BLEEDING IN PREGNANCY
A woman presents at 20 weeks’ gestation reporting vaginal bleeding. The bleeding occur- red 2 h ago and was bright red. She reported no abdominal pain with the bleeding and she had not had any previous episodes. She had had intercourse the previous evening.
Her last cervical smear was normal 2 years ago.
This is her first pregnancy and her current obstetric history is unremarkable with normal first-trimester scan and Down’s syndrome screening. She reports that her booking blood tests had been normal.
She is extremely anxious when seen, concerned that she is going to have a miscarriage.
The blood pressure is 105/65 mmHg and pulse 86/min. Abdominal examination confirms that the uterus reaches to 1 cm below the umbilicus. The uterus is soft and non-tender. The fetal heart is heard with the hand-held fetal Doppler ultrasound probe. Speculum examin- ation reveals a reddened area around the external cervical os, with an inflammatory appearance and a small amount of contact bleeding. The os itself is closed.
· What is the most likely cause of the bleeding?
· How would you manage this woman?
One of the commonest causes of bleeding in pregnancy is a cervical ectropion, and this is suggested in this case by the examination findings. An ectropion can often look florid and inflamed even in the absence of infection.
An ectropion may occur at any time in a woman’s reproductive life but tends to be prevalent:
· in pregnancy
· after puberty
· with the combined oral contraceptive pill.
Postcoital bleeding often suggests an ectropion or other cervicitis. However, caution should be exerted as an ectropion is very common in pregnancy and could be an inciden- tal finding when there is in fact a uterine source of bleeding. Thus the findings in this case are very suggestive of bleeding secondary to an ectropion but do not fully rule out a uter- ine source of the blood loss.
The woman should generally be reassured about the likely cause of the loss. She should be given anti-D if Rhesus negative, as a fetomaternal haemorrhage could potentially have occurred if this was uterine bleeding.
Swabs should be taken during the speculum examination to rule out chlamydia, as well as microscopy, culture and sensitivity for organisms including group B streptococcus and candida.
Above the gestational age of fetal viability (23–24 weeks), a woman would normally be admitted for observation for possible further bleeding and risk of premature delivery. However at 20 weeks with no possibility of fetal viability, there is no advantage to admis- sion to hospital with light bleeding.
Bedrest has not been shown to be of benefit in cases of vaginal bleeding in pregnancy.
She should be advised that the ectropion is not harmful to the pregnancy but may result in further bleeding episodes, in which case she should be seen again in the obstetric department.