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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
The study of first-trimester vaginal bleeding and its maternal and perinatal outcomes at a tertiary care center in Hyderabad

 Department of Obstetrics and Gynaecology, Deccan College of Medical Sciences, Hyderabad, Telangana, India

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Date of Submission19-Aug-2022
Date of Decision12-Oct-2022
Date of Acceptance23-Oct-2022
Date of Web Publication02-Dec-2022


Background: Among all those pregnancies with first-trimester vaginal bleeding, nearly half of them terminate into a pregnancy loss. In case the pregnancy continues, it may result in some complications such as intrauterine growth retardation (IUGR), preterm prelabor rupture of membrane (PPROM), preterm delivery, placental abruption, and preeclampsia.
Objective: The objective was to study the pregnancy outcomes in first-trimester vaginal bleeding.
Materials and Methods: This retrospective observational study was done on 100 antenatal women who attended our hospital for delivery and had a history of first-trimester vaginal bleeding. All women were evaluated for pregnancy outcomes including pregnancy-induced hypertension, anemia, abruption, preterm labor, premature rupture of membrane (PROM), PPROM, IUGR, and placenta previa and neonatal outcomes in the form of birth weight and APGAR score.
Results: Ninety-nine percentage of cases had viable outcome, and only one case had abortion after 20 weeks. Sixteen percentage had fetal growth restriction (IUGR), fifteen percentage had anemia, 14% had preterm labor, 12% had gestational hypertension, 11% had PROMs, 4% had preterm PROMs, and 2% had placental abruption and placenta previa. Among 16 patients who developed IUGR, 31% had abnormal Doppler and 69% had normal Doppler. Sixty percentage of patients delivered after 37 weeks. One case each of postpartum hemorrhage and perinatal death were observed.
Conclusions: First-trimester vaginal bleeding is an important factor in predicting late pregnancy maternal and fetal outcomes. These pregnancies should be considered high risk, and antenatal care should be given carefully. Pregnant women need to be trained regarding the associated complications and their timely management.

Keywords: Abruption, outcome, pregnancy, vaginal bleeding

How to cite this URL:
Chaitanya N, Deepthisri T, Rohin. The study of first-trimester vaginal bleeding and its maternal and perinatal outcomes at a tertiary care center in Hyderabad. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=362537

  Introduction Top

During the first trimester of pregnancy, bleeding from vagina is common. It indicates some underlying pathology in pregnancy. Hence, it is regarded as one of the most common warning signs of pregnancy. The bleeding from vagina during the first trimester may be due to chances of birth before 37 completed weeks of gestation, or the baby weight may be lower than the normal, or it may be related with the infants with small for gestation.[1],[2],[3],[4] However, it may or may not be related with the presence or absence of the congenital malformations. The studies related to the relation between vaginal bleeding and the congenital malformations are often done among pregnant women in the last trimester.[5],[6],[7]

Most of the studies done to study the relation between the bleeding from the vagina and the risk of abortion are usually hospital-based with a limited sample size. Almost all episodes of bleeding from the vagina require medical attention at its first occurrence and may indicate abortion. However, these studies lack this important information, i.e., bleeding from the vagina immediately before an episode of the abortion.[8],[9],[10],[11],[12]

Till date, there are only two studies which studied the temporal relation between bleeding from the vagina and the abortion. They studied all women with first-trimester bleeding and followed them to see how many of them had an abortion subsequently in the second trimester.[13],[14]

“Abortus imminens is diagnosed as first-trimester vaginal bleeding with closed cervix and confirmed with fetal heart rate on ultrasound.”[15],[16],[17] Cardiac activity of the fetus is confirmed by Doppler, and it tells us that the abortion is not related with the bleeding. Once this is done, the proper diagnosis and treatment are crucial.

Among all those pregnancies with first-trimester vaginal bleeding, nearly half of them terminate into a pregnancy loss. In case the pregnancy continues, it may result in some complications such as intrauterine growth restriction (IUGR), preterm prelabor rupture of membrane (PPROM), preterm delivery, placental abruption, and preeclampsia.[15],[16],[17],[18] The risk factors of abortus imminens are age of the mother, presence of systemic diseases, treatment taken for infertility, weight of the mother, anatomical abnormalities of the uterus, thrombophilia, etc.[18],[19]

With this background, the present study was carried out to study the maternal and fetal outcomes in women with first-trimester vaginal bleeding.

  Materials and Methods Top

A retrospective observational study was carried out at the Department of Obstetrics and Gynecology, Princess Durru Shehvar Children's and General Hospital, Hyderabad, from June 2017 to May 2018. All pregnant women with a history of first-trimester vaginal bleeding were interviewed at the time of admission for delivery. The Institutional Ethics Committee permission was obtained.

Sample size was determined considering the complication rate of first-trimester bleeding is 25%;[1],[2],[3] assuming the absolute precision 10% with 95% confidence level, the minimum required sample size was 72.

Women with months of amenorrhea of <3 months, positive pregnancy test, and bleeding per vaginum during the first trimester only (up to 13 weeks) were included. Women with emergency conditions, bleeding at the time of loss of more than 13 weeks of gestation, molar pregnancy, ectopic pregnancy, and twin pregnancy were excluded.

It is common for a woman to present with a history of missed menses, a positive pregnancy test, an episode of vaginal bleeding, and a high level of anxiety. In evaluating women who have vaginal bleeding in early pregnancy, it is important to use a systematic approach, so that an appropriate management strategy can be developed.

The initial approach for women who report first-trimester bleeding is to complete a thorough history which includes: patient's age, previous obstetric history, last menstrual period, regularity of menstrual cycles, past use of medications or current medication use, most recent use of contraceptive methods, especially intrauterine devices, detailed antenatal history, parity, duration of gestation, obstetric history, history of any complication in the present pregnancy, general clinical examination to determine pulse rate, blood pressure, temperature, symphysiofundal height, uterine size, presentation and adequacy of amniotic fluid clinically, and fetal heart rate.

The vaginal bleeding history included the gestational age at which bleeding per vaginum occurred, duration of bleeding in days, and the amount of bleeding. Bleeding was categorized as light (spotting) or moderate or heavy (in comparison with menstrual cycle) according to the self-assist degree of vaginal bleeding. What was associated with the onset (e.g., sexual activity, flying, lifting, vomiting, etc.).

Complete blood cell count with differential, blood typing with Rh identification was done. After evaluation, those cases which satisfy inclusion and exclusion criteria were considered. A written informed consent was taken, and these cases were followed throughout the intrapartum and postpartum period. Postdelivery follow-up was performed in-person or through a review of medical record.

The fetal outcome of the pregnancy was categorized as: nonviable outcome (termination of pregnancy before 28 weeks) a. spontaneous or induced termination, congenital malformations that were terminated before 20 weeks, viable outcome (continuation of pregnancy after 28 weeks).

The maternal outcome (only from those patients in which pregnancy continued beyond 20 weeks) was categorized as: pregnancy-induced hypertension (PIH), anemia, preterm premature rupture of membrane (PPROM), placental abruption, placenta previa, intrauterine growth retardation (IUGR), preterm labor, premature rupture of membrane (PROM), postpartum hemorrhage, cesarean delivery, and as no complications.

Fetal outcome was studied in terms of: gestational age at delivery, birth weight, and APGAR at 5 min. The study population was assured regarding the confidentiality and secrecy of the information provided by them.

Statistical methods

Statistical analysis was performed by STATA 11.2 (College Station, TX, USA). Age distribution, duration of bleeding in days, gestational age at bleeding in weeks, amount of bleeding, history of abortion, outcome of viable pregnancy, complications such as IUGR with Doppler, preterm labor, mode of delivery, birth weight (kg), perinatal death, APGAR score, etc., were analyzed as frequency and percentage. This is a descriptive study, so the descriptive statistics were performed for all the study variables. Age and gestational age were reported as mean and standard deviation.

  Results Top

Eighty-nine percentage of patients had bleeding per vaginum for 1–2 days only, 9% had bleeding for 3–4 days, and only 2% had bleeding for >4 days. Fifty-six percentage of patients had bleeding per vaginum at <8 weeks' gestation and 44% had bleeding after 8 weeks. Majority of patients had only spotting per vaginum (96%) and only 4% had moderate bleeding. Thirty-two percentage of patients had a history of spontaneous abortion and only one patient had a history of induced abortion which was done in view of fetal anomaly [Table 1].
Table 1: Characteristics of the study population

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Ninety-nine percentage cases had viable outcome and only one case had abortion after 20 weeks. Sixteen percentage of the patients with 1st trimester bleeding per vaginum had fetal growth restriction (IUGR). Fifteen percentage had anemia, 14% had preterm labor, 12% had gestational hypertension (PIH), 11% had PROMs, 4% of the patients had preterm PROMs, and 2% of the patients had placental abruption and placenta previa. Among 16 patients who developed IUGR, 31% (5 patients) had abnormal Doppler and 69% (11 patients) had normal Doppler. Sixty percentage of patients with bleeding per vaginum delivered after 37 weeks. Thirty-five percentage delivered between 34 and 37 weeks and 5% delivered before 34 weeks. One case each of postpartum hemorrhage and perinatal death were observed [Table 2].
Table 2: Outcome and complications of pregnancy

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Fifty-two percentage of patients with bleeding per vaginum delivered vaginally, while 48% delivered by cesarean section. Seventy-seven percentage of patients with bleeding per vaginum gave birth to neonates with birth weight >2.5 kg, while 18% of neonates were with birth weight between 2 and 2.5 kg. Two percentage of neonates had birth weight between 1.5 and 2 kg and 3% had birth weight <1.5 kg. Eighty-two percentage of neonates of mothers with first-trimester bleeding per vaginum had APGAR score of 9 at 5 min, while 12% had a score of 8 and 2% had a score of 7. Three percentage of patients had APGAR score of 6 and 1% had a score of 5 [Table 3].
Table 3: Type of delivery and fetal outcome

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  Discussion Top

First-trimester vaginal bleeding is a common but alarming symptom, which most commonly occurs around the time of luteal-placental shift. Although a common symptom, it needs to be evaluated and causes of bleeding need to be found out. Transvaginal ultrasonography is a useful tool to evaluate first-trimester bleeding. First-trimester vaginal bleeding results in abnormal placentation and results in suboptimal maternal and fetal outcomes. More than 70% of those with vaginal bleeding in the first trimester continue normally.

The present study included 100 women who experienced first-trimester bleeding; after satisfying the inclusion and exclusion criteria, they are followed till delivery, and maternal and fetal outcomes are noted. About 9% of pregnant women who attended our antenatal clinic experienced first-trimester bleeding, which coincides with the study of Arafa et al.,[20] in which 10.6% reported bleeding.

Most of the study population with first-trimester bleeding were in the early reproductive age group rather than the late: 80% of cases were in the age group of below 25 years, 14% were in the age group of 25–30 years, and 6% were in the age group of 30–35 years.

More than 90% of the study population were <30 years of age, which is similar to the study of Wijesiriwardana et al.,[21] where bleeding was seen in early reproductive age group rather than late, whereas few studies like Arafa et al.[20] stated that bleeding is mostly seen in women >33 years of age. Bleeding was most commonly seen around the time of luteal-placental shift. Fifty-six percentage experienced at the gestational age of <8 weeks, 44% after 8 weeks. Wijesiriwardana et al.[21] also showed similar observation, in which bleeding was seen mostly at 2–2½ months.

In the present study, cases with light bleeding or spotting (96%) are more compared to moderate bleeding (4%). Similar results were seen in the studies of Kurjak et al.[22]

Heavy bleeding cases have more pain compared to light bleeding. First-trimester bleeding associated with pain has a poor outcome; similar findings were observed in the study of Batzofin et al.[23]

About 89% of cases had bleeding for 1–2 days, out of which majority had viable gestation, 9% had bleeding for 3–4 days, and 2% had bleeding more than 4 days. Cases with heavy bleeding lasting for more than 6 days had no viable gestation. Heavy bleeding for a longer duration had nonviable gestation compared to shorter period, and among cases with light bleeding duration of bleeding mostly seen for shorter duration, majority had viable gestation; these results are consistent with other studies.[24],[25],[26]

Of a total of 100 cases, 12% of the cases developed gestational hypertension (comparable to Weiss et al.[13] and Wijesiriwardana et al.,[21]), 2% of the cases had placenta previa (comparable to Mulik et al.,[25]), two cases had abruption, four of them presented with PPROM, 11 with PROM (comparable to Johns and Jauniaux[26]), 14% of the patients had preterm labor (comparable to Yang et al.,[3]), 16 had IUGR, one case had PPH, 15 cases developed anemia, and there was one perinatal death.

Fetal outcomes noted in this study were preterm birth, low birth weight (LBW), and APGAR <7 at 5 min. Three cases had neonates with birth weight <1.5 kg and 20 had birth weight between 1.5 and 2.5 kg. Seventy-seven percentage had birth weight >2.5 kg. Four cases had neonates with APGAR <7.

  Conclusions Top

Most of the cases had mild bleeding in the form of spotting, for which there was a favorable outcome. However, some cases with mild bleeding had pregnancy complications such as gestational hypertension, anemia, preterm labor, IUGR, and PROM as well as adverse neonatal outcomes such as LBW and low APGAR score.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Correspondence Address:
N Chaitanya,
Department of Obstetrics and Gynaecology, Deccan College of Medical Sciences, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_82_22


  [Table 1], [Table 2], [Table 3]


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