Patient Presentation

A 16-year-old female called into clinic with a history of abdominal pain for 3-4 days. She described pain that was mainly in her lower abdomen and said she was also having some dark brown vaginal discharge that started that morning. The pain was increasing and she was having nausea but no emesis. She was sexually active and was using Depo-Provera® as her method of birth control. Her last shot was 20 weeks previously. She had been tested for sexually transmitted infections at that time too because she had a new partner. She was worried she was pregnant and wanted to know what she should do. She also denied being light headed or feeling like she was going to pass out. She denied any other vaginal discharge before today.

The diagnosis of vaginal bleeding in the setting of possible early pregnancy was made and the patient was referred to the emergency room. In the emergency room, an early intrauterine pregnancy diagnosis was made. She was managed with expectant monitoring and the bleeding resolved. She eventually delivered a healthy baby boy.

Discussion

Pregnancy complications in early pregnancy range from mild to severe. They can include nausea and emesis which often is treated symptomatically, but can cause hyperemesis gravidarum and need hospitalization for intravenous fluids. Mild cramping and slight spotting are not uncommon. Some type of pregnancy bleeding is common with 20-40% of women experiencing it. Women who have early vaginal bleeding have a higher risk of later pregnancy complications.

Pregnancy in adolescents is about 10% of all pregnancies. Adolescent pregnancy can be associated with various problems including higher rates of threatened abortion, pre-eclampsia, Cesarean section, pre-term delivery and lower birth weights. A review can be found here.

Patients with vaginal bleeding need to be evaluated for hemodynamic stability. Young women especially can lose a significant amount of blood before becoming hemodynamically unstable. Physical examination may reveal abdominal tenderness or signs of an acute abdomen such as rigidity, distension and guarding. Vaginal speculum examination helps to determine location of the bleeding. Bimanual examination can help to determine cervical motion or pelvic tenderness, and uterus size. Evaluation includes serum hCG (human chorionic gonadotropin) levels, ultrasound to try to determine if there is an ectopic or intra-uterine pregnancy and other labs such as hemoglobin/hematocrit and type and cross-match for potential transfusion. The patient’s blood type should be obtained if not known and Rh D immunoglobulin given for Rh negative women. Signs of acute abdomen, cervical motion or pelvic tenderness and tissue in the cervical os are usual reasons for surgical and/or gynecological consultation. Patient with threatened abortion are often managed expectantly with most women having complete expulsion of the products of conception within a few weeks. Management of ectopic pregnancy is medical management with medication such as methotrexate or surgical management particularly if the patient is hemodynamically unstable or has signs of a surgical abdomen.

Learning Point
Potential causes of bleeding in early pregnancy include:

• Ectopic pregnancy – increased risk with mini-pill or intrauterine device, pelvic infection or sexually transmitted infection, previous ectopic pregnancy, use of assisted reproduction for the pregnancy
• Threatened abortion
• Endometrial implantation
• Malignancy
• Vaginal or cervical polyps
• Uterine infection
• Gestational trophoblastic disease
• Hemorrhoids

Questions for Further Discussion

1. How do you evaluate heavy menstrual bleeding? A review can be found here

2. How do you evaluate and treat dysfunctional uterine bleeding? A review can be found here

3. What are protective factors to help prevent teenage pregnancy?

Related Cases

Disease: Vaginal Bleeding | Vaginal Diseases | Pregnancy

Symptom/Presentation: Bleeding and Bruising | Abdominal Pain | Vaginal Discharge

Specialty: Adolescent Medicine | Emergency Medicine | Obstetrics / Gynecology

Age: Teenager

To Learn More

To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vaginal Bleeding and Health Problems In Pregnancy.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Breeze C. Early pregnancy bleeding. Aust Fam Physician. 2016;45(5):283-286.

Bleeding in Early Pregnancy. American Family Physician. https://www.ncbi.nlm.nih.gov/pubmed/30702267. Accessed April 13, 2020. 286.

Karatasli V, Kanmaz AG, Inan AH, Budak A, Beyan E. Maternal and neonatal outcomes of adolescent pregnancy. J Gynecol Obstet Hum Reprod. 2019;48(5):347-350. doi:10.1016/j.jogoh.2019.02.011286.

Pontius E, Vieth JT. Complications in Early Pregnancy. Emerg Med Clin North Am. 2019;37(2):219-237. doi:10.1016/j.emc.2019.01.004286.

Author

Donna M. D’Alessandro, MD

Professor of Pediatrics, University of Iowa