Vaginal bleeding in pregnancy
Pregnancy test first. Early pregnancy, after 24 weeks, after delivery, or not pregnant: each needs a different plan.
A 26-year-old woman, 9 weeks pregnant by dates, has heavy bleeding with clots and cramping for 3 hours. Pulse 62, BP 84/50, pale and clammy. The pad count does not seem enough to explain that BP.
What do you look for on speculum examination, and why now?
- ResuscitateTwo large cannulas, bloods with crossmatch, fluids, call the senior.
- Pregnancy testEvery woman of reproductive age with bleeding.
- How many weeks?Before 24 weeks, after 24 weeks, or after delivery: different pathways.
- Speculum in early pregnancyIs the os open? Products at the os? Remove them.
- After 24 weeks: no digital vaginal examUntil placenta praevia is excluded on ultrasound.
- UltrasoundWhere is the pregnancy, is it alive, where is the placenta.
- Blood groupAnti-D if Rh-negative and indicated.
- Shock or heavy ongoing bleeding
- Positive test with pain and no intrauterine pregnancy
- After 24 weeks with any bleeding
- Fever and foul discharge after a miscarriage or procedure
- Abnormal fetal heart pattern
- Ruptured ectopic pregnancy
- Cervical shock
- Septic abortion
- Placental abruption (concealed)
- Vasa praevia
- Molar pregnancy
| Shock | Pulse above BP, pale, cold, confused: major haemorrhage |
| Cervical shock | Slow pulse and low BP from products stuck in the os: remove them |
| After 24 weeks | No digital vaginal examination until praevia excluded |
| Positive pregnancy test with pain | Ectopic until proven otherwise if no intrauterine pregnancy seen |
| Rh-negative | Anti-D in the situations listed below |
| Postmenopausal bleeding | Urgent referral to exclude endometrial cancer |
Check every dose against a current drug reference and your hospital protocol.
On this page
Which pathway?
- Miscarriage
- Ectopic pregnancy
- Molar pregnancy
- Cervical causes
- Placenta praevia
- Abruption
- Vasa praevia
- Labour (show)
- Cervical causes
- Postpartum haemorrhage
- see the PPH guide
- Heavy periods, fibroids, polyps, cervical lesions
- Postmenopausal bleeding: refer urgently
Early pregnancy: miscarriage types
| Type | Os | Ultrasound | What to do |
|---|---|---|---|
| Threatened | Closed | Live pregnancy in the uterus | Reassure; most continue; return if heavier bleeding or pain |
| Inevitable | Open | Pregnancy still in the uterus | Expectant, medical or surgical management |
| Incomplete | Open, products may be at os | Retained products | Medical (misoprostol) or surgical evacuation |
| Complete | Closed | Empty uterus, previously confirmed intrauterine | Check hCG falls if no prior scan |
| Missed | Closed | No heartbeat, little or no bleeding | Discuss options |
| Septic | Open or closed | Retained products, fever, foul discharge | Antibiotics, resuscitation, evacuation |
Products of conception stuck in the cervical os cause vagal shock: low BP with a slow or normal pulse, often out of proportion to the blood loss. Pass a speculum and remove products with sponge forceps. The BP often recovers within minutes.
Ectopic and molar pregnancy
- Ectopic: positive test, pain, bleeding, no intrauterine pregnancy on ultrasound. Shoulder-tip pain or shock means rupture: theatre now. See ectopic pregnancy.
- Molar pregnancy: uterus larger than dates, severe vomiting, very high hCG, "snowstorm" appearance on ultrasound. Evacuation and hCG follow-up.
Septic abortion
Often after an unsafe procedure. Fever, foul discharge, abdominal pain, tender uterus. It can progress to septic shock quickly.
Then evacuate the uterus once antibiotics have started. Treat as sepsis.
After 24 weeks: antepartum haemorrhage
| Feature | Placenta praevia | Placental abruption |
|---|---|---|
| Pain | Painless | Painful, constant |
| Uterus | Soft, non-tender | Tense, tender, "woody" |
| Bleeding | Bright red, matches shock | May be concealed: shock worse than visible loss |
| Fetus | Often malpresentation, usually fine | Fetal distress or death common |
| Risk factors | Previous caesarean, multiparity | Pre-eclampsia, trauma, smoking, cocaine |
- Vasa praevia: bleeding when the membranes rupture, with sudden fetal distress. Fetal blood loss: emergency caesarean.
- Monitor the fetus (CTG). Steroids for fetal lungs if under 34–35 weeks and delivery is likely, per the obstetric team.
- Abruption can cause DIC: check platelets and clotting.
Major bleeding
- Crossmatch 4–6 units for major bleeding; activate the massive transfusion protocol if needed.
- Keep the woman warm; check calcium and clotting.
Anti-D
For Rh-negative women without antibodies, give anti-D immunoglobulin (per local protocol) after:
- Surgical or medical management of miscarriage or ectopic.
- Any bleeding after 12 weeks.
- Abdominal trauma, ECV, or antepartum haemorrhage (with a test for the size of fetal bleed after 20 weeks).
Frequently asked questions
Is bleeding in the first trimester normal?
Light bleeding is common and many pregnancies continue. But any bleeding needs a pregnancy test and assessment to exclude ectopic pregnancy and miscarriage, especially with pain.
What is the difference between placenta praevia and abruption?
Placenta praevia causes painless bright red bleeding with a soft uterus. Abruption causes painful bleeding with a tense, tender uterus, and the blood loss can be hidden.
Why should you not do a vaginal examination in placenta praevia?
A finger through the cervix can disturb the low-lying placenta and cause torrential bleeding. Scan first.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman 9 weeks pregnant has heavy bleeding, BP 84/50 and pulse 62. What should be done on speculum examination?
Answer: Remove products of conception from the cervical os. Cervical shock causes low BP with a slow pulse. Removing products with sponge forceps often restores BP.
- Pack the vagina: Not first.
- Leave the speculum out until ultrasound: Products in the os cause cervical shock.
- Give methotrexate: Not for miscarriage.
- Bimanual exam only: Speculum is needed.
2. A woman at 32 weeks has painless bright red vaginal bleeding. What should be avoided until imaging?
Answer: Digital vaginal examination. Placenta praevia must be excluded before any digital examination; it can cause torrential bleeding.
- Ultrasound: Needed first.
- Large-bore IV access: Needed.
- CTG: Needed.
- Cross-match: Needed.
3. A woman at 34 weeks with pre-eclampsia has a painful, tense uterus, little visible blood and falling BP. What is the likely diagnosis?
Answer: Concealed placental abruption. Abruption can hide blood behind the placenta, so shock is worse than the visible loss. Check clotting and plan delivery.
- Labour: Not with shock and tense uterus.
- Placenta praevia: Usually painless.
- Vasa praevia: Fetal bleeding at membrane rupture.
- Uterine fibroid degeneration: Not with shock.
4. A 32-year-old at 34 weeks with pre-eclampsia has sudden constant abdominal pain, a tense ‘woody’ tender uterus and scanty dark vaginal bleeding. The fetal heart rate shows late decelerations. What is the diagnosis?
Answer: Placental abruption. Abruption: premature separation of a normally sited placenta — pain, tender tense uterus, bleeding that may be concealed (shock out of proportion to visible loss), fetal distress or death, risk of DIC and AKI. Risks: pre-eclampsia/hypertension, trauma, smoking, cocaine, previous abruption, polyhydramnios decompression. Resuscitate, cross-match, check coagulation; deliver urgently (caesarean if fetus alive and distressed; vaginal if fetus dead and mother stable).
- Placenta praevia: Painless bright bleeding, soft uterus.
- Vasa praevia: Bleeding at membrane rupture, fetal compromise.
- Uterine rupture: Previous scar, loss of contractions.
5. At membrane rupture, a woman has painless bright red vaginal bleeding with sudden fetal bradycardia; mother is stable. What is the likely diagnosis?
Answer: Vasa praevia. Vasa praevia: fetal vessels run through membranes over the internal os unprotected by placenta or cord (velamentous cord insertion, succenturiate lobe, IVF, low placenta). Rupture of membranes tears vessels → fetal exsanguination (fetal blood loss, mother stable). Emergency caesarean. Antenatal diagnosis with colour Doppler → planned caesarean at 34–36 weeks.
- Placental abruption: Abruption is painful with maternal shock.
- Placenta praevia: Placenta praevia bleeding is maternal and occurs before labour.
- Uterine rupture: Uterine rupture causes pain and loss of station.
6. Which antidiabetic drug commonly causes fluid retention and is avoided in heart failure?
Answer: Pioglitazone. Pioglitazone (a thiazolidinedione) activates PPAR-γ, improving insulin sensitivity, but increases renal sodium and water retention, causing oedema and worsening heart failure. It also raises fracture risk and has been linked to bladder cancer. Other drugs causing fluid retention include NSAIDs, steroids and calcium channel blockers (ankle oedema).
- Metformin: No fluid retention; risk of lactic acidosis.
- Gliclazide: Hypoglycaemia, weight gain.
- Sitagliptin: Weight neutral; rare pancreatitis.
- Acarbose: Flatulence.
7. Which pairing of poison and antidote is correct?
Answer: Iron — desferrioxamine. Antidotes: iron → desferrioxamine; paracetamol → N-acetylcysteine; opioids → naloxone; benzodiazepines → flumazenil; organophosphates → atropine and pralidoxime; methanol/ethylene glycol → fomepizole or ethanol; digoxin → digoxin Fab; heparin → protamine; warfarin → vitamin K; cyanide → hydroxocobalamin; lead → chelation (EDTA, DMSA).
- Paracetamol — naloxone: Paracetamol → N-acetylcysteine.
- Organophosphate — flumazenil: Organophosphate → atropine + pralidoxime.
- Methanol — vitamin K: Methanol → fomepizole.
- Digoxin — protamine: Digoxin → digoxin Fab.
References and dose sources
- NICE NG126: Ectopic pregnancy and miscarriage
- RCOG Green-top 63: Antepartum haemorrhage
- RCOG Green-top 63 — antepartum haemorrhage
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Metronidazole dosing: Drugs.com: Metronidazole dosage (see also our metronidazole dose page)
- Tranexamic acid dosing: Drugs.com: Tranexamic acid dosage (see also our tranexamic acid dose page)
- Misoprostol dosing: Drugs.com: Misoprostol dosage (see also our misoprostol dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.