Bleeding in the first trimester of pregnancy is the most common problem in pregnancy. It occurs in one out of five clinically recognized pregnancies before the 20th week, and about half of these result in miscarriage.¹

EDs provide 24-hour medical care, often making them the first place a pregnant woman goes to seek care for vaginal bleeding. ED nurses encounter this situation frequently, so it is essential that they have a sound working knowledge of the incidence, etiology, risk factors, and potential life-threatening symptoms associated with vaginal bleeding during pregnancy. Prompt recognition of significant clinical signs may save precious time in an emergent situation.

Incidence and etiology

Vaginal bleeding during the first trimester of pregnancy occurs from many causes, including spontaneous abortion; ectopic pregnancy; physiologic causes associated with the implantation of the pregnancy; and cervical, vaginal, or uterine pathology.

Spontaneous abortion: Commonly known as miscarriage, spontaneous abortion is the most frequent cause of vaginal bleeding in the first trimester. Eighty percent of spontaneous losses occur in the first 12 weeks of pregnancy.² Chromosomal abnormalities account for more than 50% of losses in all women with clinically recognized pregnancies.³ Advanced maternal age has been cited as the most significant risk factor for spontaneous abortion in normal, healthy women. This age-related risk is 20% at age 35, doubles by age 40, and doubles again at age 45. With the advent of reproductive technology extending the possibility of pregnancy for women well into their 40s, it appears that the number of women who experience spontaneous abortion is on the rise.³

Other causes of spontaneous abortion are usually related to maternal factors, including infection (syphilis and HIV), history of previous miscarriages, a luteal phase defect, uterine or cervical abnormalities (incompetent cervix or uterine leiomyomas), or maternal illness such as thyroid disease, autoimmune disease, or diabetes.⁴ Certain maternal behaviors may also play a part in first trimester losses: tobacco, alcohol, and drug use, as well as certain environmental factors such as exposure to some anesthetic agents or heavy metals.³

Spontaneous abortion is subdivided into three types: threatened, inevitable (complete or incomplete), and missed. Threatened abortion usually presents with painless, light bleeding or spotting and is the most common cause of first trimester bleeding.² In this case, the cervix remains closed, fetal heart activity may be detectable by ultrasound or Doppler www.guideline.govsummary/summary.aspxdoc_id=8318&nbr=4650&ss=6&xl=999 depending on the gestational age, and the uterine size is appropriate for gestational age.² The overall risk of pregnancy loss decreases as the pregnancy progresses, particularly if fetal cardiac activity is noted.

Inevitable abortion usually presents with heavy vaginal bleeding that is accompanied by uterine cramping and pain. This will usually cause opening of the cervix, which may result in expulsion of the entire products of conception, including the fetus, membranes, and placental tissue. This is considered a “complete” inevitable abortion. After the entire uterine contents are expelled, vaginal bleeding and cramping significantly subside.² An “incomplete” inevitable abortion involves the expulsion of some of the contents of the uterus, but not all. This can cause an excessive amount of bleeding, as the uterus cannot contract well enough to slow the bleeding. Often, if a pregnancy is greater than 12 weeks, the placental tissue is retained and the cervix remains open while heavy bleeding and cramping ensue.² An incomplete abortion can lead to bleeding that is severe enough to cause hypovolemic shock . Signs and symptoms of hypovolemia may not be apparent in healthy young women who have excellent physiologic reserves, until 10% to 15% of their blood volume is lost.⁵

Missed abortion has been defined in the literature in two ways. One refers to a nonviable pregnancy that is retained without expulsion. And the other is a blighted ovum (also called anembryonic pregnancy) — a fertilized egg that attaches itself to the uterine wall, but the embryo does not develop.^2,4 Often, these types of pregnancy losses do not present with the “typical” symptoms of miscarriage, such as bleeding or pain. They are first diagnosed when the fetal heart is inaudible with the doptone and subsequent ultrasound does not show fetal cardiac activity. The cervix usually remains closed, and vaginal bleeding is usually light or nonexistent. This can be managed surgically or expectantly.⁴

Ectopic pregnancy: The implantation of a fertilized ovum in any place other than the uterine cavity is known as ectopic pregnancy. The incidence of these pregnancies is on the rise, climbing steadily from 0.45% in the 1970s to 2% in 1992, which was the last year of an official report for the United States.⁶ With advances in assisted reproduction, the number of ectopic pregnancies is expected to increase.⁶

The majority of ectopic pregnancies are tubal pregnancies, or those that occur within the fallopian tube. Since the fertilization of the oocyte usually occurs in the ampullary segment (the wide middle segment) of the fallopian tube, this is where the majority of ectopic pregnancies implant. In a normal pregnancy, the zygote (fertilized egg) proceeds along the fallopian tube and implants in the endometrium of the uterus. Therefore, in a tubal pregnancy, the zygote does not migrate into the uterus but instead implants where it is fertilized. Interruption of the vascular supply to the placenta causes bleeding into the fallopian tube, resulting in a hematoma. The subsequent distention of the tube may result in rupture, which may cause hemorrhage into the peritoneum.⁶

Physiologic causes: First trimester bleeding is usually associated with the implantation of the zygote into the endometrium, commonly known as implantation bleeding. This happens before or on the 40th day of conception and occurs in about 8% of pregnancies.⁴ It is a benign condition in which the bleeding is usually scant and resolves spontaneously. Other physiologic causes may be due to an inflammation of the cervix (cervicitis), moderate to severe vulvovaginitis, hemorrhoids, or hemorrhagic cystitis. These conditions do not affect the viability of the pregnancy and can be treated to resolve the cause. A rare but potentially serious reason for first trimester bleeding may be due to blood dyscrasias, which inhibit clotting factors and result in persistent bleeding, as seen in von Willebrand’s disease , thrombocytopenia, and leukemia.⁴

Triage

When a woman presents to the ED with amenorrhea, vaginal bleeding, or abdominal pain, the triage nurse must obtain a brief, concise history within the first few minutes of the triage interview. This alerts the nurse to clues that may suggest an impending emergency, such as ectopic pregnancy. Healthcare providers depend heavily on technology such as ultrasound to diagnose a problem, but this should never take the place of an effective nursing assessment.

Questions in the patient interview should include —

• Is the diagnosis of pregnancy established?
• What is the estimated gestational age?
• Has an ultrasound been performed? If so, when, and what were the results? If the patient states that an intrauterine pregnancy or fetal heart rate is established or documented, ectopic pregnancy can be excluded from the differential diagnosis.

Other pertinent information the nurse should obtain includes —

• A description of the vaginal bleeding, including the amount (measured in peripad saturation amount or weight).
• The pattern, duration, and severity of the bleeding, and if it is associated with any activity (e.g., sexual intercourse or heavy lifting).
• The presence and severity of abdominal pain (ectopic pregnancy should be considered in all women of childbearing age who present with abdominal or pelvic complaints).⁷
• Any other related symptoms such as nausea and vomiting, fever, or nonabdominal pain.
• Is there a history of previous ectopic pregnancy or tubal surgery, such as tubal ligation?
• Is this pregnancy a result of in vitro fertilization?
• Is there any history of pelvic infection that required antibiotics or hospitalization?
• Is the patient now using or has she recently used an IUD for contraception? Evidence shows that women using an IUD who become pregnant are at high risk for ectopic pregnancy.⁸

Once this basic information is established, the nurse should focus on the physical assessment. One of the most important parts of this is the evaluation of vital signs. Low blood pressure and increased pulse rate are indicators of shock. However, since pregnant patients are generally younger and therefore have better physiologic reserves, they may have a better capacity to accommodate blood loss. Therefore, they may not become tachycardic and hypotensive until late in their presentations.⁷ Research indicates that orthostatic blood pressure changes do not occur until 10% to 15% of blood volume is lost.⁵ If either of these two vital signs is abnormal on initial evaluation and an intrauterine pregnancy is not established while the patient complains of abdominal pain — with or without bleeding — there is an increased likelihood of ruptured ectopic pregnancy. Immediate emergency measures must be initiated.

Other reasons for abnormal vital signs include pain, fever, hypoxia, or emotional distress.⁷ Women may also complain of normal pregnancy discomforts such as nausea, fatigue, urinary frequency, and breast tenderness. More specific symptoms include shoulder pain (from blood irritating the diaphragm) and lightheadedness or shock.⁵ These “classic” symptoms of ruptured ectopic pregnancy may provide valuable evidence of an impending emergency; however, more than 50% of women are asymptomatic before tubal rupture.⁵

Evaluation of the color, consistency, and amount of vaginal bleeding is the next step in the assessment process. This can be done by inspecting the peripad or underwear worn by the patient. Moderate or heavy bright red bleeding with clots that persists for several hours warrants prompt further evaluation by the healthcare provider, particularly if accompanied by severe cramping and abnormal vital signs. These symptoms may occur in impending or incomplete miscarriage. Scant brownish or pink discharge that is not accompanied by abdominal pain or abnormal vital signs is less of an emergency but still creates anxiety for the patient and her family.

Nursing care

In the presence of moderate or heavy bleeding, severe abdominal pain, or abnormal vital signs, IV access and baseline lab work must be initiated. Using a large-gauge angiocath — at least 18 gauge — is ideal if blood transfusion is necessary. Lab work includes a CBC and type and screen. All Rh-negative pregnant women who have had an episode of bleeding during pregnancy are candidates for an injection of anti-D immunoglobulin (RhoGAM) intramuscularly within 48 hours to 72 hours of the onset of bleeding.⁵ This prevents isoimmunization caused by fetomaternal hemorrhage. Isoimmunization is an incompatibility between an infant’s blood type and that of the mother, resulting in destruction of the infant’s red blood cells (hemolytic anemia) during pregnancy and after birth by antibodies from the mother’s blood.

Evaluation of fetal heart tones to establish fetal viability is one of the most reassuring factors for the nurse and the patient. If the patient has an established estimated due date, an accurate last menstrual period, or is determined to be at least 10 to 12 weeks pregnant, the nurse will attempt to auscultate the fetal heartbeat with a doptone. However, the nurse performing this skill must have previous experience auscultating heart tones this early in pregnancy, as it is not as easy as with a larger fetus. Inexperience may result in an inability to locate the heartbeat, in turn causing more anxiety for the patient.

Emotional support

EDs are busy areas, and sometimes it may seem that there is not enough time or personnel to attend to the emotional concerns of patients. However, pregnancy is a significant event in a woman’s life, and an attachment to the pregnancy can be established during the first few weeks of pregnancy.⁵ A woman who presents with bleeding knows her pregnancy is at risk and therefore may exhibit signs of emotional distress such as anxiety, fear, and guilt. Studies show that women appreciate when health care personnel are caring and sympathetic in their approach and when they deliver honest information even when it is not favorable.⁵ Anticipatory guidance of procedures and their limitations are also helpful. If loss occurs or is inevitable, taking those few extra minutes to acknowledge the loss in an empathetic manner will be long remembered. If possible, nurses should initiate community referrals for individual or group bereavement counseling.

Women who present to the ED with vaginal bleeding in the first trimester of pregnancy are often scared and seek reassurance of a “normal” pregnancy. The challenges of providing prompt, efficient, and empathetic care are often difficult because of varied clinical presentations. A complete understanding of the potential etiology of the bleeding, the patient’s clinical history, and physical symptoms that constitute an emergency are essential for the nurse who has the first contact with this vulnerable population. Also, an appreciation of the emotional significance of this event in the woman’s life, within the clinical framework presented in this article, can help nurses provide complete and sensitive care during this difficult time.