Reasoning GP · Algorithm · 1-page summary
Vaginal bleeding in pregnancy
For: primary-care recognition, assessment and referral of vaginal bleeding at any gestation, and any woman of reproductive age with bleeding until a pregnancy test is negative. Not for: definitive management of ectopic pregnancy, miscarriage, placenta praevia, abruption or GTD — specialist care. Local maternity and EPAU pathways take precedence.
Core rule: bleeding with a positive pregnancy test and no intrauterine pregnancy confirmed on ultrasound is an ectopic until proved otherwise — pain may be absent. In later pregnancy, never do a digital vaginal examination until placenta praevia is excluded.
0Stop — call 999 now
- Instability or collapse (pulse >100, BP <90/60), or suspected ruptured ectopic: severe or worsening pain, peritonism, shoulder-tip pain, syncope, shock → 999
- Major or ongoing haemorrhage; suspected abruption (severe pain, rigid tender uterus) or fetal compromise; vasa praevia with fetal bradycardia; uterine rupture → 999
- Sepsis or septic miscarriage — fever, rigors, tachycardia, offensive discharge after miscarriage or procedure; or deteriorating / unable to travel safely → 999
- While waiting: left lateral in later pregnancy, keep warm; tell the ambulance if praevia is suspected. Do not delay transfer for examination, blood tests or anti-D.
1Triage by gestation — if no block 0 feature
| Gestation | Action |
|---|---|
| Up to 13 completed weeks | Pain, ≥6 weeks, ectopic risk factors, significant bleeding or uncertain location → Same-day EPAU/EGU |
| <6 weeks, painless | No risk factors → local expectant pathway: urine test in 7–10 days; return if positive or still bleeding |
| 13 weeks to 23+6 | Unexplained bleeding → Same-day maternity triage |
| From 24+0 (APH) | Phone maternity triage → Same-day; stable minor bleeding needs no automatic 999. Never a routine letter. |
2Screen — one row is enough
- No confirmed intrauterine pregnancy + pain or ectopic risk factor (previous ectopic, IVF, IUCD, tubal surgery) → Same-day EPAU
- Open cervical os (inevitable miscarriage) → Same-day EPAU
- Large for dates, hyperemesis (GTD) → Same-day EPAU
- Known low-lying placenta or painless later bleeding → no digital or speculum examination; heavy → 999, otherwise Same-day maternity
- RhD-negative, 12+0 to 12+6 weeks, anti-D eligible and not given → Same-day EPAU
3Assess
☐ Urine pregnancy test; LMP, gestation, previous scan ☐ Pulse, BP, RR, SpO₂, temperature ☐ Abdomen: tenderness, guarding, uterine rigidity, fundal height ☐ Fetal heart and movements where appropriate — do not delay transfer ☐ Blood group and RhD status, FBC ☐ Domestic abuse and trauma
Do not: digital VE until praevia excluded; bimanual if ectopic suspected; speculum after 13 weeks or if unstable; diagnose by hCG or LMP alone.
4Classify — on specialist ultrasound
- Threatened — closed os, fetal heart seen → bleeding stops: routine antenatal care; worse or >14 days: reassess.
- Inevitable / incomplete — open os or retained products → EPAU-led management.
- Complete — empty uterus; may still be ectopic if no intrauterine pregnancy was confirmed → urine test at 3 weeks.
- Missed — no heartbeat; repeat scan after ≥7 days → EPAU.
- Praevia (painless) · abruption (painful, hard uterus, may be concealed) → maternity.
- Uncertain — before 13 weeks: ectopic until USS excludes; later: same-day maternity triage.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Progesterone: bleeding + previous miscarriage + intrauterine pregnancy confirmed on USS → offer vaginal micronised progesterone 400 mg BD; to 16 completed weeks if heartbeat confirmed.
- Anti-D (RhD-negative): none up to 11+6 weeks. 12+0–12+6: offer ≥250 IU with medical or surgical management; consider if threatened miscarriage with heavy or recurrent bleeding. From 13 weeks offer if at risk of isoimmunisation; within 72 h.
- Support: acknowledge the loss; Miscarriage Association; fit note; assess mood, safeguarding, suicidal ideation.
6Refer routinely
- EPAU within 24–48 h: threatened miscarriage with intrauterine pregnancy already confirmed (stable, light bleeding, no pain); stable missed miscarriage.
- Recurrent miscarriage clinic: ≥3 first-trimester losses (discretion after 2).
- After ectopic: early USS next pregnancy. After GTD: GTD-centre surveillance; contraception per its plan.
7Never reassure by
- “She doesn't think she's pregnant” — test anyway.
- Little or no pain — an ectopic can be painless.
- A positive test or rising hCG — neither shows where the pregnancy is.
- Small visible loss or pad count — abruption can be concealed.
- A scan showing the placenta — it does not exclude abruption.
- A falling hCG under ectopic surveillance — rupture can still occur.
8Safety-net — say it, then document it
999 / A&E “Call 999 or go to A&E straight away if you faint, collapse or feel very dizzy, have severe or worsening tummy or shoulder-tip pain, heavy bleeding with weakness, breathlessness or palpitations, or fever, shivers or smelly discharge after a miscarriage or procedure.”
Same day “Contact the early pregnancy unit today if pain starts, bleeding worsens, or your home test is positive 3 weeks after the miscarriage — heavy bleeding, pain or fever needs checking even if negative. From 13 weeks, phone maternity triage for any bleeding.”
✓Safe to leave primary care only if — all five, documented
Pregnancy test and gestation known; no block 0 feature on full obs
Destination phoned and arranged by gestation, clinician named
No digital VE in later pregnancy before praevia excluded
RhD status and anti-D decided for the gestation
Safety-net given, including 999 symptoms
Summary of the full Reasoning GP vaginal bleeding in pregnancy algorithm, which holds the detail, management options and evidence. Sources: NICE NG126 Ectopic pregnancy and miscarriage (anti-D update June 2026); NICE NG201 Antenatal care; RCOG Green-top 63, 27a, 27b, 17, 38; local EPAU and maternity pathways. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.