A vaginal bleeding occurs in 20-30% of all pregnancies confirmed during the first 20 SSW; about half of them ending in a spontaneous abortion. Vaginal bleeding occurs in other unwanted outputs of pregnancy such as low birth weight, premature birth, stillbirth and perinatal death. Etiology pregnant addicts or pregnant independent diseases can cause vaginal bleeding in early pregnancy (see table: causes of vaginal bleeding in early pregnancy). The most dangerous cause is Ruptured Ectopic pregnancy, the most common cause is spontaneous abortion (threatening, starting, incomplete, complete, septic, behavior) causes of vaginal bleeding in early pregnancy cause Suspicion Results Diagnostic procedure pregnancy-related disorders Ectopic pregnancy Vaginal bleeding and / or abdominal pain (often suddenly inserting, localized and persistent, non-spasmodic) Closed Mutt ermund Occasionally palpable and painful tumor in the adnexal region Usually hemodynamic instability in ruptured ectopic Quantitative ?-hCG measurement, blood blood group determination pelvic ultrasonography Threatened abortion Vaginal bleeding with or without cramping abdominal pain Closed cervix, non-painful adnexa Most Incipient in the first 12 SSW investigation as ectopic Abort (Advanced cervix) commonly seen cramping abdominal pain, vaginal bleeding open cervix pregnancy products through the cervix or feel Investigation as Incomplete in ectopic pregnancy abortion vaginal bleeding, abdominal pain Open or closed cervix often see pregnancy products through the cervix or feel investigation as ectopic Complete abortion Light vaginal bleeding during the initial examination, but usually massive vaginal bleeding immediately the doctor previously; occasionally abdominal pain Closed cervix, small and contracted uterus investigation as ectopic septic abortion fever, chills, persistent abdominal pain, vaginal bleeding, purulent vaginal discharge Usually obviously of previous induced abortion or instrumental intervention on the uterus (often illegal or self-induced) Open cervix investigation as ectopic plus. cervical cultures Cautious abortion Vaginal bleeding, symptoms of early pregnancy (nausea, fatigue, breast tenderness) that decrease over time Closed cervix Investigation as ectopic gestational trophoblastic uterus larger than expected, often elevated blood pressure, severe vomiting, occasionally leaving grape-like tissue examination as ectopic pregnancy Ruptured corpus luteum cyst localized abdominal pain, vaginal bleeding usually in the first 12 SSW investigation as ectopic pregnancy Independent diseases Trauma Obviously (a history of such. Or shows signs of the cervix or vagina by instrumental intervention or abuse, occasional complication of chorionic villus sampling or amniocentesis) Clinical examination Unless of question questions regarding any domestic violence vaginitis only lubricant or scant bleeding with vaginal discharge occasionally dyspareunia and / or pelvic pain diagnosis of exclusion Zervixkulturen cervicitis Only lubricating or scanty bleeding Occasionally cervical motion pain and / or abdominal pain diagnosis of exclusion Zervixkulturen Cervical polyp (usually benign) Scanty bleeding, no pain Polypoid mass that protrudes from the cervix Obstetric Clinical examination follow-up for further clarification and removal of ?-hCG = ?-subunit of human chorionic gonadotropin. Clarification A pregnant woman with vaginal bleeding needs to be investigated without delay. Ectopic pregnancy or other causes of heavy vaginal bleeding (eg. As incipient abortion, ruptured hemorrhagic corpus luteum cyst) can lead to hemorrhagic shock. If such complications arise, intravenous access should be created early in the investigation. History to history of the current disease should the pregnancy (number of confirmed pregnancies), parity (number of births after 20 weeks) and the number of abortions (spontaneous or induced) and the description and severity of bleeding, including the number of required tampons, the disposal of clots or tissue and the presence or absence of pain include. Beginning, location, duration and nature of any pain should be determined. The evaluation of symptoms should include fever, chills, abdominal or pelvic pain, vaginal discharge and neurological symptoms such as dizziness, drowsiness, syncope or Beinahesynkopen. Anamnestic include risk factors for ectopic pregnancy and spontaneous abortion (history) .Körperliche examination The physical examination includes checking vital signs for fever and signs of hypovolemia (tachycardia, hypotension). The investigation focuses on abdominal and gynecological examinations. The abdomen is scanned with respect to pressure sensitivity, Peritonealzeichen (rebound tenderness, hardened abdominal wall, guarding) and uterine size. The fetal heart tones should be checked with a Doppler ultrasound probe. The gynecological examination comprises inspection of external genitalia, speculum and bimanual examination. Blood or pregnancy products are in the birth channel, if present, is removed; Pregnancy products are sent for confirmation to a lab. The cervix should be inspected for leakage, expansion, injury, polyps and tissue in the cervix. The cervix is ??<14 weeks studied carefully in pregnancies with annular clamp (but not further than fingertip depth) to determine the integrity of the internal os. In pregnancies ? 14 weeks, the cervix should not be investigated because the vascular placenta may tear, especially when it covers the internal os (placenta previa). As part of the bimanual examination is on cervical motion pain, tumors or tenderness adnexal and uterine size geachtet.Warnzeichen The following findings are of particular importance: Hemodynamic instability (hypotension and / or tachycardia) Orthostatic changes in pulse or blood pressure syncope or Beinahesynkope Peritonealzeichen (rebound tenderness, hardened abdominal wall, guarding) fever, chills and mucopurulent vaginal discharge interpretation of the findings clinical findings provide evidence for a cause, but are seldom diagnostically conclusive (see table: causes of vaginal bleeding in early pregnancy). However, have an extended cervix with outlet fetal tissue and crampy abdominal pain strongly to a spontaneous abortion out; a septic abortion can be concluded as a rule by the circumstances and signs of severe infection (fever, toxic appearance, purulent or bloody discharge). Even if these classic symptoms are not present, a threatened or subdued abortion is possible, and the most serious cause of a ruptured ectopic pregnancy must be excluded. Although a lot of pain, Peritonealzeichen and a painful Adnexraumforderung occur after the classic description of an ectopic pregnancy, a Ectopic pregnancy can manifest in many ways and should always be considered, even if the bleeding sparse and the pain scheinen.Tests easy to be a self-diagnosed pregnancy is checked by urine test. In women with proven multiple pregnancy tests are carried out: Quantitative ?-hCG blood grouping and Rh test Usually sonography A Rh-test is used to determine the need for Rh0 (D) immune globulin performed to prevent a maternal sensitization. In case of heavy bleeding, the tests should include blood count and "type and screen" (for abnormal antibodies) or cross tests. In massive bleeding or shock PT / PTT also be determined. Transvaginal pelvic ultrasonography is done to confirm an intrauterine pregnancy, unless the pregnancy products were delivered intact (indicating a complete abortion). Are the patients in shock or if the bleeding considerably, ultrasonography should be performed at the bedside. Quantitative determination of ?-hCG level help interpret the ultrasound findings. If the mirror is ? 1500 mI.E./ml and is (a living or dead fetus) does not confirm an intrauterine pregnancy by sonography, an ectopic pregnancy is likely. If the mirror is <1500 mI.E./ml and be seen no intrauterine pregnancy, intrauterine pregnancy is still possible. If the patient is stable, and only a little clinical suspicion of an ectopic pregnancy, the hCG ?-values ??are determined regularly on an outpatient basis. In a normal pregnancy, the mirror all day 1.4-2.1 double up to 41 days. In an ectopic pregnancy (and abortion), the mirrors are usually lower than would be expected by date, and they do not double up so fast. Is a moderately elevated or high clinical suspicion of ectopic (z. B. due to excessive blood loss and / or tenderness of the adnexa), should a diagnostic emptying of the uterus or dilatation and curettage and possibly a diagnostic laparoscopy to be carried out. In ultrasound, a ruptured corpus luteum cyst and gestational trophoblastic tumors could be detected. It can be displayed in the uterus, which are present in patients with incomplete, septic or restrained abortion pregnancy products. Treatment Treatment depends on the underlying disease. Ruptured ectopic pregnancy: immediate laparoscopy or laparotomy Nichtrupturierte Ectopic pregnancy: methotrexate or salpingotomy or salpingectomy by laparoscopy or laparotomy Threatened abortion: waiting and observing for hemodynamically stable patients begun, incomplete or restrained Abortion: dilation and curettage or evacuation of the uterus Septic abortion: iv Antibiotics and rapid emptying of the uterus when pregnancy products were identified on ultrasound Complete abortion: obstetric follow-up summary, physicians should always draw a ectopic pregnancy into consideration; The symptoms may be mild or severe. A spontaneous abortion is the most common cause of bleeding in early pregnancy. For all women who present with vaginal bleeding in early pregnancy is a Rh testing is necessary to determine whether Rh0 (D) immunoglobulin is required.