Vaginal Bleeding In PregnancyAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

433 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Vaginal Discharge Hyperemesis Gravidarum Concern Hypertensive Disorders Of Pregnancy Symptoms Postpartum Hemorrhage Concern Postpartum Infection Concern Sexual Assault Medical Evaluation Overview Pelvic Pain Vaginal Bleeding, Nonpregnant Vaginal Bleeding In Pregnancy Pelvic Pain In Pregnancy Post Procedure Or Post Abortion Complications Concern

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx58

Pregnancy details

›Pregnancy context

›Gestational age

›Estimated due date

›Multiple gestation

›Prior ultrasound confirmation of intrauterine pregnancy

›Placental location known

Bleeding characterization

›Bleeding details

›Onset timing

›Quantity

›Pad count pattern

›Clots

›Tissue passage

›Color

›Intercourse related bleeding

Onset

›Onset

›Sudden onset

›Gradual onset

›Triggering event

Provocation/Palliation

›Provocation and palliation

›Worse with activity

›Worse after intercourse

›Relief with rest

Quality

›Quality

›Spotting

›Heavy bleeding

›Gush of fluid and blood

Region/Radiation

›Region and radiation

›Pelvic pain location

›Shoulder tip pain

›Back pain

Severity

›Severity

›Pain score

›Presyncope or syncope

Timing

›Timing

›Constant bleeding

›Intermittent bleeding

›Progressive worsening

Associated symptoms

›Associated symptoms

›Abdominal pain

›Cramping

›Contractions

›Leakage of fluid

›Fever

›Foul discharge

›Dizziness

›Dyspnea

›Chest pain

Obstetric risk context

›Obstetric history and context

›Prior miscarriage or ectopic pregnancy

›Prior cesarean delivery

›Prior postpartum hemorrhage

›Prior placenta previa or accreta spectrum

›Assisted reproduction

Traumatic and iatrogenic context

›Precipitating context

›Trauma

›Recent procedures

›Recent cervical examination

›Recent chorionic villus sampling or amniocentesis

02Alarm Features/alarm30

Maternal instability

›Maternal danger features

›Hypotension

›Tachycardia

›Altered mental status

›Ongoing heavy bleeding

›Syncope

Hemorrhage and shock thresholds

›Hemorrhage thresholds

›Shock index at or above 0.9

›Persistent heart rate at or above 120

›Systolic blood pressure below 90

›Lactate elevation

Life threatening obstetric causes

›Cannot miss diagnoses

›Ectopic pregnancy

›Placental abruption

›Placenta previa with active bleeding

›Vasa previa

›Uterine rupture

Infection and sepsis

›Infection red flags

›Fever

›Uterine tenderness

›Foul discharge

›Rigors

Fetal compromise

›Fetal danger features

›Decreased fetal movement

›Nonreassuring fetal heart tracing

›Significant bleeding in third trimester

Immediate escalation triggers

›Escalation triggers

›If hemodynamic instability, resuscitation bay and activate obstetrics

›If suspected abruption or uterine rupture, immediate obstetrics and anesthesia

›If bleeding with placenta previa suspected, avoid digital exam until ultrasound placental location

03Medications/meds18

Current and recent medications

›Medication inventory

›Prenatal vitamins

›Progesterone support

›Antihypertensives

›Insulin or oral glucose lowering agents

›Thyroid replacement

Bleeding risk medications

›Bleeding risk medications

›Anticoagulants

›Antiplatelets

›NSAID exposure

Allergies and transfusion considerations

›Allergy and transfusion considerations

›Medication allergies

›Prior transfusion reaction

›Refusal of blood products

Rh immune globulin related

›Rh immune globulin history

›Rh status known

›Prior Rh immune globulin this pregnancy

›Prior sensitization history

04Diet/diet8

Intake and hydration

›Intake and hydration context

›Oral intake tolerance

›Vomiting

›Hydration status

Exposures

›Exposures

›Caffeine and energy drinks

›Alcohol exposure

›Illicit substances

05Review of Systems/ros27

General and infectious

›General and infectious

›Fever

›Chills

›Malaise

›Myalgias

Cardiopulmonary

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

›Leg swelling

Gastrointestinal

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Right upper quadrant pain

Genitourinary and obstetric

›Genitourinary and obstetric

›Dysuria

›Flank pain

›Vaginal discharge

›Leakage of fluid

›Contractions

›Decreased fetal movement

Neurologic

›Neurologic

›Lightheadedness

›Syncope

›Headache

›Visual changes

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral context

›Source

›Reliability

Family history relevant to pregnancy complications

›Family history

›Venous thromboembolism

›Bleeding disorders

›Early cardiovascular disease

Social support and safety

›Support and safety

›Ability to return for follow up

›Reliable transportation

›Safety at home

07Risk Factors/rf26

Obstetric risk factors

›Obstetric risks

›Prior cesarean delivery

›Known placenta previa or low lying placenta

›Prior placenta accreta spectrum

›Multiple gestation

›Hypertension

›Preeclampsia risk factors

Ectopic pregnancy risks

›Ectopic pregnancy risks

›Prior ectopic pregnancy

›Prior tubal surgery

›Pelvic inflammatory disease history

›IUD in situ at conception

›Assisted reproduction

Abruption risks

›Abruption risks

›Hypertension or preeclampsia

›Abdominal trauma

›Cocaine or stimulant use

›Smoking

Bleeding diathesis risks

›Bleeding and coagulation risks

›Anticoagulant therapy

›Thrombocytopenia history

›Liver disease

Infection risks

›Infection risks

›Recent STI exposure

›Recent uterine instrumentation

›Prolonged rupture of membranes

08Differential Diagnosis/ddx48

Life threatening

›Life threatening

›Ectopic pregnancy (O00.9)

›Pelvic pain with bleeding

›Syncope or shoulder tip pain

›Placental abruption (O45)

›Painful bleeding

›Uterine tenderness or hypertonus

›Placenta previa (O44)

›Painless bleeding after mid pregnancy

›Bleeding triggered by intercourse

›Vasa previa (O69.4)

›Bleeding after membrane rupture

›Fetal heart rate abnormalities

›Uterine rupture (O71.1)

›Prior uterine surgery

›Sudden severe pain with fetal compromise

›Septic abortion (O03.3)

›Fever

›Uterine tenderness

Common

›Common

›Threatened miscarriage (O20.0)

›Bleeding with closed cervix

›Viable intrauterine pregnancy possible

›Early pregnancy loss (O03)

›Tissue passage

›Open cervix or absent fetal cardiac activity

›Subchorionic hemorrhage

›Ultrasound hematoma

›Variable bleeding volume

›Cervicitis and STI related bleeding (N72)

›Discharge

›Cervical friability

›Cervical polyp

›Postcoital spotting

›Visible cervical lesion

Less common

›Less common

›Molar pregnancy (O01)

›Disproportionate nausea

›Very high hCG

›Placenta accreta spectrum (O43.2)

›Placenta previa with prior cesarean delivery

›Abnormal placental imaging

›Vaginal or cervical trauma

›Lacerations

›Recent intercourse or injury

›Nonobstetric gynecologic bleeding

›Vaginal malignancy

›Cervical malignancy

09Past Medical History/pmh16

Relevant chronic conditions

›Chronic conditions

›Hypertension (I10)

›Diabetes mellitus (E11.9)

›Thyroid disease (E03.9)

›Bleeding disorders

Prior pregnancy outcomes

›Prior pregnancy outcomes

›Miscarriage history

›Ectopic pregnancy history

›Preterm birth history

Surgeries and uterine procedures

›Surgeries and procedures

›Cesarean delivery

›Myomectomy

›Dilation and curettage

Baseline status

›Baseline

›Baseline hemoglobin if known

›Baseline blood pressure pattern

10Physical Exam/exam26

Initial and hemodynamic assessment

›General and vitals

›Mental status

›Skin perfusion

›Orthostatic symptoms

›Estimated blood loss on arrival

Cardiopulmonary

›Cardiopulmonary

›Tachycardia pattern

›Signs of volume depletion

›Work of breathing

Abdominal and uterine

›Abdominal and uterine

›Tenderness location

›Guarding or peritoneal signs

›Uterine tone

›Fundal height relative to dates

Pelvic examination precautions

›Pelvic exam approach

›Speculum exam for source of bleeding

›Avoid digital cervical exam if placenta previa not excluded after mid pregnancy

Pelvic exam findings

›Pelvic findings

›Cervical os status

›Active bleeding from cervix

›Products of conception visible

›Cervical lesions

Fetal assessment

›Fetal assessment

›Fetal heart tones if viable gestation

›Fetal movement report correlation

›Contraction frequency

11Lab Studies/labs21

Core labs for most presentations

›Baseline labs

›CBC

›Type and screen

›ABO and Rh

›Quantitative hCG in early pregnancy when diagnosis uncertain

Coagulation and hemorrhage labs

›Hemorrhage labs

›PT and INR

›aPTT

›Fibrinogen

›CMP

Infection and alternative causes

›Infection and other labs

›Urinalysis

›Urine culture

›NAAT for gonorrhea and chlamydia

›Vaginal swabs as indicated

Fetomaternal hemorrhage and Rh considerations

›Fetomaternal hemorrhage

›Kleihauer Betke test when large bleed or trauma and Rh negative

›Anti D dose adjustment local protocol dependent

Interpretation pearls and pitfalls

›Interpretation pearls

›Hemoglobin may be normal early in acute hemorrhage

›Low fibrinogen suggests consumptive coagulopathy and severe abruption risk

12Imaging/img17

Scoring Systems

›Risk and severity tools

›Shock index

›Obstetric early warning scores local protocol dependent

›Massive transfusion triggers local protocol dependent

MRI

›MRI considerations

›Placenta accreta spectrum evaluation when ultrasound equivocal

›Avoid gadolinium unless essential

›Protocol local radiology dependent

›CT considerations

›Trauma evaluation when indicated despite pregnancy

›Contrast use risk benefit and fetal shielding local protocol dependent

›Pulmonary embolism workup if indicated

Ultrasound

›Ultrasound

›Transvaginal ultrasound for early pregnancy location and viability

›Transabdominal ultrasound for placental location in later pregnancy

›POCUS for free fluid in suspected ruptured ectopic or trauma

›Avoid relying on ultrasound alone to exclude placental abruption

13Special Tests/spec12

Bedside obstetric monitoring

›Monitoring tests

›Continuous fetal monitoring when viable gestation and significant bleeding

›Tocometry for contractions

Pelvic and obstetric procedural diagnostics

›Procedural diagnostics

›Speculum exam for cervical and vaginal source

›Removal of visible products of conception from cervical os only if trained and stable

Rh and fetomaternal hemorrhage testing

›Rh related testing

›Antibody screen interpretation

›Kleihauer Betke limitations and lab variability

Trauma focused tests when indicated

›Trauma adjuncts

›FAST or eFAST

›Pelvic stability assessment

14ECG/ecg8

Indications in pregnancy bleeding presentations

›ECG indications

›Syncope

›Chest pain

›Significant tachycardia out of proportion

ECG patterns to recognize

›High risk ECG patterns

›Ischemia patterns in shock states

›Supraventricular tachycardia

›QT prolongation with electrolyte disturbance

15Assessment/ax20

Problem representation

›Problem representation

›Vaginal bleeding in pregnancy with gestational age stratification

›Maternal stability status

›Fetal status when viable gestation

Severity stratification

›Severity

›Mild bleeding with stable vitals and reassuring fetal status

›Moderate bleeding or symptomatic anemia

›Severe bleeding or shock physiology

Working diagnosis buckets

›Likely category

›Early pregnancy bleeding

›Mid to late pregnancy bleeding

›Nonobstetric genital tract source

Key complications to rule out

›Complications

›Hemorrhagic shock

›Coagulopathy

›Infection

›Fetal compromise

Diagnostic uncertainty handling

›Uncertainty management

›If pregnancy location unknown, treat as pregnancy of unknown location until confirmed

›If placenta previa not excluded, avoid digital exam after mid pregnancy

16Plan/plan43

First 5 minutes

›First 5 minutes

›Airway and breathing support if compromised

›Cardiac monitor and continuous pulse oximetry

›Two large bore IV access if moderate to severe bleeding

›Type and screen early

›Immediate obstetrics notification for heavy bleeding or any instability

Resuscitation and hemorrhage control

›Hemorrhage management

›Crystalloid bolus only as bridge to blood products if hemorrhagic shock

›Activate massive transfusion protocol if ongoing instability local protocol dependent

›Tranexamic acid use for obstetric hemorrhage per protocol local protocol dependent

Diagnostic sequencing

›Diagnostic sequence

›Ultrasound priority to determine intrauterine pregnancy in early gestation

›Ultrasound placental location before any digital exam in later gestation

›Serial hemoglobin and vitals when ongoing bleeding

Rh immune globulin

›Rh prophylaxis

›If Rh negative and bleeding, Rh immune globulin per gestational age and volume local protocol dependent

›If large bleed or trauma, consider additional dosing guided by fetomaternal hemorrhage testing local protocol dependent

Condition specific management

›Condition specific pathways

›Threatened miscarriage with viable pregnancy

›Expectant management with return precautions

›Follow up ultrasound timing local protocol dependent

›Early pregnancy loss

›Expectant versus medical versus surgical management with obstetrics

›Hemodynamic instability requires urgent uterine evacuation

›Ectopic pregnancy suspected

›If unstable, immediate surgery activation

›If stable, obstetrics for methotrexate eligibility local protocol dependent

›Placenta previa

›Avoid digital exam

›Obstetrics admission often indicated with active bleeding

›Placental abruption

›Continuous monitoring when viable gestation

›Prepare for expedited delivery if maternal or fetal deterioration

Reassessment loop

›Reassessment loop

›Repeat vitals every 5 to 15 minutes in active bleeding

›Repeat abdominal exam and uterine tone

›Ongoing quantified blood loss tracking

›Escalate if rising shock index or worsening fetal tracing

Consults

›Consults

›Obstetrics immediately for second or third trimester bleeding

›Anesthesia early for significant hemorrhage

›Interventional radiology for refractory hemorrhage local protocol dependent

›Neonatology for imminent preterm delivery

17Disposition/dispo22

ICU and high acuity criteria

›ICU or high acuity

›Persistent hemodynamic instability

›Massive transfusion requirement

›Ongoing coagulopathy

›Nonreassuring fetal tracing with maternal instability

Admission criteria

›Admission

›Moderate to heavy bleeding

›Symptomatic anemia

›Suspected placenta previa

›Suspected placental abruption

›Pregnancy of unknown location with concerning features

Observation pathway

›Observation

›Stable vitals with resolved bleeding but uncertain diagnosis

›Need for repeat hemoglobin or repeat ultrasound

Discharge criteria

›Discharge

›Stable vitals

›Minimal bleeding

›Reassuring evaluation for life threats

›Reliable follow up within 24 to 72 hours as appropriate

Follow up timing

›Follow up

›Obstetrics follow up within 24 to 72 hours for early pregnancy bleeding local protocol dependent

›Immediate return if recurrent heavy bleeding or pain

18Discharge Instructions/di7

Copy discharge instructions

›Copy discharge instructions

›You were seen for bleeding during pregnancy

›Small amounts of spotting can occur, but heavier bleeding can be serious

›Return now for soaking pads quickly, passing large clots, fainting, severe belly pain, fever, or new shortness of breath

›Avoid inserting anything in the vagina until cleared, including tampons and intercourse

›If you are Rh negative, you may need Rh immune globulin and follow up testing

›Follow up with your pregnancy care team within the recommended timeframe

19References/r15

Guidelines and key resources

›ACOG Practice Bulletin on early pregnancy loss, year varies by update

›Management options and follow up recommendations

›Local protocol dependent details for availability and pathways

›ACOG guidance on ectopic pregnancy, year varies by update

›Medical and surgical criteria

›Discriminatory zone concepts and ultrasound correlation

›ACOG guidance on placenta previa and placenta accreta spectrum, year varies by update

›Avoid digital exam until placental location known

›Imaging approach with ultrasound and MRI when needed

›ACOG guidance on placental abruption, year varies by update

›Maternal stabilization priorities

›Fetal monitoring and delivery considerations

›Society of Obstetricians and Gynaecologists of Canada guidance on early pregnancy complications, year varies by update

›Rh immune globulin use local protocol dependent

›Follow up pathways by region

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Vaginal Bleeding In PregnancyAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

433 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx58

Pregnancy details

›Pregnancy context

›Gestational age

›Estimated due date

›Multiple gestation

›Prior ultrasound confirmation of intrauterine pregnancy

›Placental location known

Bleeding characterization

›Bleeding details

›Onset timing

›Quantity

›Pad count pattern

›Clots

›Tissue passage

›Color

›Intercourse related bleeding

Onset

›Onset

›Sudden onset

›Gradual onset

›Triggering event

Provocation/Palliation

›Provocation and palliation

›Worse with activity

›Worse after intercourse

›Relief with rest

Quality

›Quality

›Spotting

›Heavy bleeding

›Gush of fluid and blood

Region/Radiation

›Region and radiation

›Pelvic pain location

›Shoulder tip pain

›Back pain

Severity

›Severity

›Pain score

›Presyncope or syncope

Timing

›Timing

›Constant bleeding

›Intermittent bleeding

›Progressive worsening

Associated symptoms

›Associated symptoms

›Abdominal pain

›Cramping

›Contractions

›Leakage of fluid

›Fever

›Foul discharge

›Dizziness

›Dyspnea

›Chest pain

Obstetric risk context

›Obstetric history and context

›Prior miscarriage or ectopic pregnancy

›Prior cesarean delivery

›Prior postpartum hemorrhage

›Prior placenta previa or accreta spectrum

›Assisted reproduction

Traumatic and iatrogenic context

›Precipitating context

›Trauma

›Recent procedures

›Recent cervical examination

›Recent chorionic villus sampling or amniocentesis

02Alarm Features/alarm30

Maternal instability

›Maternal danger features

›Hypotension

›Tachycardia

›Altered mental status

›Ongoing heavy bleeding

›Syncope

Hemorrhage and shock thresholds

›Hemorrhage thresholds

›Shock index at or above 0.9

›Persistent heart rate at or above 120

›Systolic blood pressure below 90

›Lactate elevation

Life threatening obstetric causes

›Cannot miss diagnoses

›Ectopic pregnancy

›Placental abruption

›Placenta previa with active bleeding

›Vasa previa

›Uterine rupture

Infection and sepsis

›Infection red flags

›Fever

›Uterine tenderness

›Foul discharge

›Rigors

Fetal compromise

›Fetal danger features

›Decreased fetal movement

›Nonreassuring fetal heart tracing

›Significant bleeding in third trimester

Immediate escalation triggers

›Escalation triggers

›If hemodynamic instability, resuscitation bay and activate obstetrics

›If suspected abruption or uterine rupture, immediate obstetrics and anesthesia

›If bleeding with placenta previa suspected, avoid digital exam until ultrasound placental location

03Medications/meds18

Current and recent medications

›Medication inventory

›Prenatal vitamins

›Progesterone support

›Antihypertensives

›Insulin or oral glucose lowering agents

›Thyroid replacement

Bleeding risk medications

›Bleeding risk medications

›Anticoagulants

›Antiplatelets

›NSAID exposure

Allergies and transfusion considerations

›Allergy and transfusion considerations

›Medication allergies

›Prior transfusion reaction

›Refusal of blood products

Rh immune globulin related

›Rh immune globulin history

›Rh status known

›Prior Rh immune globulin this pregnancy

›Prior sensitization history

04Diet/diet8

Intake and hydration

›Intake and hydration context

›Oral intake tolerance

›Vomiting

›Hydration status

Exposures

›Exposures

›Caffeine and energy drinks

›Alcohol exposure

›Illicit substances

05Review of Systems/ros27

General and infectious

›General and infectious

›Fever

›Chills

›Malaise

›Myalgias

Cardiopulmonary

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

›Leg swelling

Gastrointestinal

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Right upper quadrant pain

Genitourinary and obstetric

›Genitourinary and obstetric

›Dysuria

›Flank pain

›Vaginal discharge

›Leakage of fluid

›Contractions

›Decreased fetal movement

Neurologic

›Neurologic

›Lightheadedness

›Syncope

›Headache

›Visual changes

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral context

›Source

›Reliability

Family history relevant to pregnancy complications

›Family history

›Venous thromboembolism

›Bleeding disorders

›Early cardiovascular disease

Social support and safety

›Support and safety

›Ability to return for follow up

›Reliable transportation

›Safety at home

07Risk Factors/rf26

Obstetric risk factors

›Obstetric risks

›Prior cesarean delivery

›Known placenta previa or low lying placenta

›Prior placenta accreta spectrum

›Multiple gestation

›Hypertension

›Preeclampsia risk factors

Ectopic pregnancy risks

›Ectopic pregnancy risks

›Prior ectopic pregnancy

›Prior tubal surgery

›Pelvic inflammatory disease history

›IUD in situ at conception

›Assisted reproduction

Abruption risks

›Abruption risks

›Hypertension or preeclampsia

›Abdominal trauma

›Cocaine or stimulant use

›Smoking

Bleeding diathesis risks

›Bleeding and coagulation risks

›Anticoagulant therapy

›Thrombocytopenia history

›Liver disease

Infection risks

›Infection risks

›Recent STI exposure

›Recent uterine instrumentation

›Prolonged rupture of membranes

08Differential Diagnosis/ddx48

Life threatening

›Life threatening

›Ectopic pregnancy (O00.9)

›Pelvic pain with bleeding

›Syncope or shoulder tip pain

›Placental abruption (O45)

›Painful bleeding

›Uterine tenderness or hypertonus

›Placenta previa (O44)

›Painless bleeding after mid pregnancy

›Bleeding triggered by intercourse

›Vasa previa (O69.4)

›Bleeding after membrane rupture

›Fetal heart rate abnormalities

›Uterine rupture (O71.1)

›Prior uterine surgery

›Sudden severe pain with fetal compromise

›Septic abortion (O03.3)

›Fever

›Uterine tenderness

Common

›Common

›Threatened miscarriage (O20.0)

›Bleeding with closed cervix

›Viable intrauterine pregnancy possible

›Early pregnancy loss (O03)

›Tissue passage

›Open cervix or absent fetal cardiac activity

›Subchorionic hemorrhage

›Ultrasound hematoma

›Variable bleeding volume

›Cervicitis and STI related bleeding (N72)

›Discharge

›Cervical friability

›Cervical polyp

›Postcoital spotting

›Visible cervical lesion

Less common

›Less common

›Molar pregnancy (O01)

›Disproportionate nausea

›Very high hCG

›Placenta accreta spectrum (O43.2)

›Placenta previa with prior cesarean delivery

›Abnormal placental imaging

›Vaginal or cervical trauma

›Lacerations

›Recent intercourse or injury

›Nonobstetric gynecologic bleeding

›Vaginal malignancy

›Cervical malignancy

09Past Medical History/pmh16

Relevant chronic conditions

›Chronic conditions

›Hypertension (I10)

›Diabetes mellitus (E11.9)

›Thyroid disease (E03.9)

›Bleeding disorders

Prior pregnancy outcomes

›Prior pregnancy outcomes

›Miscarriage history

›Ectopic pregnancy history

›Preterm birth history

Surgeries and uterine procedures

›Surgeries and procedures

›Cesarean delivery

›Myomectomy

›Dilation and curettage

Baseline status

›Baseline

›Baseline hemoglobin if known

›Baseline blood pressure pattern

10Physical Exam/exam26

Initial and hemodynamic assessment

›General and vitals

›Mental status

›Skin perfusion

›Orthostatic symptoms

›Estimated blood loss on arrival

Cardiopulmonary

›Cardiopulmonary

›Tachycardia pattern

›Signs of volume depletion

›Work of breathing

Abdominal and uterine

›Abdominal and uterine

›Tenderness location

›Guarding or peritoneal signs

›Uterine tone

›Fundal height relative to dates

Pelvic examination precautions

›Pelvic exam approach

›Speculum exam for source of bleeding

›Avoid digital cervical exam if placenta previa not excluded after mid pregnancy

Pelvic exam findings

›Pelvic findings

›Cervical os status

›Active bleeding from cervix

›Products of conception visible

›Cervical lesions

Fetal assessment

›Fetal assessment

›Fetal heart tones if viable gestation

›Fetal movement report correlation

›Contraction frequency

11Lab Studies/labs21

Core labs for most presentations

›Baseline labs

›CBC

›Type and screen

›ABO and Rh

›Quantitative hCG in early pregnancy when diagnosis uncertain

Coagulation and hemorrhage labs

›Hemorrhage labs

›PT and INR

›aPTT

›Fibrinogen

›CMP

Infection and alternative causes

›Infection and other labs

›Urinalysis

›Urine culture

›NAAT for gonorrhea and chlamydia

›Vaginal swabs as indicated

Fetomaternal hemorrhage and Rh considerations

›Fetomaternal hemorrhage

›Kleihauer Betke test when large bleed or trauma and Rh negative

›Anti D dose adjustment local protocol dependent

Interpretation pearls and pitfalls

›Interpretation pearls

›Hemoglobin may be normal early in acute hemorrhage

›Low fibrinogen suggests consumptive coagulopathy and severe abruption risk

12Imaging/img17

Scoring Systems

›Risk and severity tools

›Shock index

›Obstetric early warning scores local protocol dependent

›Massive transfusion triggers local protocol dependent

MRI

›MRI considerations

›Placenta accreta spectrum evaluation when ultrasound equivocal

›Avoid gadolinium unless essential

›Protocol local radiology dependent

›CT considerations

›Trauma evaluation when indicated despite pregnancy

›Contrast use risk benefit and fetal shielding local protocol dependent

›Pulmonary embolism workup if indicated

Ultrasound

›Ultrasound

›Transvaginal ultrasound for early pregnancy location and viability

›Transabdominal ultrasound for placental location in later pregnancy

›POCUS for free fluid in suspected ruptured ectopic or trauma

›Avoid relying on ultrasound alone to exclude placental abruption

13Special Tests/spec12

Bedside obstetric monitoring

›Monitoring tests

›Continuous fetal monitoring when viable gestation and significant bleeding

›Tocometry for contractions

Pelvic and obstetric procedural diagnostics

›Procedural diagnostics

›Speculum exam for cervical and vaginal source

›Removal of visible products of conception from cervical os only if trained and stable

Rh and fetomaternal hemorrhage testing

›Rh related testing

›Antibody screen interpretation

›Kleihauer Betke limitations and lab variability

Trauma focused tests when indicated

›Trauma adjuncts

›FAST or eFAST

›Pelvic stability assessment

14ECG/ecg8

Indications in pregnancy bleeding presentations

›ECG indications

›Syncope

›Chest pain

›Significant tachycardia out of proportion

ECG patterns to recognize

›High risk ECG patterns

›Ischemia patterns in shock states

›Supraventricular tachycardia

›QT prolongation with electrolyte disturbance

15Assessment/ax20

Problem representation

›Problem representation

›Vaginal bleeding in pregnancy with gestational age stratification

›Maternal stability status

›Fetal status when viable gestation

Severity stratification

›Severity

›Mild bleeding with stable vitals and reassuring fetal status

›Moderate bleeding or symptomatic anemia

›Severe bleeding or shock physiology

Working diagnosis buckets

›Likely category

›Early pregnancy bleeding

›Mid to late pregnancy bleeding

›Nonobstetric genital tract source

Key complications to rule out

›Complications

›Hemorrhagic shock

›Coagulopathy

›Infection

›Fetal compromise

Diagnostic uncertainty handling

›Uncertainty management

›If pregnancy location unknown, treat as pregnancy of unknown location until confirmed

›If placenta previa not excluded, avoid digital exam after mid pregnancy

16Plan/plan43

First 5 minutes

›First 5 minutes

›Airway and breathing support if compromised

›Cardiac monitor and continuous pulse oximetry

›Two large bore IV access if moderate to severe bleeding

›Type and screen early

›Immediate obstetrics notification for heavy bleeding or any instability

Resuscitation and hemorrhage control

›Hemorrhage management

›Crystalloid bolus only as bridge to blood products if hemorrhagic shock

›Activate massive transfusion protocol if ongoing instability local protocol dependent

›Tranexamic acid use for obstetric hemorrhage per protocol local protocol dependent

Diagnostic sequencing

›Diagnostic sequence

›Ultrasound priority to determine intrauterine pregnancy in early gestation

›Ultrasound placental location before any digital exam in later gestation

›Serial hemoglobin and vitals when ongoing bleeding

Rh immune globulin

›Rh prophylaxis

›If Rh negative and bleeding, Rh immune globulin per gestational age and volume local protocol dependent

›If large bleed or trauma, consider additional dosing guided by fetomaternal hemorrhage testing local protocol dependent

Condition specific management

›Condition specific pathways

›Threatened miscarriage with viable pregnancy

›Expectant management with return precautions

›Follow up ultrasound timing local protocol dependent

›Early pregnancy loss

›Expectant versus medical versus surgical management with obstetrics

›Hemodynamic instability requires urgent uterine evacuation

›Ectopic pregnancy suspected

›If unstable, immediate surgery activation

›If stable, obstetrics for methotrexate eligibility local protocol dependent

›Placenta previa

›Avoid digital exam

›Obstetrics admission often indicated with active bleeding

›Placental abruption

›Continuous monitoring when viable gestation

›Prepare for expedited delivery if maternal or fetal deterioration

Reassessment loop

›Reassessment loop

›Repeat vitals every 5 to 15 minutes in active bleeding

›Repeat abdominal exam and uterine tone

›Ongoing quantified blood loss tracking

›Escalate if rising shock index or worsening fetal tracing

Consults

›Consults

›Obstetrics immediately for second or third trimester bleeding

›Anesthesia early for significant hemorrhage

›Interventional radiology for refractory hemorrhage local protocol dependent

›Neonatology for imminent preterm delivery

17Disposition/dispo22

ICU and high acuity criteria

›ICU or high acuity

›Persistent hemodynamic instability

›Massive transfusion requirement

›Ongoing coagulopathy

›Nonreassuring fetal tracing with maternal instability

Admission criteria

›Admission

›Moderate to heavy bleeding

›Symptomatic anemia

›Suspected placenta previa

›Suspected placental abruption

›Pregnancy of unknown location with concerning features

Observation pathway

›Observation

›Stable vitals with resolved bleeding but uncertain diagnosis

›Need for repeat hemoglobin or repeat ultrasound

Discharge criteria

›Discharge

›Stable vitals

›Minimal bleeding

›Reassuring evaluation for life threats

›Reliable follow up within 24 to 72 hours as appropriate

Follow up timing

›Follow up

›Obstetrics follow up within 24 to 72 hours for early pregnancy bleeding local protocol dependent

›Immediate return if recurrent heavy bleeding or pain

18Discharge Instructions/di7

Copy discharge instructions

›Copy discharge instructions

›You were seen for bleeding during pregnancy

›Small amounts of spotting can occur, but heavier bleeding can be serious

›Return now for soaking pads quickly, passing large clots, fainting, severe belly pain, fever, or new shortness of breath

›Avoid inserting anything in the vagina until cleared, including tampons and intercourse

›If you are Rh negative, you may need Rh immune globulin and follow up testing

›Follow up with your pregnancy care team within the recommended timeframe

19References/r15

Guidelines and key resources

›ACOG Practice Bulletin on early pregnancy loss, year varies by update

›Management options and follow up recommendations

›Local protocol dependent details for availability and pathways

›ACOG guidance on ectopic pregnancy, year varies by update

›Medical and surgical criteria

›Discriminatory zone concepts and ultrasound correlation

›ACOG guidance on placenta previa and placenta accreta spectrum, year varies by update

›Avoid digital exam until placental location known

›Imaging approach with ultrasound and MRI when needed

›ACOG guidance on placental abruption, year varies by update

›Maternal stabilization priorities

›Fetal monitoring and delivery considerations

›Society of Obstetricians and Gynaecologists of Canada guidance on early pregnancy complications, year varies by update

›Rh immune globulin use local protocol dependent

›Follow up pathways by region

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.