Bleeding During Pregnancy

Vaginal bleeding during pregnancy is always scary for the expectant mother. There are many causes of vaginal bleeding and often the bleeding will stop on its own. You should always alert your doctor or midwife when you have vaginal bleeding since the bleeding may pose a risk to you or the fetus.

Bleeding in Early Pregnancy
Many women have vaginal spotting or bleeding in early pregnancy. This bleeding may be as a result of implantation - when the fertilized egg attaches to the uterine wall. Early in pregnancy your doctor or midwife may order a series of blood pregnancy tests. These tests measure the level of human chorionic gonadotropin (hCG) in your bloodstream. HCG is a hormone produced by the placenta during pregnancy. Following the increasing levels of hCG in the blood can help your doctor or midwife to monitor the progress of your pregnancy in the early weeks. An ultrasound, or sonogram, may be performed to help locate the reason for the bleeding. Your doctor or midwife may wish to do a pelvic exam. Sometimes the cause of the bleeding is never found.

Miscarriage
A miscarriage is the loss of a pregnancy in the early stages. Although a miscarriage can occur any time during the first half of a pregnancy, it is most common during the first twelve weeks. Although 15 to 20% of all known pregnancies end in miscarriage, approximately ½ of those with bleeding in pregnancy do not miscarry. Most miscarriages cannot be prevented. This is nature's way of dealing with a pregnancy that is not developing normally. Although a woman may first notice the bleeding after sex, having sexual intercourse in early pregnancy will not cause a miscarriage. Most women who miscarry will go on to deliver healthy babies with future pregnancies.

There is a possibility of miscarriage if you notice vaginal bleeding, the passage of tissue, and cramping pain in the lower abdomen. Many women with bleeding have little or no cramping. The bleeding may stop and the pregnancy progresses. Other times, though, the bleeding will continue to get heavier and miscarriage occurs. Generally the cramping experienced with a miscarriage is stronger than normal menstrual cramps.

If you think you may be having a miscarriage, call your doctor or midwife. If you have passed any tissue, you will be asked to bring it to the office with you. It will be sent to a pathologist for examination. If you have had a miscarriage, but tissue remains in your uterus, you will continue to bleed. You will need a D&C to remove the tissue. This procedure is performed by dilating (widening) the cervix and either suctioning or wiping the tissue away from the lining of the uterus.

Having a miscarriage does not mean you will not be able to carry a child to term in the future. If you have two or three miscarriages in a row, your doctor or midwife may want to perform tests to look for a possible cause for the miscarriages.

Ectopic Pregnancy
An ectopic pregnancy is one that occurs outside the uterus. Because the pregnancy is not in the uterus, it cannot progress normally and must be removed. About 1 in 60 pregnancies are ectopic. Usually the pregancy is in a fallopian tube. A ruptured tubal pregnancy will cause major bleeding into the abdomen and can even cause death. The symptoms are typically pelvic pain (usually a sharp pain on one side) and vaginal bleeding. If the tube has ruptured, there may be shoulder pain, dizziness, or fainting. Since there may not be much warning, you should call your doctor or midwife if you have pain or bleeding.

The treatment for an ectopic pregnancy varies according to how early the problem is found. Sometimes the pregnancy can be removed from the tube using a laproscope. This will preserve the tube for later use.

If the pregnancy is larger, or the tube has ruptured, a larger incision will need to be made. This is called a laparotomy. The pregnancy may be removed from the tube, or the tube may need to be removed.

Sometimes a drug (methotrexate) may be given to stop the growth of the pregnancy. Your body will absorb the tissue over time. The progression of the treatment is monitored by blood tests.

Women who have already had an ectopic pregnancy, who have a history of pelvic inflammatory disease (PID) or pelvic infections, have a history of infertility, or pelvic surgeries are at an increased risk for an ectopic pregnancy.

Bleeding in Late Pregnancy
The causes of bleeding the second half of pregnancy are different from in early pregnancy. The most common causes of heavy vaginal bleeding are related to the placenta. Bleeding can be heavy and may pose a serious threat to the mother or the fetus. The two most common culprits are placenta previa and placental abruption. If you have any bleeding in the second half of pregnancy, you should alert your doctor or midwife.

Placenta Previa - During pregnancy, the baby receives nourishment from you through the placenta. The placenta usually develops in the top part of the uterus. When the placenta lies low in the uterus, partically or completely covering the cervix (uterine opening), it is referred to as a placenta previa. In late pregnancy, this may result in painless vaginal bleeding. Placenta previa is diagnosed by ultrasound. The doctor or midwife may prescribe bed rest to prevent heavy bleeding. The baby should not be delivered vaginally if the placenta previa persists at term.

Placenta previa occurs in 1 in 200 pregnancies. It is most common in women who have had a previous cesarean section, have had placenta previa in the past, are over the age of 35, have had previous uterine infections or surgery (such as a D&C), or are pregnant with more than one baby.

Placental Abruption - When the placenta detaches from the side of the uterus either partically or completely before or during labor, this is called placental abruption. This is a life threatening complication for the mother and the baby. The mother can hemorrhage, while the baby will have its oxygen supply decreased or cut off. The symptoms include vaginal bleeding, severe abdominal pain, and nausea and vomiting. Placental abruption occurs in 1 in 100 pregnancies. Placental abruption is associated with high blood pressure, smoking, cocaine use (even once), and blows or injuries to the abdomen. Women are at a higher risk for placental abruption if they are over the age of 35, have had a previous placental abruption, have had several pregnancies or have sickle cell anemia.

Labor
Vaginal bleeding can be a sign of labor. When the mucous plug that covers the opening of the uterus is passed, this is called "show". The mucous is mixed with a little blood. If this happens within a few weeks of your due date, it is not a problem. It means your cervix is beginning to shorten and thin out ("effacing"), it is getting ready for labor. If it occurs earlier, you should call your doctor or midwife as it may be a sign of premature labor. Other signs of labor include:

• A change in vaginal discharge (watery, mucous, or bloody, an increase in the amount.
• Lower abdominal or pelvic pressure.
• A low, dull backache.
• Abdominal cramps, with or without diarrhea.
• Regular contractions or cramping of the uterus.

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