Bleeding in early pregnancy

This is a common problem that strikes fear in the hearts of every pregnant woman. All fear the possibility of a miscarriage. Whilst it is true that such bleeding can herald the onset of a miscarriage, it is also true that bleeding can be due to many other reasons. A lot of these reasons do not lead to a miscarriage.

There are many causes for this to happen. They include:

  1. Miscarriage or threatened miscarriage
  2. Ectopic pregnancy
  3. Implantation bleeding
  4. Vaginal infection
  5. Polyps in the vagina or cervix
  6. Cancer
  7. “One of those things”

To what extent one has to be concerned will depend on other associated symptoms or events  including:

  • Pain or itchy vaginal discharge
  • The amount of bleeding,
  • Whether it is a once off event or recurring,
  • Time in the pregnancy
  • Association with sexual activity

Whilst the heavy painful bleeding need urgent attention, less symptomatic bleeding should also be investigated. Some miscarriages develop over time and may present at light dark bleeding with no or minimal pain. Many causes can be determined by taking a history and performing a vaginal examination. However, in others further investigations will be required including:

  • Pelvic ultrasound. This normally required a vaginal ultrasound. Here, the ultrasound probe is inserted into the vagina. This will give a more accurate view of the baby. It can detect changes earlier than an ultrasound performed through the tummy. Even then the pelvic ultrasound is only able to detect viability after 6 ½ weeks of pregnancy at best.
  • HCG hormone levels. Usually this means doing a pregnancy hormone level. Repeat levels over time may be required to assess the viability of the pregnancy. Usually this is undertaken when the pregnancy is very early, before the pelvic ultrasound is able to detect the pregnancy.
  • Progesterone hormone level. This is another hormone level I commonly use when monitoring a pregnancy. Progesterone is released by the ovary and is required to maintain the pregnancy. If it is too low, then an otherwise viable pregnancy may miscarry. However, a low progesterone can also be present in a poor non-viable pregnancy. So the interpretation of a low progesterone level can be difficult. The importance of a low level is that I can use progesterone supplementation to try and boost the chance of helping the pregnancy. Whether or not it will help can be open to debate at times. The value of its use will be a matter of discussion depending on the clinical situation
  • Vaginal swabs can be taken to exclude an infection. This can then be treated if appropriate.
  • Cervical screening (or Pap smear in the old nomenclature) may be required if thought appropriate.
  • Blood group checks should be performed if not known. If you are having bleeding related to a possible miscarriage, then you may need anti D if your blood group is Rh Negative. This will depend on the stage of your pregnancy.

The management of bleeding will then depend on the findings.  These may include:

  • Do nothing. This is one of the most common situations.
  • D and C – this may be required if you are having a miscarriage
  • Hormone therapy with progesterone
  • Laparoscopy if an ectopic pregnancy is suspected.
  • Treatment of any vaginal infections

Bleeding therefore whilst of concern does not necessarily mean a poor outcome. There are many things that can be performed to check and provide assurance.

These notes reflect my personal opinion and are intended for general advice only. It should not be used for any one individual case. You should consult your own doctor to determine the appropriate management of your own individual situation. No part of these notes can be used or reproduced in any manner without my express consent