Doctors Revision

Obstetrics

Vaginal Bleeding in Early Pregnancy / Abortion Management

Management of vaginal bleeding occurring before 28 weeks of gestation, encompassing threatened, inevitable, incomplete, complete, septic, missed, and molar abortions.

Also known as: Miscarriage Management, Early Pregnancy Bleeding

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Urgent Referral to Hospital (HC4/H): Shock/severe bleeding, Septic abortion, Molar pregnancy, Suspected ectopic, Incomplete/Inevitable requiring evacuation beyond capacity, Missed abortion, Significant anaemia.

Red flags

  • Heavy vaginal bleeding
  • Signs of shock
  • Signs of sepsis
  • Severe abdominal pain
  • Passage of grape-like vesicles

Signs and symptoms

  • Threatened Abortion: Slight bleeding +/- mild pain, cervix CLOSED.
  • Inevitable Abortion: Moderate/heavy bleeding, pain, cervix OPEN, POC not passed.
  • Incomplete Abortion: Heavy bleeding/clots, pain, cervix OPEN, some POC passed.
  • Complete Abortion: Bleeding/pain subsided, cervix CLOSED, uterus empty.
  • Septic Abortion: Signs of incomplete abortion + infection (fever, foul discharge, tenderness, shock).
  • Missed Abortion: Fetal demise, POC retained, uterus small, cervix CLOSED.
  • Molar Abortion: Bleeding, grape-like vesicles, large uterus, severe N/V.

Risk factors

  • Advanced maternal age.
  • Previous miscarriage.
  • Chromosomal abnormalities.
  • Uterine abnormalities.
  • Infections.
  • Uncontrolled chronic diseases.
  • Smoking/alcohol/drugs.
  • Trauma.
  • Unsafe induced abortion.

Diagnosis

Clinical assessment

History (LMP, bleeding, pain, tissue passage). Vitals. Abdo exam (size, tenderness). Speculum exam (bleeding, cervix open/closed, POC). Bimanual exam (cervical motion tenderness, size, adnexa - rule out ectopic).

Investigations

  • Urine Pregnancy Test (hCG).
  • Ultrasound Scan (Confirm IUP vs ectopic, viability, retained POC, molar).
  • FBC (assess blood loss).
  • Blood Group & Cross-match (if bleeding/surgery).
  • Swabs for C&S (if septic).

Diagnostic criteria

Clinical presentation + cervical status + ultrasound findings (if available) to classify type.

Management

Non-pharmacological management

  • General: Assess ABC, resuscitate if shocked. Emotional support.
  • Threatened Abortion: Bed rest (limited evidence), pelvic rest. Follow up ANC.
  • Inevitable/Incomplete (pre-evacuation): Remove visible POC at os.
  • Septic Abortion: Stabilize first.
  • Molar Abortion: Resuscitate, urgent referral.
  • Post-Abortion Care: Contraception, hygiene, danger signs, follow-up.

Pharmacological treatment

  • Analgesia: Paracetamol, NSAIDs (cautious if heavy bleed), Opioids.
  • Inevitable/Incomplete Abortion: Medical (Misoprostol 600mcg PO/SL) OR Surgical (MVA preferred <16wks OR D&C). Antibiotic prophylaxis (Doxycycline/Azithromycin).
  • Septic Abortion: Broad Spectrum IV Antibiotics (Ceftriaxone + Metronidazole) IMMEDIATELY, then evacuate uterus.
  • Missed Abortion: Medical (Misoprostol +/- Mifepristone) or Surgical evacuation. Refer.
  • Molar Abortion: Evacuation (suction preferred) in hospital. Follow hCG.
  • Iron supplementation if anaemic.
  • Anti-D Immunoglobulin for Rh-negative women.

Monitoring

Monitor vitals, bleeding, uterine tone. Assess evacuation completion. Monitor for infection. Follow hCG (molar).

Complications

  • Haemorrhage, Shock.
  • Infection, Sepsis.
  • Uterine perforation.
  • Incomplete evacuation.
  • Asherman's syndrome.
  • Psychological distress.
  • Persistent trophoblastic disease (molar).

Prevention

  • Family planning.
  • Early ANC.
  • Manage risk factors.
  • Safe abortion services.
  • Prompt management.

Patient education

  • Explanation of type and cause.
  • Management options.
  • What to expect.
  • Signs of complications.
  • Follow-up need.
  • Contraception.
  • Emotional support.

Uganda-specific notes

Unsafe abortion major issue. MVA preferred evacuation method. Misoprostol increasingly used. Ultrasound access varies. High suspicion for ectopic needed.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.3.2

Scroll to Top