Indications for speculum examination in early pregnancy, Gynaecology (1114)

Objectives

To provide guidance on when to perform speculum examination in women presenting with issues in early pregnancy

Scope

Women attending the early pregnancy service with vaginal bleeding

Audience

All healthcare professionals involved in the care of women in early pregnancy

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Bleeding is a common presentation in early pregnancy affecting approximately 20% of pregnancies in the first trimester. Whilst this bleeding is most commonly pregnancy related, it is important to remember that non pregnancy causes of bleeding can present for the first time in pregnancy.

There are number of possible causes for bleeding in early pregnancy including:

Implantation bleeding – commonly light spotting occurring at around the time of the missed period
Miscarriage – can range from light spotting to heavy/life threatening
Ectopic – can range from light to heavy
Molar pregnancy
Cervical ectropion or polyp – bleeding can be unprovoked or provoked such as following intercourse
Infection causing cervicitis
Trauma
Cancer of the cervix, vagina or vulva (rare)

Early Pregnancy Assessment Service (EPAS) management of early pregnancy bleeding

Miscarriage is the most common cause for early pregnancy bleeding, with ectopic pregnancy being an important second differential to be considered. As such any women presenting for the first time with vaginal bleeding >6 weeks gestation; vaginal bleeding with associated pain or ectopic risk factors at any gestation; or vaginal bleeding at an uncertain gestation should be assessed, ideally through local EPAS units.

This assessment should include an ultrasound scan to assess the location and viability of the pregnancy. If a miscarriage, ectopic or molar pregnancy is diagnosed on ultrasound scan these should be managed accordingly.

Women in whom a viable intrauterine pregnancy, with a fetal heartbeat, is confirmed should be advised that their risk of miscarriage falls to around 10% once the heartbeat has been detected. They should therefore be reassured and discharged, with advice to contact a midwife to book their pregnancy. If the bleeding continues beyond 14 days, or restarts after stopping, women should be advised to re-contact EPAS for further assessment.

Indications for speculum examination

Indications for urgent speculum examination:

Heavy vaginal bleeding
Signs and symptoms suggestive of cervical shock – bradycardia and hypotension

In these circumstances resuscitation of the patient should be commenced while a member of staff trained and competent in speculum examination to remove products from the cervical os is contacted for urgent review.

Other indications for speculum examination:

Single episode of vaginal bleeding persisting >14 days
Presentation with a second episode with vaginal bleeding in pregnancy
Symptoms suggestive of infection eg. foul smelling PV discharge, vaginal itch
Ultrasound suggesting cervical ectopic - If cervical ectopic is suspected speculum should be performed by senior medical staff as findings will inform decisions regarding management.

In these circumstances speculum examination should be performed by a member of staff competent in assessing the vulva, vagina and cervix for abnormalities warranting further investigation.

Cervical Smear History

Cervical screening status should be assessed in all women presenting with bleeding in pregnancy. If cervical screening history is uncertain and the patient is ≥25 years of age, the national database (SCCRS) may contain relevant information.

Opportunistic cervical smears should not be taken during pregnancy within the Obstetric Department.

Last reviewed: 14/11/2023

Next review date: 31/10/2027

Author(s): Dr Alison Platten, Consultant O&G.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1114