ACR Appropriateness Criteria® First Trimester Vaginal Bleeding: 2025 Update

Sherelle L. Laifer-Narin, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, New York. Electronic address: sll2122@cumc.columbia.edu.
Alana Fruauff, Research Author, New York-Presbyterian, Columbia University Irving Medical Center, New York, New York.
Cinthia Cruz Romero, Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts.
Dorothy I. Bulas, Children's National Hospital and George Washington University, Washington, District of Columbia.
Ingrid Burger, Kaiser Permanente, Los Angeles, California.
Christopher Fung, University of Alberta, Edmonton, Alberta, Canada.
Jane Goldman, Mount Sinai Medical Center, New York, New York and Valley Hospital, Ridgewood, New Jersey; American College of Obstetricians and Gynecologists.
Michael Gottlieb, Rush University Medical Center, Chicago, Illinois; American College of Emergency Physicians.
Priyanka Jha, Stanford University School of Medicine, Stanford, California.
Mark A. Kliewer, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
Robin B. Levenson, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ACR Committee on Emergency Radiology-GSER.
Catherine H. Phillips, Vanderbilt University Medical Center, Nashville, Tennessee.
Liina Poder, University of California San Francisco, San Francisco, California.
David Schultz, Evansville Primary Care, Evansville, Indiana; American Academy of Family Physicians.
Ashish P. Wasnik, Specialty Chair, University of Michigan, Ann Arbor, Michigan.

Document Type

Journal Article

Publication Date

11-1-2025

Journal

Journal of the American College of Radiology : JACR

Volume

22

Issue

11S

DOI

10.1016/j.jacr.2025.08.043

Keywords

AUC; Appropriate Use Criteria; Appropriateness Criteria; ectopic pregnancy; first trimester; intrauterine pregnancy; nonviable pregnancy; vaginal bleeding; viable pregnancy

Abstract

Vaginal bleeding is a relatively common occurrence in the first trimester of pregnancy, but can be distressing for both patients and clinicians. Differential considerations include normal intrauterine pregnancy (IUP), a nonviable IUP, an ectopic pregnancy (EP), or much less commonly gestational trophoblastic disease (GTD). Although the diagnosis of EP, nonviable IUP, and GTD is important, it is also crucial to avoid harming potentially normal pregnancies through early medical or surgical treatment. Fortunately, most diagnoses can be made using a combination of ultrasound (US), serum human chorionic gonadotropin levels, and physical examination. When a diagnosis is in question, serial examinations and close clinical evaluation is paramount. Occasionally, MRI of the pelvis without contrast may be helpful in problem-solving for challenging cases, where grayscale US is limited or when there is high concern for nontubal EP. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Department

Radiology

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