Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
The medical evaluation begins with a thorough history and physical exam. Depending on the setting (medical office or hospital) and the seriousness of your symptoms, laboratory and ultrasound tests may be performed. For bleeding in the early part of pregnancy, the doctor's main goal will be to make sure you don't have an ectopic pregnancy. That is what the evaluation will focus on. For late-pregnancy bleeding, the doctor first will make sure you are stable.
Medical history: Your health care professional will ask you a lot of questions:
If early in pregnancy, your pregnancy history will be reviewed regarding the certainty of the dates of your pregnancy. If you think you are pregnant, you usually are. Although, in many cases, women who don't think they are pregnant, often can be.
You may be asked about recent trauma or sexual intercourse and whether you have abdominal pain or contractions.
Your medical history will be reviewed, with emphasis
on bleeding disorders, liver problems, and drug or tobacco use.
You will be asked about prior Cesarean deliveries, preterm labor, placenta previa, or placental abruptions.
Physical exam: Regardless of
where you are being treated, the first thing that should be established is how
sick you are as a result of the bleeding. This is done by evaluating vital signs
(pulse and blood pressure), and by a quick physical assessment of volume of
blood loss by looking to see if you are pale or if you have abdominal
tenderness. If you have lost a significant amount of blood, you will be treated
with IV fluids and you may need surgery.
Your abdomen will be examined to see if you are tender and to check the size of your uterus.
You will be checked for bleeding from other sites,
such as the nose or rectum.
The results of the pelvic exam may or may not be very helpful in differentiating between ectopic pregnancy and threatened miscarriage: 10% of women with an ectopic pregnancy will have a completely normal pelvic exam. How enlarged the uterus is on examination may help, because in less than 3% of ectopic pregnancies is the uterus enlarged to greater than 10 cm.
Quantity and quality of abdominal pain and vaginal bleeding is important for the doctor to know. Pain is seen in most women with ectopic pregnancy (up to 90%) and vaginal bleeding (50%-80%).
Late in pregnancy, you will have an abdominal ultrasound prior to a vaginal exam to see if you have a placenta previa. If ultrasound does not show previa, you will have a sterile speculum vaginal
exam to evaluate you for injury to the lower genital tract. If the vaginal
exam is normal, you will have a digital exam to check for cervical dilation.
You will have monitors attached to your abdomen to check for contractions and
for the baby's heart rate.
Symptoms and physical examination diagnose uterine
rupture. The symptoms that suggest rupture are sudden onset of severe abdominal pain, abnormality of the size and shape of the uterine contour, and regression of the baby's head up the birth canal.
Lab tests: Several lab tests
are routinely obtained. They include a urine pregnancy test, a
urinalysis, a blood type and Rh, and a
complete blood count (CBC).
Serum quantitative bhCG,
which is a blood hormone marker of pregnancy, is also frequently obtained.
The urine pregnancy test is extremely sensitive for
diagnosing pregnancy at or about the same time you miss your period, or
possibly a few days before. A urinalysis can diagnose
urinary tract
infections, regardless of whether you have symptoms of this type of infection.
This is because infections, specifically of the urinary tract, are a cause of
miscarriage. Also, a urinary tract infection with no symptoms is relatively
common in pregnancy, occurring in 2%-11% of pregnant women. Up to a fourth of
these women will go on to have kidney infections.
Your blood type will be checked. You are being
screened for whether your type is Rh negative or positive. If you are negative
and the father of the baby is positive, your body may make antibodies against the baby's
blood cells. If this occurs without treatment, the next time you are pregnant, these antibodies will appear again and harm that baby. If this is discovered during the first pregnancy and treatment with an injection called
RhoGAM is given, this prevents the antibodies from forming.
A blood count is routinely obtained to have an estimate of how much bleeding has already occurred.
The bhCG level is a measure of the volume of living tissue associated with the developing pregnancy. Both ectopic and intrauterine pregnancies (IUP) produce bhCG, although there is usually a difference in the rate at which the quantitative bhCG level increases. Although a single value of bhCG isn't useful for differentiating between a normal or abnormal pregnancy or an ectopic pregnancy, a variation in the expected rate of rise of the bhCG level can be helpful. A falling bhCG does not exclude the possibility of tubal rupture. The real value of the quantitative bhCG for diagnosis of ectopic pregnancy is when it is used in correlation with the results of a pelvic ultrasound.
Ultrasound: Ultrasound can often determine if the fetus is healthy and growing inside the uterus. Ultrasound is a form of imaging using sound waves, not
X-rays. It is a test that is often able to identify a pregnancy and estimate the age of the fetus. However, a pregnancy may be too early to be seen on ultrasound.
Ultrasound may be able to identify an ectopic pregnancy
growing outside of the uterus. It also may be used to look for blood in the
pelvis, a very serious complication that can occur when the ectopic pregnancy has ruptured the
Fallopian tube.
Late in pregnancy, placenta previa is diagnosed almost exclusively by abdominal ultrasound, which can detect it 95% of the time.
Placental abruption is diagnosed by excluding other
causes. It often cannot be confirmed until after delivery when the placenta is
found to have a blood clot attached to it. An ultrasound is performed to make certain that the bleeding is not from a placenta previa. Ultrasound at best is only able to detect about half of placental abruptions.
Fetal bleeding can be distinguished from maternal bleeding by performing a special test on the blood present in the vagina. Also, a special type of ultrasound (Doppler) may be used to see the blood flow within the blood vessels.
Lower genital tract problems can easily be diagnosed
with a speculum examination. It is important that an ultrasound rule out
placenta previa prior to any vaginal exam.
