital signs frequently; two large-bore IVs and isotonic fluids for heavy bleeding or suspected rupture; oxygen if hypoxic; keep NPO when surgery is possible
   • Type and crossmatch, prepare blood products; monitor hemoglobin/hematocrit
   • Recognize shock early: tachycardia, anxiety, pallor, cool skin, falling BP and urine output
2. Quantify bleeding — pad count/weight; save passed tissue
3. Pain management as ordered; report sudden severe pain or shoulder pain immediately
4. Prepare for procedures — consent, pre-procedure care, post-procedure bleeding and vital-sign checks
5. Rh status — confirm; give RhIG per current protocol
6. Methotrexate care — verify labs, handle as a hazardous drug, teach precautions (below)
7. Grief and emotional support
   • Acknowledge feelings, use the pregnancy's name if the family has named it, offer accurate information (e.g., "Thank you for telling me you are anxious. The ultrasound shows the baby's heartbeat right now."), and avoid false reassurance or minimizing ("You can always have another")
   • Emphasize that the loss was not caused by anything the client did
   • Offer mementos when appropriate, chaplain or counseling, support groups

After pregnancy loss or evacuation

• Expect bleeding like a heavy period that lessens over 1–2 weeks
• Report soaking 2 or more pads per hour for 2 hours, fever, foul discharge, severe pain, or dizziness
• Pelvic rest (no tampons or intercourse) for about 1–2 weeks or as instructed
• Ovulation can return within about 2 weeks — discuss contraception or timing of the next pregnancy (no medical need for a long wait after uncomplicated early loss)

Methotrexate for ectopic pregnancy

• Avoid folic acid supplements and prenatal vitamins (they reduce the drug's effect), alcohol, NSAIDs (interaction and masking pain), and sun exposure
• Avoid intercourse, vigorous exercise, and pelvic exams until hCG is undetectable (rupture risk)
• Mild abdominal pain for a few days is expected; seek emergency care for severe pain, dizziness, fainting, or heavy bleeding — possible rupture
• Keep all hCG blood tests; avoid pregnancy for at least 3 months after treatment
• Future pregnancies need an early ultrasound (higher recurrence risk)

Molar pregnancy — attend every hCG test and use reliable contraception during surveillance; a rising or plateauing hCG needs treatment.

• Threatened = bleeding with closed cervix and a viable intrauterine pregnancy; inevitable/incomplete = open cervix; complete = all tissue out, bleeding and pain decrease, cervix closed
• Missed loss can (rarely) cause DIC if retained for a long time
• Bed rest does not prevent early pregnancy loss; most losses are chromosomal — not the client's fault
• Ectopic classic triad: amenorrhea, pain, bleeding; rupture → shoulder pain, rigid abdomen, hypotension, tachycardia → emergency surgery
• Priority lab with suspected rupture: hemoglobin/hematocrit plus type and crossmatch
• Methotrexate: stable and unruptured only; no folic acid, alcohol, NSAIDs, sun; hCG day 4 and 7 (≥ 15% fall); watch for stomatitis, marrow suppression
• Molar pregnancy: uterus larger than dates, very high hCG, no fetal heart, early preeclampsia → serial hCG and contraception
• RhIG: may be forgone for loss/abortion before 12 weeks (ACOG 2024); otherwise give to Rh-negative unsensitized clients
• Grief care: acknowledge feelings, give accurate information, avoid false reassurance