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Avaliação e diagnóstico diferencial de sangramento

vaginal antes das 20 semanas de gestação
AUTORES: Errol R Norwitz, MD, PhD, MBA, Joong Shin Park, MD, PhD
EDITOR DE SEÇÃO: Charles J Lockwood, MD, MHCM
EDITOR ADJUNTO: Vanessa A Barss, MD, FACOG

Todos os tópicos são atualizados à medida que novas evidências são disponibilizadas e nosso processo de revisão por
pares é concluído.

Revisão da literatura atualizada até: novembro de 2023.

Última atualização deste tópico: 16 de março de 2023.

INTRODUÇÃO

O sangramento vaginal é comum na primeira metade da gravidez. Geralmente resulta da

ruptura dos vasos sanguíneos na decídua (isto é, endométrio da gravidez) ou de uma lesão
cervical ou vaginal discreta. O médico normalmente faz um diagnóstico clínico provisório
com base na idade gestacional e na natureza do sangramento (por exemplo, manchas, fluxo
leve ou intenso, intermitente ou constante, associado a dor ou indolor). O exame físico e os
exames laboratoriais e/ou de imagem são então utilizados para apoiar ou revisar o
diagnóstico inicial. O sangramento pode estar associado a um resultado adverso na gravidez
ou a uma gravidez ectópica, que pode ser fatal.

A avaliação e o diagnóstico diferencial de sangramento vaginal na primeira metade da

gravidez (ou seja, até 20 semanas de gestação) são discutidos aqui. A avaliação e o
diagnóstico diferencial de sangramento vaginal na segunda metade da gravidez (ou seja, 20
semanas ou mais de gestação) são revisados ​separadamente. (Consulte "Avaliação e
diagnóstico diferencial de sangramento vaginal após 20 semanas de gestação".)

INCIDÊNCIA

Manchas ou sangramento vaginal ocorrem em aproximadamente 25% das gestações no

primeiro trimestre (até 13+6 semanas [ou seja, 13 semanas mais 6 dias de gestação]) [1 ]. É
muito menos comum no segundo trimestre (14+0 a 27+6 semanas), ocorrendo em um a dois

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por cento das gestações [2]. A incidência relatada varia amplamente dependendo da
definição de sangramento e do método de apuração do caso.

AVALIAÇÃO

Local — O local de avaliação do paciente (consultório versus pronto-socorro) depende do

volume de sangramento e da presença de outros sintomas. Pacientes com sangramento
intenso (por exemplo, imersão ≥1 absorvente/hora por mais de duas horas ou passagem de
grandes coágulos), tontura/síncope e/ou dor pélvica geralmente necessitam de avaliação
imediata em um pronto-socorro para que medidas de suporte e tratamento possam ser
rapidamente iniciado se o paciente estiver hemodinamicamente instável. Em pacientes
hemodinamicamente instáveis, dois cateteres intravenosos (IV) periféricos de grande calibre
(calibre 14 ou 16) são colocados para fluidos intravenosos, e um nível de
hemoglobina/hematócrito, estudos de coagulação e um tipo e triagem ou prova cruzada são
obtidos, com transfusão de sangue produtos conforme necessário.

Embora os pacientes com perda sanguínea grave (isto é, necessitando de cuidados de

suporte e tratamento rápido) geralmente apresentem alterações ortostáticas (queda da
pressão arterial sistólica de ≥20 mmHg ou queda da pressão arterial diastólica de ≥10 mmHg
ou aumento da frequência cardíaca de ≥30 batimentos/minuto presentes após três minutos
em pé, síncope), ocasionalmente pacientes grávidas jovens podem apresentar sangramento
volumoso sem demonstrar ortostase. Uma avaliação imediata e cuidadosa é importante
para evitar atrasos desnecessários no manejo desses pacientes.

Objetivo — O objetivo da avaliação é fazer um diagnóstico definitivo quando possível e

excluir a presença de patologia grave nos casos restantes ( algoritmo 1). A etiologia real
do sangramento muitas vezes não pode ser determinada.

História

● Uma gravidez intrauterina foi documentada? — É particularmente importante

excluir a gravidez ectópica, pois pode ser fatal. Assim, o primeiro passo na avaliação é
determinar se o paciente fez um exame de ultrassom e revisar os resultados desse
exame. A documentação prévia de que a gravidez está no local intrauterino normal
exclui imediatamente a gravidez ectópica, embora a possibilidade de que a
ultrassonografia anterior possa ter perdido uma gravidez heterotópica (ou seja, uma
gravidez intrauterina e uma gravidez extrauterina) ou ter diagnosticado erroneamente
uma gravidez ectópica intersticial (cornual) como intrauterina deve sempre ser
considerado.

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Se houver dúvida sobre a localização intrauterina da gravidez, repita o exame

ultrassonográfico. (Veja 'Ultrassonografia' abaixo.)

● Os sintomas são preocupantes para gravidez ectópica ou perda de gravidez? — A

extensão do sangramento deve ser determinada: a paciente está formando coágulos
sanguíneos ou o sangue está encharcado em suas roupas? Eles se sentem tontos? Eles
têm dores pélvicas significativas ou cólicas? Eles passaram algum tecido?

If the patient answers yes to any of these questions, then ectopic pregnancy and
pregnancy loss (also called miscarriage or spontaneous abortion) are much more likely
diagnoses than threatened abortion, implantation bleeding, cervical and vaginal
disorders (or ectropion), or cervical insufficiency (in the second trimester). However, the
presence of only light, intermittent, painless bleeding does not exclude the possibility
of a life-threatening underlying disorder, such as ectopic pregnancy. (See 'Differential
diagnosis' below.)

● Are there risk factors for ectopic pregnancy or pregnancy loss? — What is the
patient's medical history? A past history of ectopic pregnancy or risk factors for ectopic
pregnancy ( table 1) increase the probability of this disorder, but many patients with
ectopic pregnancy have no risk factors. (See 'Ectopic pregnancy' below.)

A history of ≥2 consecutive pregnancy losses or a condition associated with pregnancy

loss (eg, chromosomal translocation in either parent, maternal antiphospholipid
syndrome, uterine anomaly) increases the likelihood that bleeding is related to
pregnancy loss. (See 'Pregnancy loss' below.)

● Does the patient say that they don't "feel pregnant" anymore? — Patients with a
pregnancy loss may notice that symptoms associated with early pregnancy (eg, nausea,
breast tenderness, urinary frequency, fatigue) have abated and they do not "feel
pregnant" anymore. (See 'Pregnancy loss' below.)

● Has the patient had a prior cesarean birth? — In patients with a prior cesarean birth,
a subsequent pregnancy may implant in the area of the uterine scar. This is termed
cesarean scar pregnancy and can only be diagnosed by ultrasound examination.
Diagnosis is important as it is associated with an increased risk of adverse pregnancy
outcome. (See 'Cesarean scar pregnancy' below.)

Focused physical examination

● Examine any tissue that has been passed — Any tissue the patient has passed
vaginally should be examined. Patients may mistake blood clot for the products of
conception. Passage of blood clot alone is not diagnostic of any disorder whereas a
gestational sac/fetal membranes, fronds indicative of placental villi, or an intact

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embryo/fetus are diagnostic of a partial or complete pregnancy loss. Products of

conception, if present, should be visible upon careful examination. Visualization of villi
can be facilitated by rinsing the specimen to clear away blood clot and then floating it in
water ( picture 1A-B). (See 'Pregnancy loss' below.)

● Examine the abdomen — An abdominal examination should be performed before the

internal examination. It is best to begin by examining the quadrant of the abdomen
where the patient is experiencing the least pain and then moving toward the painful
area. Gentle percussion is preferable to deep palpation since it causes less pain and
guarding.

Midline pain is more consistent with pregnancy loss, while lateral pain is more
consistent with ectopic pregnancy. (See 'Pregnancy loss' below and 'Ectopic pregnancy'
below.)

Nongynecologic causes of pain should also be considered. (See "Approach to acute

abdominal/pelvic pain in pregnant and postpartum patients", section on 'Medical-
surgical causes of acute abdominal pain'.)

Check for embryonic/fetal cardiac activity — Presence of embryonic/fetal cardiac activity

is reassuring, as it indicates bleeding is not related to embryonic/fetal demise and highly
unlikely to be related to an ectopic pregnancy.

● If bedside ultrasound is available, absence of previously documented embryonic/fetal

cardiac activity is diagnostic of pregnancy loss. In the absence of a previous ultrasound,
pregnancy failure can be diagnosed in the absence of embryonic/fetal cardiac activity
when the crown-rump length is ≥7 mm or mean gestational sac diameter is ≥25 mm.
Ultrasound diagnosis of pregnancy loss very early in gestation can be complicated and
is reviewed in detail separately. (See "Pregnancy loss (miscarriage): Ultrasound
diagnosis".)

● If the pregnancy is ≥10 to 12 weeks of gestation, a handheld Doppler ultrasound device

can be used to check for a fetal heartbeat. The fetal heart rate usually can be easily
distinguished from the maternal heart rate since it is typically in the range of 110 to 160
beats per minute; however, the difference in fetal and maternal heart rates can be
minimal if the mother has tachycardia and/or the embryo/fetus has bradycardia [3].
Inability to detect fetal heart motion by handheld Doppler device, particularly in the
first trimester, may merely reflect the difficulty in blindly finding the location of the
embryo/fetus.

Speculum examination

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● Does the vagina contain tissue or blood clot? — A speculum is inserted into the
vagina to assess the volume and source of bleeding. If blood clots, products of
conception, or both are present, they can be removed with gauze sponges on a sponge
forceps. This tissue is examined for a gestational sac/fetal membranes, fronds
indicative of placental villi, or an intact embryo/fetus and, by convention, sent for
pathologic examination to confirm the presence of products of conception, which are
diagnostic of pregnancy loss, and to exclude gestational trophoblastic disease. (See
'Pregnancy loss' below and 'Gestational trophoblastic disease' below.)

The utility of routine histopathological examination is questionable, as it rarely

suggests the underlying cause of the pregnancy failure or establishes a diagnosis of
gestational trophoblastic disease [4]. However, pathologists can sometimes diagnose
entities that are the probable cause of the loss or associated with recurrent loss. These
include massive chronic intervillositis, massive intervillous fibrin deposition, maternal
vasculitis, findings suggestive of some fetal chromosomal anomalies (eg, triploidy,
some trisomies), and septic abortion.

● Can the source of bleeding be seen? — Speculum examination usually confirms that
the uterus is the source of bleeding but may reveal a vaginal or cervical source
unrelated to pregnancy; in such cases, further evaluation depends upon the nature of
the abnormality. (See 'Cervical and vaginal disorders' below and 'Ectropion' below.)

If no blood is seen in the vagina, then the bleeding is either resolved, occurring
intermittently, or from a nongenital tract source (eg, hemorrhoids).

● Is the internal cervical os dilated?

• First trimester – Visualization of the internal cervical os is possible in some cases

and if dilated, raises concern that a complete or incomplete pregnancy loss has
occurred. Cramping is typically present when the cervix is open. Direct visualization
of the gestational sac in a dilated internal cervical os is generally sufficient to
conclude that early pregnancy loss is occurring. An open internal cervical os will
admit a small instrument, such as a cotton-tipped swab. Ultrasound can provide
additional information in these cases, such as whether there are retained products
of conception or the unexpected presence of a twin pregnancy with a second viable
gestational sac. Therefore, it is prudent to not inform patients that the pregnancy
has been lost until ultrasound findings are available and the diagnosis is confirmed.
(See 'Pregnancy loss' below.)

A closed internal cervical os is not diagnostic of any pregnancy disorder and can be
consistent with ectopic pregnancy, threatened abortion, implantation bleeding, and
other intrauterine pathologies. If the internal cervical os appears closed and there

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are no obvious vaginal or cervical bleeding lesions, the speculum is removed and a
bimanual pelvic examination is performed. (See 'Ectopic pregnancy' below and
'Threatened abortion' below and 'Physiologic or implantation bleeding' below and
'Vanishing twin' below.)

In contrast to the internal os, an open external cervical os is usually not helpful
diagnostically because it can be a normal finding, especially in parous patients.

• Second trimester – A dilated internal cervical os with painful cramps/contractions in

the second trimester suggests pregnancy loss. (See 'Pregnancy loss' below.)

By comparison, painless cervical dilation and/or effacement (thinning) in the second

trimester suggests cervical insufficiency. The fetal membranes may be prolapsed or
ruptured. Uterine cramps/contractions are absent or weak and irregular. (See
'Cervical insufficiency' below.)

Pelvic examination — If findings on speculum examination do not lead to a specific

diagnosis, the clinician should determine whether uterine size is appropriate for the
estimated gestational age. The size-gestational age correlation is learned by experience and
is often described in terms of fruit (eg, 6- to 8-week size = small pear, 8- to 10-week size =
orange, 10- to 12-week size = grapefruit). The uterus remains a pelvic organ until
approximately 12 weeks of gestation, when it becomes sufficiently large to palpate
transabdominally just above the symphysis pubis. The normal uterus is nontender, smooth,
and firm.

● Uterus large for dates – Uterine size larger than expected for dates suggests a
multiple gestation; gestational trophoblastic disease; other uterine pathology (fibroids
often cause irregular uterine enlargement and may cause pain/tenderness); or
incorrect dating. (See "Twin pregnancy: Overview" and 'Gestational trophoblastic
disease' below and "Uterine fibroids (leiomyomas): Epidemiology, clinical features,
diagnosis, and natural history".)

● Uterus small for dates – Uterine size smaller than expected for dates suggests loss of
an intrauterine pregnancy (see 'Pregnancy loss' below and 'Vanishing twin' below),
ectopic pregnancy (see 'Ectopic pregnancy' below), or incorrect dating.

● Other findings – With an ectopic pregnancy, findings on pelvic examination may

include adnexal, cervical motion, or abdominal tenderness; an adnexal mass; and mild
uterine enlargement; however, the physical examination is often unremarkable in a
patient with a small, unruptured ectopic pregnancy. (See 'Ectopic pregnancy' below.)

One review of data from observational studies concluded that ultrasound examination and
human chorionic gonadotropin (hCG) concentration (both discussed below) could replace

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pelvic examination in the initial evaluation of patients with early pregnancy bleeding [5].
However, some diagnoses will be missed with this approach (eg, bleeding from cervical or
vaginal lesions), this combination of tests may not distinguish between a complete
pregnancy loss and an ectopic pregnancy (both will have an empty uterus and positive hCG),
and the additional cost of these tests can be avoided in some patients. For example, in
bleeding patients in whom sonography has previously confirmed a viable singleton
intrauterine pregnancy, another examination is not necessary to exclude ectopic pregnancy
or to confirm embryonic/fetal viability if embryonic/fetal heart motion can be detected by a
handheld Doppler device. Additionally, there is no value in checking the hCG concentration
once the presence of an intrauterine pregnancy has been established sonographically (eg,
presence of an intrauterine gestational sac containing a yolk sac or fetus).

Ultrasonography — Ultrasonography is the cornerstone of the evaluation of bleeding in

pregnancy. It is most useful in bleeding patients with a positive pregnancy test in whom an
intrauterine pregnancy has not been previously confirmed by imaging studies. In these
patients, ultrasound examination is performed to determine whether the pregnancy is
intrauterine or extrauterine (ectopic) and, if intrauterine, whether embryonic/fetal cardiac
activity present. The possibility of heterotopic pregnancy should always be considered. (See
'Heterotopic pregnancy' below.)

Transabdominal ultrasound is performed initially and findings may be diagnostic. At very

early gestational ages, transvaginal ultrasound allows for earlier and more reliable detection
of an intrauterine or ectopic pregnancy and is more sensitive for detecting embryonic/fetal
cardiac activity compared with transabdominal ultrasound, but the latter is useful for
assessing free fluid in the abdomen (eg, bleeding from an ectopic pregnancy) and
abnormalities beyond the field of view of a high-frequency vaginal probe.

It is important to note that the absence of an intrauterine gestational sac on ultrasound

examination is highly suggestive of ectopic pregnancy if more than 5.5 to 6 weeks have
elapsed since the first day of the patient's last normal menstrual period ( table 2). At
earlier gestational ages, however, an intrauterine pregnancy may be present, but not yet
identifiable, even by transvaginal ultrasound. In a patient with a positive pregnancy test and
a transvaginal ultrasound that shows neither an intrauterine pregnancy nor an ectopic
pregnancy (ie, pregnancy of unknown location), serum hCG is tested serially to determine
the rate of rise. Ultrasound findings, absolute hCG level, and change in hCG level over time
are correlated until a final diagnosis (ie, live intrauterine pregnancy, early pregnancy loss,
ectopic pregnancy) is possible. This is described in detail separately. (See "Pregnancy loss
(miscarriage): Terminology, risk factors, and etiology" and "Ectopic pregnancy: Clinical
manifestations and diagnosis" and "Approach to the patient with pregnancy of unknown
location".)

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Rarely, ultrasound examination reveals unusual causes of vaginal bleeding, such as

gestational trophoblastic disease or loss of one fetus from a multiple gestation. (See
'Gestational trophoblastic disease' below and 'Vanishing twin' below.)

Role of other imaging tests — Magnetic resonance imaging (MRI) is rarely indicated but
may be used as a second-line imaging modality for further evaluation of limited and
nondiagnostic ultrasound, an unusual ectopic pregnancy, gestational trophoblastic disease,
and differentiating causes of severe pelvic pain and adnexal masses.

Computed tomography (CT) may be useful in pregnant patients with trauma or acute
nongynecologic pain, for staging of malignancy, or if MRI is not possible and additional
information is needed. It is not the preferred modality since it involves use of ionizing
radiation, but it can be performed safely and should be used when other imaging modalities
do not provide adequate diagnostic information. (See "Diagnostic imaging in pregnant and
lactating patients".)

Laboratory tests

● Baseline hemoglobin/hematocrit – In hemodynamically stable patients, a baseline

hemoglobin/hematocrit measurement can be useful in those with heavy vaginal
bleeding, particularly if persistent, since a marked fall in hemoglobin/hematocrit from a
previous level or on subsequent testing is consistent with severe bleeding from a
pregnancy loss or a ruptured ectopic pregnancy.

● Human chorionic gonadotropin (hCG) – Once the presence of an intrauterine

pregnancy has been established sonographically, measurement of the hCG level is
rarely informative.

Serial measurements of hCG are helpful during the first six weeks of pregnancy if
ultrasonography is nondiagnostic (ie, the location of the pregnancy is not known). The
pattern of hCG change in very early normal and abnormal pregnancies and its
correlation with ultrasound findings is complicated and discussed in detail separately.
(See "Approach to the patient with pregnancy of unknown location", section on
'Subsequent testing in selected patients'.)

Other hormone assays (eg, progesterone, estrogen, inhibin A, pregnancy-associated

protein-A [PAPP-A]) are less useful than hCG and beyond the scope of this topic.

● RhD type – RhD typing should be performed in patients >12 weeks of gestation as anti-
D immune globulin is administered to those with uterine bleeding to prevent
alloimmunization from concurrent fetomaternal bleeding. Expert opinion varies as to
whether RhD typing is needed at ≤12 weeks since anti-D immune globulin is no longer
routinely administered to D-negative patients with uterine bleeding at ≤12 weeks.

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Patient selection for anti-D immune globulin for prophylaxis against alloimmunization
is discussed in detail separately. (See "RhD alloimmunization: Prevention in pregnant
and postpartum patients", section on 'Indications'.)

DIFFERENTIAL DIAGNOSIS

Common diagnoses with potentially serious consequences

Ectopic pregnancy — Ectopic pregnancy accounts for up to 2 percent all pregnancies. Most
patients with a tubal ectopic pregnancy present in the first trimester; presentation after the
first trimester increases the chances that the location is nontubal (abdominal, cervical,
cesarean scar, or interstitial [cornual]) or heterotopic. (See 'Heterotopic pregnancy' below
and 'Cervical pregnancy' below and 'Cesarean scar pregnancy' below and "Abdominal
pregnancy".)

Rupture can lead to life-threatening intraabdominal hemorrhage; therefore, the diagnosis of

ectopic pregnancy should be suspected in any pregnant patient with vaginal bleeding with or
without abdominal pain and no evidence of an intrauterine pregnancy on transvaginal
ultrasound.

Visualization of an extraovarian adnexal mass containing an empty gestational sac, a

complex extraovarian adnexal mass, or intraperitoneal bleeding on transvaginal ultrasound
strongly supports the diagnosis of ectopic pregnancy. Visualization of an extrauterine
gestational sac with a yolk sac or fetus (with or without a heartbeat) on transvaginal
ultrasound is diagnostic. (See "Ectopic pregnancy: Clinical manifestations and diagnosis",
section on 'Transvaginal ultrasound'.)

In the absence of these findings, sonography and human chorionic gonadotropin (hCG) are
used until a final diagnosis (ie, live intrauterine pregnancy, early pregnancy loss, ectopic
pregnancy) is made. (See "Approach to the patient with pregnancy of unknown location".)

Management of ectopic pregnancy is generally medical (methotrexate therapy) or surgical

(see "Ectopic pregnancy: Methotrexate therapy" and "Tubal ectopic pregnancy: Surgical
treatment"). Expectant management can be dangerous for the patient, but may be possible
in carefully selected patients. (See "Ectopic pregnancy: Expectant management of tubal
pregnancy".)

Pregnancy loss — A variety of terms ( table 3) are used to describe pregnancy loss. (See
"Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

Complete pregnancy loss — When a pregnancy loss occurs before 12 weeks of

gestation, it is common for the entire contents of the uterus to be expelled, thereby resulting

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in complete pregnancy loss. If this has occurred, the uterus is small on physical examination
and well contracted with an open or closed internal cervical os and the patient may describe
diminishing bleeding and pain. Ultrasound will reveal an empty uterus and no extrauterine
gestation. The diagnosis is certain if a previous ultrasound examination documented an
intrauterine pregnancy. This is important since the uterus may appear empty on ultrasound
in a normal pregnancy that is too early to visualize or in an ectopic pregnancy.

In the absence of previous sonographic documentation of an intrauterine pregnancy, other

findings that suggest that an empty uterus is due to complete pregnancy loss rather than an
ectopic pregnancy or early normal pregnancy are evidence of products of conception in
tissue passed vaginally or documentation of falling rather than rising or plateaued hCG
levels. If tissue is unavailable or does not show products of conception, then serum hCG
levels should be checked and a falling level should be followed serially until the level is
undetectable. (See "Approach to the patient with pregnancy of unknown location".)

Incomplete pregnancy loss — The early stage of an incomplete pregnancy loss should
be suspected when the internal cervical os is dilated and/or effaced, vaginal bleeding is
increasing, and painful uterine cramps/contractions are present. The gestational tissue often
can be felt or seen at the dilated and/or effaced internal cervical os on speculum. At a more
advanced stage, the gestational sac/fetal membranes may rupture and the embryo/fetus
may be passed, but significant amounts of placental tissue can be retained. In such cases the
uterine size may be smaller than expected for gestational age and not well contracted.
Ultrasound examination showing a focal hyperechoic mass in the endometrium, particularly
with evidence of blood flow and enhanced myometrial vascularity by Doppler imaging,
supports the diagnosis of retained products of conception.

Management may be expectant, or a medical or surgical intervention to complete the

evacuation process can be undertaken. (See "Pregnancy loss (miscarriage): Description of
management techniques" and "Pregnancy loss (miscarriage): Counseling and comparison of
treatment options and discussion of related care".)

Vanishing twin — Vanishing twin is a type of pregnancy loss. The diagnosis is made
when an early ultrasound examination shows a twin (or other multiple) gestation but a
subsequent examination shows absence or demise of one twin (or one member of a triplet
or higher order multiple gestation). Vanishing twins are often the product of assisted
reproduction techniques and can be associated with vaginal bleeding [6]. No intervention is
indicated. (See "Assisted reproductive technology: Pregnancy and maternal outcomes",
section on 'Early pregnancy loss' and "Twin pregnancy: Overview", section on 'Vanishing
twins'.)

Diagnoses identifiable on speculum examination

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Cervical insufficiency — The diagnosis of cervical insufficiency is clinical; the classic

presentation is cervical dilation and effacement in the second trimester with fetal
membranes visible at or beyond the external os in the absence of contractions or with weak
irregular contractions that appear inadequate to explain the cervical dilation and effacement.
Symptoms include one or more of the following: vaginal fullness or pressure; vaginal
spotting or bleeding; an increased volume of watery, mucus or brown vaginal discharge; and
mild discomfort in the lower abdomen or back.

Management may involve placement of a cerclage and/or daily administration of vaginal

progesterone. (See "Cervical insufficiency".)

Cervical and vaginal disorders — These conditions are diagnosed by visual inspection,
with ancillary tests as indicated (eg, wet mount and pH of vaginal discharge, cervical cytology
and/or biopsy of mass lesions, ultrasound examination of uterus to detect neoplastic
lesions). Even if a lesion appears to be the source bleeding on speculum examination, it is
prudent to always consider the possibility of ectopic pregnancy in patients with first-
trimester bleeding, especially if associated with pain. (See 'Ectopic pregnancy' above.)

● Vaginal laceration (see "Evaluation and management of female lower genital tract
trauma")

● Vaginal neoplasm (see "Vaginal cancer")

● Vaginal warts (see "Condylomata acuminata (anogenital warts) in adults: Epidemiology,

pathogenesis, clinical features, and diagnosis")

● Vaginal discharge (see "Vaginitis in adults: Initial evaluation")

● Cervical polyps, fibroids (see "Benign cervical lesions and congenital anomalies of the
cervix")

● Mucopurulent cervical discharge or friability at the cervical os (see "Acute cervicitis")

● Cervical neoplasm (see "Invasive cervical cancer: Epidemiology, risk factors, clinical
manifestations, and diagnosis")

Management of bleeding related to these conditions depends upon the specific condition.
(Refer to individual topic reviews on each disorder).

Ectropion — Cervical ectropion (columnar epithelium exposed to the vaginal milieu by

eversion of the endocervix) is a common and normal finding in pregnancy. The exposed
columnar epithelium is prone to light bleeding when touched, such as during vaginal
intercourse, insertion of a speculum, bimanual examination, or when a cervical specimen is

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obtained for cytology or culture. No biopsy or intervention is indicated. (See "Benign cervical
lesions and congenital anomalies of the cervix", section on 'Ectropion'.)

Diagnoses of exclusion

Threatened abortion — Bleeding related to threatened abortion is the most common

nontraumatic cause of first-trimester bleeding (prevalence: 15 to 20 percent of pregnancies).
Although bleeding may be heavy, almost all patients remain hemodynamically stable; only
an approximate 1 percent of expectantly managed patients require blood transfusion [7].

Threatened abortion is a provisional diagnosis in patients with vaginal bleeding, a closed

cervix, and sonographic visualization of an intrauterine pregnancy with detectable
embryonic/fetal cardiac activity. The term "threatened" is used to describe these cases
because pregnancy loss does not always follow vaginal bleeding, even after repeated
episodes or large amounts of bleeding. In fact, 90 to 96 percent of pregnancies with both
embryonic/fetal cardiac activity and vaginal bleeding at 7 to 11 weeks of gestation are not
lost; the 96 percent ongoing pregnancy rate is associated with bleeding at the later end of
this gestational age range [8,9].

Bleeding in threatened abortion is likely due to disruption of decidual vessels at the

maternal-fetal interface. These separations generally cannot be visualized by ultrasound, but
may sometimes appear as a subchorionic hematoma. Subchorionic hemorrhage or
hematoma is associated with increased risk of pregnancy loss, particularly when it amounts
to 25 percent or more of the volume of the gestational sac ( image 1A-B) [10,11]. There is
no clear association between subchorionic hematoma and risk of preterm birth [12].

Management is expectant; available evidence does not support a benefit of progesterone

supplementation in patients with threatened abortion and zero or one previous pregnancy
loss [13]. The role of progesterone supplementation in recurrent pregnancy loss (two or
more failed clinical pregnancies or three consecutive pregnancy losses) is reviewed
separately. (See "Recurrent pregnancy loss: Definition and etiology" and "Recurrent
pregnancy loss: Evaluation" and "Recurrent pregnancy loss: Management".)

Physiologic or implantation bleeding — This is a diagnosis of exclusion. It is characterized

by a small amount of spotting or bleeding approximately 10 to 14 days after fertilization
(around the time of the missed menstrual period), and is presumed to be related to
implantation of the fertilized egg in the decidua (ie, lining of the uterus) [14], although this
hypothesis has been questioned [15]. No intervention is indicated.

Less common disorders

Heterotopic pregnancy — Heterotopic pregnancy (ie, one intrauterine and one

extrauterine pregnancy) is rare (1 in 30,000 pregnancies) but the risk is increased in patients

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who conceived via assisted reproductive technology (ART; 1.5 per 1000 ART pregnancies).
The diagnosis is suggested by visualization of both an intrauterine pregnancy and a complex
adnexal mass or echogenic fluid in the posterior cul-de-sac. The diagnosis is confirmed when
the adnexal mass contains a yolk sac or embryonic/fetal pole. Management is surgical
removal of the extrauterine pregnancy. (See "Ectopic pregnancy: Clinical manifestations and
diagnosis", section on 'Heterotopic pregnancy'.)

Cesarean scar pregnancy — Cesarean scar pregnancy occurs from implantation of the
pregnancy into either a wedge defect in the lower uterine segment at the site of the
hysterotomy for a previous cesarean birth or a microscopic fistula within the hysterotomy
scar. As the pregnancy enlarges, vaginal bleeding with or without pain may occur. It occurs in
1 in 2000 pregnancies and accounts for approximately 6 percent of abnormally implanted
pregnancies among patients with a prior cesarean birth.

The sonographic findings in cesarean scar pregnancy are an empty uterus with clearly
visualized endometrium; empty cervical canal; a gestational sac implanted in the lower
anterior uterine segment at the presumed site of cesarean incision scar; a triangular (at ≤8
weeks of gestation) or rounded or oval (at >8 weeks of gestation) gestational sac that fills the
shallow area representing a healed hysterotomy site; a prominent or rich vascular pattern at
or in the area of a cesarean scar; an embryonic or fetal pole, yolk sac, or both with or without
fetal cardiac activity; and thin or absent myometrium between the gestational sac and the
bladder [16]. All of these findings may not be present. Histologic confirmation is not required
for diagnosis.

Hemodynamically unstable patients require surgery. For hemodynamically stable patients,

the optimal management (ie, surgical or medical termination, expectant management) is
unclear. (See "Cesarean scar pregnancy".)

Rare disorders

Cervical pregnancy — Cervical pregnancy is a rare form of ectopic pregnancy in which the
pregnancy implants in the lining of the endocervical canal. Vaginal bleeding is the most
common symptom and is often painless and profuse, resulting in hemodynamic instability. It
may be misdiagnosed as an incomplete pregnancy loss.

The sonographic criteria for diagnosis of a cervical pregnancy are a gestational sac or
placenta within the cervix (typically with embryonic/fetal cardiac activity or blood flow to the
sac), visualization of an endometrial stripe and absence of an intrauterine pregnancy, and an
hourglass (figure of eight) shaped uterus with ballooned cervical canal. Histologic
confirmation is not required for diagnosis.

Because cervical pregnancy is rare, there are no established criteria for candidates for
medical versus surgical treatment. A combination of methods may be required. (See
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"Cervical pregnancy: Diagnosis and management".)

Gestational trophoblastic disease

Hydatidiform mole — Patients with a molar pregnancy typically present with a positive
pregnancy test and signs and symptoms consistent with early pregnancy or early pregnancy
complications (bleeding, pelvic discomfort, hyperemesis gravidarum). Molar pregnancy may
be suspected based on unusually high hCG levels and, less commonly, uterine size that is
large for dates.

Sonographic features suggestive of a complete mole include a central intrauterine

heterogeneous mass with numerous discrete anechoic spaces (snowstorm appearance),
absence of a fetus, and absence of amniotic fluid.

Surgical removal of the hydatidiform mole is the central component of treatment. (See
"Hydatidiform mole: Epidemiology, clinical features, and diagnosis" and "Hydatidiform mole:
Treatment and follow-up".)

Choriocarcinoma — Choriocarcinoma is a rare cause of uterine bleeding. A history of a

molar pregnancy is the most important risk factor, but it can occur after any type of
antecedent pregnancy (spontaneous or induced abortion, preterm or term birth) and rarely
occurs coexistent with a normal intrauterine pregnancy. Antepartum vaginal bleeding is the
most common presenting symptom and can occur in any trimester. Bleeding may result
from vaginal metastases or from the intrauterine tumor. Other symptoms that have been
reported include respiratory symptoms from lung metastases, neurologic symptoms from
brain metastases, and acute abdominal pain from bleeding intraabdominal metastases
[17,18].

The diagnosis should be considered after other more common causes of antepartum
bleeding have been excluded and especially in patients with respiratory or neurologic
symptoms. Gestational trophoblastic neoplasia is a clinical diagnosis based upon elevation of
serum hCG, after a nonmolar pregnancy and after other etiologies of an elevated hCG have
been excluded. On ultrasound, choriocarcinoma appears as a mass enlarging the uterus,
with a heterogeneous appearance that correlates with areas of necrosis and hemorrhage.
The tumor is usually markedly hypervascular on color Doppler and may extend into the
parametrium.

Chemotherapy is the major treatment modality. (See "Gestational trophoblastic neoplasia:

Epidemiology, clinical features, diagnosis, staging, and risk stratification" and "Initial
management of high-risk gestational trophoblastic neoplasia".)

PROGNOSIS
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In ongoing pregnancies, studies consistently show an association between first-trimester

uterine bleeding and adverse outcome later in pregnancy (eg, pregnancy loss, preterm birth,
preterm prelabor rupture of membranes, fetal growth restriction) [15,19-32]. The prognosis
is most favorable when bleeding is light and limited to early pregnancy (ie, less than 6 weeks
of gestation) [15,27] and worsens when bleeding is heavy or extends into the second
trimester [22-26].

For most patients with ongoing pregnancies, no effective interventions are available, but
they can be reassured of the relatively low likelihood of adverse outcome. For example:

● In a series of 550 patients followed prospectively from the time of their positive
pregnancy test, 117 (21 percent) had bleeding prior to 20 weeks of gestation and 67
miscarried (12 percent, or approximately one-half of those with bleeding) [32]. Fourteen
of 18 pregnancies with heavy bleeding (eg, clots) and moderate pain miscarried (78
percent).

● In a prospective series in which all subjects (n >16,500) had a viable pregnancy at

enrollment at 10 to 14 weeks, the frequency of preterm birth in those with no, light, or
heavy first-trimester bleeding was approximately 6, 9, and 14 percent, respectively, and
the frequency of pregnancy loss before 24 weeks of gestation was 0.4, 1, and 2 percent,
respectively [22]. A limitation of this series is that patients were enrolled late in the first
trimester and with sonographically confirmed embryonic/fetal cardiac activity, thus
those with very early bleeding and pregnancy loss had already been excluded.

Bed rest is unnecessary and will not improve outcome. Rarely, patients with a history of
recurrent pregnancy loss may benefit from vaginal progesterone therapy. This is
controversial and these patients are discussed separately. (See "Recurrent pregnancy loss:
Management", section on 'Progesterone'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Obstetric
hemorrhage".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
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and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Bleeding in early pregnancy (The Basics)")

SUMMARY AND RECOMMENDATIONS

● General principles – Vaginal bleeding is a common event in early pregnancy, especially

the first trimester; the source is virtually never from the embryo/fetus. A provisional
clinical diagnosis of the cause is based on the patient's gestational age and character of
the bleeding (eg, light or heavy, associated with pain or painless). Physical examination
and laboratory and/or imaging tests are then used to support or revise the initial
diagnosis. The goal of the evaluation is to make a definitive diagnosis when possible
and exclude the presence of serious pathology in the remaining cases ( algorithm 1)
(See 'Introduction' above and 'Incidence' above and 'Goal' above.)

● Etiology – Vaginal bleeding in the first half of pregnancy may be related to:

• Ectopic pregnancy (See 'Ectopic pregnancy' above.)

• Pregnancy loss (See 'Pregnancy loss' above.)

• Threatened abortion (See 'Threatened abortion' above.)

• Cervical, vaginal, or uterine pathology (See 'Cervical and vaginal disorders' above
and 'Ectropion' above and 'Cervical insufficiency' above and 'Cervical pregnancy'
above and 'Gestational trophoblastic disease' above.)

• Physiologic bleeding (ie, related to implantation of the pregnancy) (See 'Physiologic

or implantation bleeding' above.)

● Diagnostic evaluation – Evaluation consists of a focused history and physical

examination (bimanual and speculum), and often ultrasound examination
( algorithm 1). (See 'Evaluation' above.)

• Exclude ectopic pregnancy – An important goal in the evaluation of patients with

bleeding in early pregnancy is to rule out the possibility of ectopic pregnancy, since

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ruptured ectopic pregnancy can result in severe hemorrhage and death.

Sonographic confirmation of an intrauterine pregnancy excludes ectopic pregnancy,
except in rare cases of heterotopic pregnancy, which should be considered,
especially in patients who conceive by assisted reproductive technology (ART). (See
'Evaluation' above and 'Ectopic pregnancy' above and 'Heterotopic pregnancy'
above.)

• Examine any tissue that has been passed – Products of conception, if present in
tissue the patient has passed vaginally, should be visible upon careful examination
and are diagnostic of a partial or complete pregnancy loss. Visualization of villi can
be facilitated by rinsing the specimen to clear away blood clot and then floating it in
water ( picture 1A-B). (See 'Focused physical examination' above and 'Speculum
examination' above and 'Pregnancy loss' above.)

• Check for embryonic/fetal cardiac activity – Handheld Doppler or ultrasound

confirmation of embryonic/fetal cardiac activity is reassuring, as it indicates bleeding
is not related to embryonic/fetal demise. (See 'Check for embryonic/fetal cardiac
activity' above and 'Ultrasonography' above.)

• Examine the vagina and cervix – Speculum examination usually confirms that the
uterus is the source of bleeding but may reveal a vaginal or cervical source
unrelated to pregnancy; in such cases, further evaluation depends upon the nature
of the abnormality. If no blood is seen in the vagina, then the bleeding is either
resolved, occurring intermittently, or from a nongenital tract source (eg,
hemorrhoids). (See 'Speculum examination' above and 'Pelvic examination' above
and 'Diagnoses identifiable on speculum examination' above.)

Direct visualization of the gestational sac in a dilated internal cervical os in a patient

with bleeding and/or pain is generally sufficient to conclude that pregnancy loss is
occurring. In contrast, in the second trimester, cervical dilation and/or effacement
(possibly with prolapsed fetal membranes) that is painless or associated with only
mild discomfort in the lower abdomen or back suggests cervical insufficiency. (See
'Speculum examination' above and 'Cervical insufficiency' above.)

● Diagnoses of exclusion – Threatened abortion and implantation bleeding are

diagnoses of exclusion in patients with vaginal bleeding, a closed cervix, and
sonographic visualization of an intrauterine pregnancy with detectable embryonic/fetal
cardiac activity. (See 'Threatened abortion' above and 'Physiologic or implantation
bleeding' above.)

Use of UpToDate is subject to the Terms of Use.

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REFERENCES

1. Hasan R, Baird DD, Herring AH, et al. Patterns and predictors of vaginal bleeding in the
first trimester of pregnancy. Ann Epidemiol 2010; 20:524.
2. Koifman A, Levy A, Zaulan Y, et al. The clinical significance of bleeding during the second
trimester of pregnancy. Arch Gynecol Obstet 2008; 278:47.
3. Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health
and Human Development workshop report on electronic fetal monitoring: update on
definitions, interpretation, and research guidelines. Obstet Gynecol 2008; 112:661.
4. Jindal P, Regan L, Fourkala EO, et al. Placental pathology of recurrent spontaneous
abortion: the role of histopathological examination of products of conception in routine
clinical practice: a mini review. Hum Reprod 2007; 22:313.

5. Isoardi K. Review article: the use of pelvic examination within the emergency
department in the assessment of early pregnancy bleeding. Emerg Med Australas 2009;
21:440.

6. De Sutter P, Bontinck J, Schutysers V, et al. First-trimester bleeding and pregnancy

outcome in singletons after assisted reproduction. Hum Reprod 2006; 21:1907.
7. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for
miscarriage. Cochrane Database Syst Rev 2012; :CD003518.
8. Tongsong T, Srisomboon J, Wanapirak C, et al. Pregnancy outcome of threatened
abortion with demonstrable fetal cardiac activity: a cohort study. J Obstet Gynaecol
(Tokyo 1995) 1995; 21:331.
9. Tannirandorn Y, Sangsawang S, Manotaya S, et al. Fetal loss in threatened abortion after
embryonic/fetal heart activity. Int J Gynaecol Obstet 2003; 81:263.

10. Pearlstone M, Baxi L. Subchorionic hematoma: a review. Obstet Gynecol Surv 1993;
48:65.
11. Tuuli MG, Norman SM, Odibo AO, et al. Perinatal outcomes in women with subchorionic
hematoma: a systematic review and meta-analysis. Obstet Gynecol 2011; 117:1205.
12. Yan X, Xu H, Li J, et al. Subchorionic hematoma and risk of preterm delivery: a systematic
review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100791.
13. Coomarasamy A, Devall AJ, Brosens JJ, et al. Micronized vaginal progesterone to prevent
miscarriage: a critical evaluation of randomized evidence. Am J Obstet Gynecol 2020;
223:167.
14. SPEERT H, GUTTMACHER AF. Frequency and significance of bleeding in early pregnancy.
J Am Med Assoc 1954; 155:712.
15. Harville EW, Wilcox AJ, Baird DD, Weinberg CR. Vaginal bleeding in very early pregnancy.
Hum Reprod 2003; 18:1944.

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16. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Miller
R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM)
Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol 2020; 222:B2.

17. Steigrad SJ, Cheung AP, Osborn RA. Choriocarcinoma co-existent with an intact
pregnancy: case report and review of the literature. J Obstet Gynaecol Res 1999; 25:197.
18. Jorgensen K, Roychowdhury M, da Cunha G, et al. Stage IV Gestational Choriocarcinoma
Diagnosed in the Third Trimester. Obstet Gynecol 2019; 133:163.

19. Williams MA, Mittendorf R, Lieberman E, Monson RR. Adverse infant outcomes
associated with first-trimester vaginal bleeding. Obstet Gynecol 1991; 78:14.
20. Berkowitz GS, Harlap S, Beck GJ, et al. Early gestational bleeding and pregnancy
outcome: a multivariable analysis. Int J Epidemiol 1983; 12:165.
21. Ananth CV, Savitz DA. Vaginal bleeding and adverse reproductive outcomes: a meta-
analysis. Paediatr Perinat Epidemiol 1994; 8:62.

22. Weiss JL, Malone FD, Vidaver J, et al. Threatened abortion: A risk factor for poor
pregnancy outcome, a population-based screening study. Am J Obstet Gynecol 2004;
190:745.

23. Yang J, Hartmann KE, Savitz DA, et al. Vaginal bleeding during pregnancy and preterm
birth. Am J Epidemiol 2004; 160:118.
24. Chung TK, Sahota DS, Lau TK, et al. Threatened abortion: prediction of viability based on
signs and symptoms. Aust N Z J Obstet Gynaecol 1999; 39:443.

25. Gracia CR, Sammel MD, Chittams J, et al. Risk factors for spontaneous abortion in early
symptomatic first-trimester pregnancies. Obstet Gynecol 2005; 106:993.

26. Harger JH, Hsing AW, Tuomala RE, et al. Risk factors for preterm premature rupture of
fetal membranes: a multicenter case-control study. Am J Obstet Gynecol 1990; 163:130.
27. Hasan R, Baird DD, Herring AH, et al. Association between first-trimester vaginal
bleeding and miscarriage. Obstet Gynecol 2009; 114:860.
28. Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. First-trimester vaginal bleeding
and complications later in pregnancy. Obstet Gynecol 2010; 115:935.
29. Velez Edwards DR, Baird DD, Hasan R, et al. First-trimester bleeding characteristics
associate with increased risk of preterm birth: data from a prospective pregnancy
cohort. Hum Reprod 2012; 27:54.
30. McPherson JA, Odibo AO, Shanks AL, et al. Adverse outcomes in twin pregnancies
complicated by early vaginal bleeding. Am J Obstet Gynecol 2013; 208:56.e1.
31. Bever AM, Pugh SJ, Kim S, et al. Fetal Growth Patterns in Pregnancies With First-
Trimester Bleeding. Obstet Gynecol 2018; 131:1021.

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32. Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy:
prospective study from general practice. BMJ 1997; 315:32.
Topic 6799 Version 58.0

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GRAPHICS

Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of

gestation in hemodynamically stable patients

When evaluating patients with bleeding before 20 weeks of gestation, it is important to also consider
the possibility of a heterotopic pregnancy (multiple gestation with one gestation inside the uterine
cavity and the other outside the uterine cavity) and the loss of one gestation from a multiple
gestation.

hCG: human chorionic gonadotropin.

* In the early first trimester when cardiac activity is not normally seen by ultrasound, diagnosis of a
nonviable embryo is based on factors such as the mean gestational sac diameter and crown-rump
length. Refer to UpToDate topics on ultrasound diagnosis of pregnancy loss. Repeat ultrasound in 7 to
10 days may be required to make a diagnosis of viable versus nonviable pregnancy.

¶ Evaluation for ectopic pregnancy involves a combination of serial hCG levels and ultrasound
examinations. Refer to the UpToDate topic on diagnosis of ectopic pregnancy for detailed
information.

Δ If there is no intrauterine pregnancy on ultrasound but the uterus is not empty, then gestational
trophoblastic disease should be considered if ultrasound shows a central intrauterine heterogeneous

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mass. Refer to UpToDate topics on gestational trophoblastic disease for detailed information.

◊ Implantation bleeding is a diagnosis of exclusion. It is characterized by a small amount of spotting

or bleeding approximately 10 to 14 days after fertilization (around the time of the missed menstrual
period).

§ Cervical insufficiency is characterized by cervical dilation and/or effacement in the second trimester
in the absence of contractions or with weak irregular contractions that appear inadequate to explain
the cervical dilation and effacement. Fetal membranes may be visible at or beyond the os.

Graphic 88947 Version 6.0

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Risk factors for ectopic pregnancy compared with pregnant controls

Degree of risk Risk factors Odds ratio

High Previous ectopic pregnancy 2.7 to 8.3

Previous tubal surgery 2.1 to 21

Tubal pathology 3.5 to 25

Sterilization 5.2 to 19

IUD

Past use 1.7

Current use 4.2 to 16.4

Levonorgestrel IUD 4.9*

In vitro fertilization in current 4 to 9.3

pregnancy

Moderate Current use of 1.7 to 4.5

estrogen/progestin oral
contraceptives

Previous sexually transmitted 2.8 to 3.7

infections (gonorrhea,
chlamydia)

Previous pelvic inflammatory 2.5 to 3.4

disease

In utero DES exposure 3.7

Smoking

Past smoker 1.5 to 2.5

Current smoker 1.7 to 3.9

Previous pelvic/abdominal 4
surgery

Previous spontaneous abortion 3

Low Previous medically induced 2.8

abortion

Infertility 2.1 to 2.7

Age ≥40 years 2.9

Vaginal douching 1.1 to 3.1

Age at first intercourse <18 1.6

years

Previous appendectomy 1.6

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IUD: intrauterine device; DES: diethylstilbestrol.

* Rates of ectopic pregnancy may be higher among those using the 13.5 mg compared with the 52
mg levonorgestrel IUD. This is discussed in related UpToDate content.

Data from:
Clayton HB, Schieve LA, Peterson HB, et al. Ectopic pregnancy risk with assisted reproductive technology procedures.
Obstet Gynecol 2006; 107:595.
Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril 1996;
65:1093.
Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-
control, population-based study in France. Am J Epidemiol 2003; 157:185.
Mol BW, Ankum WM, Bossuyt PM, Van der Veen F. Contraception and the risk of ectopic pregnancy: a meta-analysis.
Contraception 1995; 52:337.
Li C, Zhao WH, Zhu Q, et al. Risk factors for ectopic pregnancy: a multicenter case-control study. BMC Pregnancy
Childbirth 2015; 15:187.
Cheng L, Zhao WH, Meng CX, et al. Contraceptive use and the risk of ectopic pregnancy: a multicenter case-control
study. PLoS One 2014; 9:e115031.
Hoover RN, Hyer M, Pfeiffer RM, et al. Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J
Med 2011; 365:1304.

Graphic 82282 Version 10.0

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Chorionic villi

One method of distinguishing placenta from organized clot is to rinse with water and then float the
tissue in a dish of water, preferably with a good light source underneath. Villi have a frond-like
appearance, which has been described as similar to seaweed floating in the ocean.

Courtesy of Errol R Norwitz, MD, PhD.

Graphic 78715 Version 3.0

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Chorionic villi 2

Courtesy of Errol R Norwitz, MD, PhD.

Graphic 61424 Version 2.0

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Timing of first appearance of gestational landmarks on transvaginal

ultrasound examination

First appearance on transvaginal ultrasound

Landmark
examination

Gestational sac 4.5 to 5 weeks

Yolk sac 5 weeks

Cardiac activity 5.5 to 6 weeks

Measurable crown-rump 6 weeks

length

The yolk sac is visible when the mean gestational sac diameter (MSD) is 8 mm and fetal cardiac activity
can be observed when MSD is 16 mm. For transabdominal sonograms, the corresponding MSDs are
larger than 20 and 25 mm, respectively. MSD = (length + height + width of the gestational sac)/3. In
addition, MSD(mm)+30 = gestational age(days).

Graphic 83304 Version 6.0

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Clinical scenario and ICD-10 diagnosis

ICD-10 diagnosis
Clinical scenario
Code Definition

Complete EPL: Complete spontaneous passage of O03.9* Complete or unspecified spontaneous

gestational tissue. abortion without complication

Incomplete EPL: Ultrasound or other evidence of O03.4* Incomplete spontaneous abortion

retained pregnancy tissue, with history of or without complication
ongoing vaginal bleeding. No cardiac activity or
other evidence of viability.

Incomplete EPL: Fetal or embryonic demise has O02.1 Missed abortion

occurred, and gestational tissue remains in the
uterus. Typically with little or no vaginal bleeding
and evidence that the nonviable gestation has
remained in the uterus for a period of time

Vaginal bleeding with evidence of embryonic or O20.0 Threatened abortion

fetal viability, such as fetal cardiac activity.

ICD: International Statistical Classification of Diseases and Related Health Problems, 10th revision;
EPL: early pregnancy loss.

* Refer to ICD-10 for coding when complications are present.

Courtesy of Sarah Prager, MD, MAS, Elizabeth Micks, MD, MPH, and Vanessa Dalton, MD, MPH.

Graphic 120361 Version 3.0

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Distinction between subchorionic hematoma and unfused amnion in patient

with vaginal bleeding at 13 weeks' gestational age

Transabdominal sagittal sonogram of uterus reveals subchorionic hematoma (H) extending

posteriorly around chorion (arrows) and lifting edge of anterior placenta (P). Appearance should not
be confused with that of unfused amnion. Amnion is the thin membrane continuous along anterior
placental edge, but limited by umbilical cord insertion; subchorionic bleeding leads to edge of
placenta.

Reproduced with permission from Trop I, Levine D. Hemorrage During Pregnancy: Sonography and MR Imaging. AJR Am J
Roentgenol 2001; 176:607. Copyright 2001 American Roentgen Ray Society.

Graphic 76333 Version 3.0

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Subchorionic bleeding in fetus at 5.5 weeks' gestational age

(A) Transverse transvaginal sonogram reveals intrauterine gestational sac with yolk sac. Note small
amount of blood (arrow) adjacent to gestational sac.

(B) Transvaginal sagittal sonogram obtained 2 weeks after (A) because of vaginal bleeding shows
subchorionic hematoma (dashed arrow) with debris. Collection could be mistaken for second
gestational sac with embryonic demise.

Reproduced with permission from Trop I, Levine D. Hemorrage During Pregnancy: Sonography and MR Imaging. AJR Am J
Roentgenol 2001; 176:607. Copyright 2001 American.

Graphic 64570 Version 4.0

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