Management of women presenting with vaginal bleeding in the second trimester (<24+0 weeks gestation) and a positive pregnancy test.

Applicable unit policies:

• Anti-D Administration Following Antenatal Sensitising Events in Rhesus Negative Women
• PPROM
• See EPAS Guidelines

Bleeding less than 17+0 weeks: Refer EPAS (Clyde <20+0 weeks) – out of hours contact Maternity Assessment.

Bleeding > 17+0 weeks: Refer to Maternity Assessment (Clyde > 20+0 weeks).

Opening Hours EPAS:

RAH – 0900 - 1700 hours Monday – Friday

VOL – 0900 – 1700 hours Monday – Friday

IRH – Mornings only Monday – Friday

PRM – 0830 – 1630 hours (7 days)

QEUH – 0800 – 1600 hours Monday – Friday; 0830 – 1630 hours Saturday/Sunday

For All Women:

• Record accurate history (noting amount of bleeding and any related events such as pain or intercourse). Note any risk factors for cervical incompetence (previous history/cervical surgery).
• Record blood pressure and urinalysis.
• Perform clinical examination including abdominal palpation and assessment of fundal height.
• Review any previous ultrasound if available. A low placental site <24+0 weeks should not preclude speculum examination.
• Auscultate fetal heart if fundus palpable.
• Speculum examination and LVS is indicated when:
  • No previous speculum examination has been performed this pregnancy
  • If pain/bleeding indicative of high risk of miscarriage.
  • If risk factors for, or clinical suspicion of cervical incompetence.

• Repeat speculum examination should not be a routine procedure.
• Check Rhesus status and need for Anti D
• Ultrasound is indicated when there is diagnostic uncertainty. Urgency of ultrasound depends on clinical situation.

Maternity Assessment Action:

1. If bleeding settled and examination normal discharge home.
2. If associated pain or continued vaginal bleeding consider admission.
3. If findings suggest cervical incompetence Middle Grade to discuss with on-call Consultant
4. If ruptured membranes refer to linked policy
5. If any concerns re the appearance of the cervix then a more senior obstetrician should inspect cervix and consider urgent referral to Colposcopy.
6. Any administration of steroids before 24 weeks gestation should be a Consultant decision.