Vaginal bleeding during pregnancy first trimester

If you experience the slightest vaginal bleeding in pregnancy, your mind by reflex jumps to the worst scenario. I understand that. its alarming, its unexpected and its very very scary. It gives you this sense of immense helplessness as you turn to your doctor looking for an answer and a miracle to save the baby. 

Difference between spotting and bleeding

Spotting is that blood

• Which is visible on your underwear or the toilet paper when you wipe after urinating
• Appears as light brown or pink spots, something that you might be used to seeing at the beginning or end of your periods
• May not even require a pad or liner

Bleeding on the other hand 

• Is brighter red
• Is much heavier than spotting, well you could compare it to your periods
• Definitely requires a sanitary pad to manage

We need to understand here that every episode of vaginal bleeding during pregnancy does not always mean sinister things. About 30% of all pregnancies will experience spotting and bleeding in the first 3 months, IVF pregnancies little more so. Let’s discuss what are 6 common reason for this happening:

1. Implantation bleeding: Implantation bleeding is (usually) light spotting or bleeding that occurs between 6 to 12 days after conception. This happens when a fertilized egg begins dividing and forms an embryo, which then implants into the uterine wall. It is often one of the first signs of pregnancy and can occur before a woman realizes she is pregnant. Implantation bleeding is completely normal, harmless, and does not require any medical attention. Roughly one-third of pregnant women will experience this type of vaginal bleeding during pregnancy . It can often be confused with regular menstrual bleeding. It usually lasts from a few hours to about 3 days maximum. It is usually just light spotting and does not result in bleeding. It may be accompanied by otter pregnancy symptoms like nausea, breast tenderness and cramping etc. if this is followed by a positive test for pregnancy then you know this was implantation bleeding and you know you are safe.
2. The 2^nd cause of Vaginal bleeding during pregnancy that is obviously important because it is also common is unfortunately miscarriage. Roughly 25% of all pregnancies will be lost and 75% of them will be lost within the first 3 months of pregnancy. I am not going into details of this right now because this will be subject of a complete podcast as there is so much to discuss but in a nut shell I will tell you that human fertility is defective and it has been made so by nature so that our numbers don’t increase exponentially. Thus, despite the mating of a healthy sperm and egg it is possible that there are genetic defects in the embryo. This if Gods way of keeping fertility low. But to ensure that such an abnormal embryo does not result in an abnormal baby, God has put some sensitive checks in our body which detect this abnormality and then don’t allow that embryo to grow causing a miscarriage. The good part is no future treatment is necessary for most cases and subsequent pregnancy the next time is normal. 

Coming to our point of discussion, if there is miscarriage, the bleeding will be much heavier and accompanied by pain or abdominal cramps. Some women may experience a decrease in the pregnancy symptoms. 

How do we diagnose if a miscarriage has happened?

• If the beta hCG is done and the levels are falling in repeated tests
• If a scan has been done previously and a particular milestone was reached and this time when you repeat the scan after an interval of days or weeks and the next milestone is not reached
• Or if you do a scan and find that the baby’s heartbeat which was seen previously is no longer present 

If unfortunately, this doesn’t happen, you will need to speak to your doctor about the future course of action.

1. Ectopic pregnancy: this is a condition wherein the pregnancy or the embryo instead of implanting inside the womb, gets stuck inside the fallopian tube or to the ovary. This is a dangerous situation because these areas are not equipped to support the growing pregnancy leading to rupture of the tube or bleeding from the tube or ovary. There is no pregnancy inside the womb yet there is some amount of bleeding usually from it usually accompanied by pain in the lower abdomen or even fainting. This is probably a mechanism set by nature to warn us that something abnormal is happening so that you inform your doctor and he or she takes corrective measures. The pregnancy can’t be saved but alteast we can save your life to come back and fight another day. 
2. Sub chorionic haemorrhage: or sub chorionic haematoma or bleed is when blood collects between the placenta and the womb wall. This tends to separate the attachment of the growing foetus from the wall creating a situation called threatened abortion that is abortion hasn’t happened but there is a threat of it. 

About 1 % of all pregnancies and 10% of all IVF pregnancies will experience this phenomenon. 20% of all women who bleed during the first 3 months will have this condition. 

I won’t deny that this is a scary situation where you have spotting or bleeding and doing a scan one sees a big clot sitting inside the womb. There are 3 things you need to remember at this point:

• In most cases the clot inside will either get absorbed or come out in the form of vaginal bleeding and the foetus will attach back securely again
• We need to definitely evaluate any possible reasons for miscarriage at this point and take corrective measures. I am not going to elaborate on this here as this too is long enough for an entire podcast episode. 
• This is one situation where bed rest for a short while may help as it helps prevent the clot from dislodging or increasing. 

1. Vanishing twin syndrome: this is a condition wherein twins had developed, either spontaneously or as a result of infertility treatment like IUI or IVF but probably one of the foetuses wasn’t healthy and thus could not grow. The body preferentially chooses to abort this foetus in trying to save the other normal one. This may result in temporary spotting or bleeding till nature corrects things. The abnormal foetus gets absorbed into the mother’s body without a trace and the 2^nd baby continues healthy and without complications. This is easily diagnosed by ultrasound first showing twins and then a repeat scan few days or weeks later showing one healthy pregnancy and the other one not seen.  
2. Sometimes we think of big issues and forget the small issues that may be the simple cause of our problems. Am getting philosophical eh? 😊 

There may be some minor issues like inflammation of the mouth of the womb, urine infections or small grape like polyps at the mouth of the womb which are harmless but may lead to spotting or bleeding. I have often come across such patients where we keep searching for causes for the bleeding and then finally realise it was a local cause in the vagina. 

Vaginal bleeding during pregnancy – do’s and donts

What do you do if you experience spotting or bleeding?

1. Rest in bed till you manage to contact your doctor
2. Your doctor will decide which conditions are serious and which are not depending on your past history, your particular case and its associated complications and the severity of bleeding
3. If the bleeding is heavy and you can’t reach your doctor, go straight to the hospital where you are scheduled to deliver or a nearby hospital
4. Sometimes doctors mention some medicines in their initial prescriptions. Medicines which are safe to use in an emergency. You can take that medicine while you wait for a diagnosis and treatment.
5. Wear pads so you can monitor how much you are bleeding as well as what type of bleeding you are experiencing.
6. Do not use a tampon or introduce anything into the vaginal area if you are bleeding. Avoid sexual intercourse as well. —
7. Do not panic. Remember that in most instances the outcome is good. Infact if a previous ultrasound has shown that the baby’s heart is present then there is a 95% chance that all shall be well.
8. Lastly Listen to and trust your doctor. He knows what is best for you and your baby. 

Another burning question is whether bed rest helps if the patient is having spotting or bleeding or if the patient has a previous history of miscarriages

Am sure all of you must have either faced or heard of someone who has been put on bed rest for weeks, months or sometimes the entire duration of the pregnancy because of the reasons I mentioned earlier. How much of real help does one gain? is there evidence to support this practice or is it just an additional torture on the woman and probably even her family. A practise which makes everyone from the patient to her doctor feel that they are doing something worthwhile to try and save the situation?

let’s first understand what happens if one does bed rest for weeks?

• Pregnancy is a time when there is an increased of clots forming inside the blood vessels in the body and these clots can be dangerous if they travel to the heart of brain. By resting in bed, we increase the chances of such clots forming
• 12% of muscle strength is lost with each week of bed rest. Thus, after weeks of rest the pregnant woman will be quite incapable of holding herself up and will feel weak and tired and complain of aches and pains when she finally tries to walk.
• Bed rest also leads to loss of bone strength and the bones become hollower and more brittle. This is further aggravated by pregnancy because of the increased calcium requirement which is sometimes not met.
• Lastly depression and a breakdown of the family structure. Being in bed all the time, away from friends and sometimes even away from family in hospital, being uncertain about the pregnancy and rarely even feeling worthless because the woman feels it’s her fault that all this is happening. I can only imagine what she must be having to go through. 

In today’s medical world treatments are based on research work done by millions of doctors across the world. We all submit out individual work online and then there are others who combine all the researches and come out with collective data. Cochrane library is one such body that collates data and is quite respected for that. research over the years has clearly shown that bed rest does in any way prevent a miscarriage and thus should not be advised. Having said that there are some situations where bed rest for a short duration might help. Why so?

When bleeding happens, the body automatically tries to seal off the bleeding with a clot. But if we keep shaking or disturbing the clot, it will not settle down and keep breaking. Thus, in acute bleeding conditions, or if there is blood collected inside like in a haematoma, then bed rest just for a few short days helps. In no times does the situation resolve and then the lady can be up and about her life again including sitting on the floor, climbing stairs and going out of the house.

Is there anything special I need to remember or inform my doctor?

An important reason to see a doctor for any type of Vaginal bleeding during pregnancy is the condition known as Rh incompatibility or Rh isoimmunization. “If a pregnant woman bleeds and her blood type is Rh negative, and her husband’s blood group is Rh positive then the woman has the potential of developing antibodies. These antibodies will harm the baby in the next pregnancy if that baby has a Rh-positive blood group. The baby can develop severe anaemia, jaundice, brain damage, and heart failure.

Rh incompatibility can be treated with injections of Rh immune globulin. This is a simple injection which your doctor will administer if you have spotting or bleeding even if you don’t have a miscarriage if he or she knows that you have Rh negative blood group. This medicine prevents your body from creating Rh antibodies that will harm your baby.

If I experience vaginal bleeding during the first 3 months of my pregnancy, could it hurt or harm my baby?

Well the answer is yes and no. bleeding as we have understood in the last few minutes can be normal during these times and can be sign of impending miscarriage. From that perspective yes it can be harmful but if your concern is that if the pregnancy survives, will this bleeding harm my baby in the long run in terms of development or any abnormalities…. the answer is a strict and confident NO

The baby will be absolutely safe so do not worry about it. 

Also read: First Trimester Investigations – why are they essential ?

This brings me to the end of yet another discussion. This discussion is also available as a podcast – check out here.

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