Bleeding During Pregnancy

Picture of a Woman with Pregnancy Issue

• Because bleeding during all phases of pregnancy may be dangerous, a woman should call her health care professional if she has any signs of vaginal bleeding during her pregnancy.
• Vaginal bleeding is any blood coming from the vagina (the canal leading from the uterus to the external genitals).
• First trimester bleeding is any vaginal bleeding during the first three months of pregnancy. Vaginal bleeding may vary from light spotting to heavy bleeding with clots. Vaginal bleeding is a common problem in early pregnancy, complicating 20% to 30% of all pregnancies.
• Any vaginal bleeding during the second and third trimesters of pregnancy (the last 6 months of a 9-month pregnancy) involves concerns different from bleeding in the first three months of the pregnancy. Any bleeding during the second and third trimesters is abnormal.
• Bleeding from the vagina after the 28th week of pregnancy is a true emergency. The bleeding can range from very mild to extremely brisk and may or may not be accompanied by abdominal pain. Hemorrhage (another word for bleeding) and its complications are the most common cause of death in the United States.

Picture of an Ectopic Pregnancy

Media file 1: An early intrauterine pregnancy seen on ultrasound.

An early intrauterine pregnancy seen on ultrasound

Vaginal bleeding in the first trimester of pregnancy can be caused by several different factors. Bleeding affects 20% to 30% of all pregnancies. , and many women wonder how much bleeding during pregnancy is normal. Implantation bleeding is a form of bleeding that takes place when the fertilized egg is implanted in the wall of the uterus, around the time of the expected menstrual period. Implantation bleeding is typically lighter than a usual menstrual period.

Bleeding increases the risk of having a miscarriage (lose the baby). Of even more concern, however, is that about 2% of all pregnancies are ectopic in location (the fetus is not inside the uterus), and vaginal bleeding can be a sign of an ectopic pregnancy. An ectopic pregnancy may be life-threatening. All bleeding, but particularly heavy or period-like bleeding during early pregnancy should prompt a call to your health care professional for immediate evaluation.

• Implantation bleeding: There can be a small number of spots associated with the normal implantation of the embryo into the uterine wall, called implantation bleeding. This is usually very minimal but frequently occurs on or about the same day as your period was due. This can be very confusing if you mistake it for simply a mild period and don't realize you are pregnant. This is a normal part of pregnancy and no cause for concern.
• Threatened miscarriage: You may be told you have a threatened miscarriage (sometimes also referred to as threatened abortion) if you are having some bleeding or cramping. The fetus is definitely still inside the uterus (based usually on an exam using ultrasound), but the outcome of your pregnancy is still in question. This may occur if you have an infection, such as a urinary tract infection, become dehydrated, use certain drugs or medications, have been involved in physical trauma, if the developing fetus is abnormal in some way, or for no apparent reason at all. Other than these reasons, threatened miscarriages are generally not caused by things you do, such as heavy lifting, having sex, or by emotional stress.
• Completed miscarriage: You may have a completed miscarriage (also called a spontaneous abortion) if your bleeding and cramping have slowed down and the uterus appears to be empty based on ultrasound evaluation. This means you have lost the pregnancy. The causes of this are the same as those for a threatened miscarriage. This is the most common cause of first trimester bleeding.
• Incomplete miscarriage: You may have an incomplete miscarriage (or a miscarriage in progress) if the pelvic exam shows your cervix is open and you are still passing blood, clots, or tissue. The cervix should not remain open for very long. If it does, it indicates the miscarriage is not completed. This may occur if the uterus begins to clamp down before all the tissue has passed, or if there is an infection.
• Blighted ovum: You may have a blighted ovum (also called embryonic failure). An ultrasound would show evidence of an intrauterine pregnancy, but the embryo has failed to develop as it should in the proper location. This may occur if the fetus were abnormal in some way and not generally due to anything you did or didn't do.
• Intrauterine fetal demise: You may have an intrauterine fetal demise (also called IUFD, missed abortion, or embryonic demise) if the developing baby dies inside the uterus. This diagnosis would be based on ultrasound results and can occur at any time during pregnancy. This may occur for any of the same reasons a threatened miscarriage occurs during the early stages of pregnancy; however, it is very uncommon for this to occur during the second and third trimesters of pregnancy.
• Ectopic pregnancy: You may have an ectopic pregnancy (also called tubal pregnancy). This would be based on your medical history and ultrasound and in some cases laboratory results. Bleeding from an ectopic pregnancy is the most dangerous cause of first trimester bleeding. An ectopic pregnancy occurs when the fertilized egg implants outside of the uterus, most often in the Fallopian tube. As the fertilized egg grows, it can rupture the Fallopian tube and cause life-threatening bleeding. Symptoms are often variable and may include pain, bleeding, or lightheadedness. Most ectopic pregnancies will cause pain before the tenth week of pregnancy. The fetus is not going to develop and will die because of lack of supply of nutrients. This condition occurs in about 3% of all pregnancies.
  • There are risk factors for ectopic pregnancy. These include a history of prior ectopic pregnancy, history of the pelvic inflammatory disease, history of Fallopian tube surgery or ligation, history of infertility for more than two years, having an IUD (birth control device placed in the uterus) in place, smoking, or frequent (daily) douching. Only about 50% of women who have an ectopic pregnancy have any risk factors, however.
• Molar pregnancy: You may have a molar pregnancy (technically called gestational trophoblastic disease). Your ultrasound results may show the presence of abnormal tissue inside the uterus rather than a developing fetus. This is actually a type of tumor that occurs as a result of the hormones of pregnancy and is usually not life-threatening to you. However, in rare cases the abnormal tissue is cancerous. If it is cancerous it can invade the uterine wall and spread throughout the body. The cause of this is generally unknown.
• Postcoital bleeding is vaginal bleeding after sexual intercourse. It may be normal during pregnancy.
• Bleeding may also be caused by reasons unrelated to pregnancy. For example, trauma or tears to the vaginal wall may bleed, and some infections may cause bleeding.

The most common cause of late-pregnancy bleeding is a problem with the placenta. Some bleeding can also be due to an abnormal cervix or vagina.

Placenta previa

The placenta, which is a structure that connects the baby to the wall of your womb, can partially or completely cover the cervical opening (the opening of the womb to the vagina). When you bleed because of this, it is called placenta previa. Late in pregnancy as the opening of your womb, called the cervix, thins and dilates (widens) in preparation for labor, some blood vessels of the placenta stretch and rupture. This causes about 20% of third-trimester bleeding and happens in about 1 in 200 pregnancies. Risk factors for placenta previa include these conditions:

• Multiple pregnancies
• Prior placenta previa
• Prior Cesarean delivery

Placental abruption

This condition occurs when a normal placenta separates from the wall of the womb (uterus) prematurely and blood collects between the placenta and the uterus. Such separation occurs in 1 in 200 of all pregnancies. The cause is unknown. Risk factors for placental abruption include these conditions:

• High blood pressure (140/90 or greater)
• Trauma (usually a car accident or maternal battering)
• Cocaine use
• Tobacco use
• Abruption in prior pregnancies (you have a 10% risk it will happen again)

Uterine rupture

This is an abnormal splitting open of the uterus, causing the baby to be partially or completely expelled into the abdomen. Uterine rupture is rare, but very dangerous for both mother and baby. About 40% of women who have uterine rupture had prior surgery on their uterus, including Cesarean delivery. The rupture may occur before or during labor or at the time of delivery. Other risk factors for uterine rupture are these conditions:

• More than 4 pregnancies
• Trauma
• Excessive use of oxytocin (Pitocin), a medicine that helps strengthen contractions
• A baby in any position other than head down
• Having the baby's shoulder get caught on the pubic bone during labor
• Certain types of forceps deliveries

Fetal vessel rupture

The baby's blood vessels from the umbilical cord may attach to the membranes instead of the placenta. The baby's blood vessels pass over the entrance to the birth canal. This is called vasa previa and occurs in 1 in 5,000 pregnancies.

Less common causes of late-pregnancy bleeding include injuries or lesions of the cervix and vagina, including polyps, cancer, and varicose veins.

Inherited bleeding problems, such as hemophilia, are very rare, occurring in 1 in 10,000 women. If you have one of these conditions, such as von Willebrand disease, tell your doctor.

It is helpful for your health care professional to know the amount and the quality of the bleeding that you have. Keep track of the number of pads used and passage of clots and tissue. If you pass a clump of tissue and are going to see your doctor, bring the tissue with you for examination.

Other symptoms you may experience are increased fatigue, excessive thirst, dizziness, or fainting. Any of these may be signs of significant blood loss. You may notice a fast pulse rate that increases when you stand up from lying down or sitting. Moreover, dizziness may worsen when you stand up.

With late-pregnancy bleeding, you may have these specific symptoms:

• Placenta previa: About 70% of women have painless bright red blood from the vagina. Another 20% have some cramping with the bleeding, and 10% have no symptoms.
• Placental abruption: About 80% of women have dark blood or clots from the vagina, but 20% have no external bleeding. More than one-third have a tender uterus. About two-thirds of women with placental abruption have the classic "pain and bleeding." Over half of the time, the baby shows signs of distress. Most abruptions occur before labor begins.
• Uterine rupture: Symptoms are highly variable. Classic uterine rupture is described as intense abdominal pain, heavy vaginal bleeding, and a "pulling back" from the birth canal of the baby's head. The pain may initially be intense, then get better with rupture, only to worsen as the lining of the abdomen is irritated. Bleeding can range from spotting to severe hemorrhage.
• Fetal bleeding: This condition may show up as vaginal bleeding. The baby's heart rate on the monitor will first be very fast, then slow, as the baby loses blood.

If you begin to bleed during early pregnancy call your OB or midwife to be seen. Until you have been seen by a medical professional for bleeding during pregnancy, and they have given you different instructions, you should take it easy. There is no way to stop bleeding during pregnancy, so you should rest and contact your healthcare provider. Rest and relax, do not undertake heavy lifting or strenuous exercise, and abstain from sex, tampon use, or douching. Drink plenty of water and try to avoid against dehydration. Remember to keep track of the number of pads used and if the bleeding is increasing or decreasing.

Bleeding is not normal at any time during pregnancy. Report any vaginal bleeding during pregnancy to your healthcare professional. Be prepared to give information about the amount of blood loss and a description of how you are feeling overall. If your bleeding is light and you have no pain, your evaluation may be in the doctor's office.

There is no home care for late-pregnancy bleeding. You must see a healthcare professional immediately.

Go to a hospital's emergency department if the following conditions develop:

• Severe, heavy bleeding or cramps and contractions (call 911)
• Vaginal bleeding in pregnancy lasts for more than 24 hours and you are unable to get in touch with your healthcare professional or you don't have one
• Fainting (pass out) or feel very dizzy
• Bleeding and a fever over 100.5 F (38.05 C)
• Pain worse than a normal period, or severe localized pain in your abdomen, pelvis, or back
• You have undergone an abortion and develop a fever, abdominal or pelvic pain, or increased bleeding
• You have been given medical treatment for ectopic pregnancy with methotrexate (Rheumatrex, Trexall), and you develop increased abdominal or pelvic pain within the first week after the injection

The medical evaluation begins with a thorough history and physical exam. Depending on the setting (medical office or hospital) and the seriousness of your symptoms, laboratory and ultrasound tests may be performed. For bleeding in the early part of pregnancy, the doctor's main goal will be to make sure you don't have an ectopic pregnancy. That is what the evaluation will focus on. For late-pregnancy bleeding, the doctor first will make sure you are stable.

Medical history: Your health care professional will ask you a lot of questions. If early in pregnancy, your pregnancy history will be reviewed regarding the certainty of the dates of your pregnancy. If you think you are pregnant, you usually are. You may be asked about recent trauma or sexual intercourse and whether you have abdominal pain or contractions. Your medical history will be reviewed, with emphasis on bleeding disorders, liver problems, and drug or tobacco use. You will be asked about prior pregnancies, Cesarean deliveries, preterm labor, placenta previa, or placental abruptions.

Physical exam: Regardless of where you are being treated, the first thing that should be established is how sick you are as a result of the bleeding. This is done by evaluating vital signs (pulse and blood pressure), and by a quick physical assessment of volume of blood loss by looking to see if you are pale or if you have abdominal tenderness. If you have lost a significant amount of blood, you will be treated with IV fluids and you may need surgery.

• Your abdomen will be examined to see if you are tender and to check the size of your uterus.
• You will be checked for bleeding from other sites, such as the nose or rectum.
• The results of the pelvic exam may or may not be very helpful in differentiating between ectopic pregnancy and threatened miscarriage: 10% of women with an ectopic pregnancy will have a completely normal pelvic exam. How enlarged the uterus is on examination may help, because in less than 3% of ectopic pregnancies is the uterus enlarged to greater than 10 cm. In some cases, especially late in the pregnancy, the pelvic examination might not be performed until an ultrasound is available.
• Quantity and quality of abdominal pain and vaginal bleeding is important for the doctor to know. Pain is seen in most women with ectopic pregnancy (up to 90%) and vaginal bleeding (50% to 80%).
• Late in pregnancy, you will have an abdominal ultrasound prior to a vaginal exam to see if you have a placenta previa. If ultrasound does not show previa, you will have a sterile speculum vaginal exam to evaluate you for injury to the lower genital tract. If the vaginal exam is normal, you will have a digital exam to check for cervical dilation. You will have monitors attached to your abdomen to check for contractions and for the baby's heart rate.
• Symptoms and physical examination diagnose uterine rupture. The symptoms that suggest rupture are sudden onset of severe abdominal pain, abnormality of the size and shape of the uterine contour, and regression of the baby's head up the birth canal.

Lab tests: Several lab tests are routinely obtained. They include a urine pregnancy test, a urinalysis, a blood type and Rh, and a complete blood count (CBC). Serum quantitative bhCG, which is a blood hormone marker of pregnancy, is also frequently obtained.

• The urine pregnancy test is extremely sensitive for diagnosing pregnancy at or about the same time you miss your period, or possibly a few days before. A urinalysis can diagnose urinary tract infections, regardless of whether you have symptoms of this type of infection. This is because infections, specifically of the urinary tract, are a cause of miscarriage. Also, a urinary tract infection with no symptoms is relatively common in pregnancy, occurring in 2% to 11% of pregnant women. Up to a fourth of these women will go on to have kidney infections.
• Your blood type will be checked. You are being screened for whether your type is Rh negative or positive. If you are negative and the father of the baby is positive, your body may make antibodies against the baby's blood cells. If this occurs without treatment, the next time you are pregnant, these antibodies will appear again and harm that baby. If this is discovered during the first pregnancy and treatment with an injection called RhoGAM is given, this prevents the antibodies from forming.
• A blood count is routinely obtained to have an estimate of how much bleeding has already occurred.
• The bhCG level is a measure of the volume of living tissue associated with the developing pregnancy. Both ectopic and intrauterine pregnancies (IUP) produce bhCG, although there is usually a difference in the rate at which the quantitative bhCG level increases. Although a single value of bhCG isn't useful for differentiating between a normal or abnormal pregnancy or an ectopic pregnancy, a variation in the expected rate of rise of the bhCG level can be helpful. The real value of the quantitative bhCG for diagnosis of ectopic pregnancy is when it is used in correlation with the results of a pelvic ultrasound.

Ultrasound: Ultrasound can often determine if the fetus is healthy and growing inside the uterus. Ultrasound is a form of imaging using sound waves, not X-rays. It is a test that is often able to identify a pregnancy and estimate the age of the fetus. However, a pregnancy may be too early to be seen on ultrasound.

• Ultrasound may be able to identify an ectopic pregnancy growing outside of the uterus. It also may be used to look for blood in the pelvis, a very serious complication that can occur when the ectopic pregnancy has ruptured the Fallopian tube.
• Late in pregnancy, placenta previa is diagnosed almost exclusively by abdominal ultrasound, which can detect it 95% of the time.
• Placental abruption is diagnosed by excluding other causes. It often cannot be confirmed until after delivery when the placenta is found to have a blood clot attached to it. An ultrasound is performed to make certain that the bleeding is not from a placenta previa. Ultrasound at best is only able to detect about half of placental abruptions.
• Fetal bleeding can be distinguished from maternal bleeding by performing a special test on the blood present in the vagina. Also, a special type of ultrasound (Doppler) may be used to see the blood flow within the blood vessels.
• Lower genital tract problems can easily be diagnosed with a speculum examination. It is important that an ultrasound rule out placenta previa prior to any vaginal exam.

Ectopic pregnancy: If you have been diagnosed with an ectopic pregnancy by ultrasound, you may be given medication or taken into surgery.

• Medical management is with methotrexate (Rheumatrex, Trexall), a drug that kills rapidly developing tissue.
• Surgery is reserved for those women who do not meet certain criteria for receiving medical treatment with methotrexate, and for those who are too sick to wait for the methotrexate to work. Also, if you choose not to have methotrexate therapy, then surgery would be the only other option. Surgery is usually a laparoscopic procedure (small incisions in your abdomen for tiny instruments) into the Fallopian tube and removal of the ectopic pregnancy, while attempting to save as much of the tube as possible. This may not be possible; however, if there has been much damage to the tube by the ectopic pregnancy itself or from significant bleeding.

Threatened miscarriage: If you are diagnosed with a threatened miscarriage, your health care practitioner will give you instructions about activities, what to watch for, and when to return for follow-up. Home care for threatened miscarriages includes resting until any pain or bleeding stops. Avoid sexual intercourse for 3 weeks. You should not douche or use tampons.

Incomplete/inevitable abortion: You will be admitted to the hospital for a procedure to remove any remaining fetal tissue in your uterus. This is called dilation and curettage (uterine evacuation or D&C) to prevent any further complications such as hemorrhage or infection.

Missed abortion: In this case, you may either be admitted to the hospital for a D&C or monitored at home with the possibility of passing the tissue without surgery. This decision is made by you and your doctor after a discussion of the risks and benefits of both choices. The age and size of the fetus may be important when deciding which course of action to pursue.

Complete abortion: You may be sent home after complete passage of fetal tissue is ensured or if an ultrasound shows no remaining tissue.

Molar pregnancy: Immediate D&C is necessary. Follow-up blood B-hCG levels should be obtained to check for chorionic carcinoma (a type of cancer).

Late pregnancy bleeding

With late-pregnancy bleeding, you will be monitored for blood loss and signs of shock. You will receive IV fluids and possibly blood transfusions. Your baby will be monitored closely for signs of distress. Your treatment will be guided by the cause of your bleeding, your condition, and the age of the baby (weeks' gestation).

Placenta Previa

• Cesarean delivery (the baby is delivered surgically) is the preferred route of delivery.
• If you or your baby is in danger from severe bleeding, you will have an emergency Cesarean delivery.
• If you are having contractions, you may get IV medicine to slow them or stop them.
• If your pregnancy is fewer than 36 weeks and your bleeding is not severe, you will be admitted to the hospital for observation, monitoring of your baby's heart rate, and repeated blood counts to check for anemia. You will get a medicine to help your baby's lungs mature. When you are 36 weeks pregnant, the doctor will check your baby's lungs, and, if they are mature, you will have a Cesarean delivery.
• Almost all deliveries will be Cesarean deliveries because of the high risk of severe bleeding and danger to the baby by a vaginal delivery. In very rare cases, when the placenta is next to but not covering the cervix, a vaginal delivery may be attempted.
• Even with a Cesarean delivery, you can lose up to 3 pints of blood.

Placental Abruption

• Vaginal delivery is the preferred delivery. Cesarean delivery is reserved for emergencies.
• If you have massive bleeding and you or your baby are in danger, then an emergency Cesarean delivery will be performed.
• If your baby is more than 36 weeks, you will have a rapid but controlled vaginal delivery. You may be given some IV medication to make your contractions more effective.
• If your pregnancy is fewer than 36 weeks and your bleeding is not severe, you will be admitted to the hospital for observation, monitoring of your baby's heart rate, and repeated blood counts to check for anemia. You will get a medicine to help your baby's lungs mature. When you are 36 weeks pregnant, the doctor will check your baby's lungs, and, if they are mature, you will have a Cesarean delivery.

Uterine Rupture

• If there is a high suspicion for rupture of the uterus, you will have an immediate Cesarean delivery.
• Your uterus may have to be removed.
• If you are stable and want to have more children, the surgeon may be able to repair your uterus.
• You will probably need to have blood transfusions with several units of blood.
• Fetal bleeding is treated by performing an immediate Cesarean delivery.

If you have any complications including bleeding, abdominal pain, or fever, you should return to the doctor for reexamination.

If you have been treated for ectopic pregnancy and have increased pain or any weakness or dizziness, you should call an ambulance or have someone take you to a hospital's emergency department immediately.

• You may be placed on bed rest with instructions to place nothing into the vagina.
• Do not douche, use tampons, or have sexual intercourse until the bleeding stops.
• Follow-up care with your gynecologist should be arranged within 1-2 days.
• Women who have had a molar pregnancy need regular, long-term follow-up and repeat measurements of beta-hCG to ensure that no cancer will develop.

The effects of bleeding during your pregnancy depend on many factors. The cause of the bleeding and whether it is treatable is the most important issue.

Early pregnancy bleeding

The definite rate of miscarriages after vaginal bleeding in early pregnancies are difficult to estimate as a significant percentage of pregnancies miscarriage without any specific symptoms prior to the miscarriage.

• Ectopic pregnancy: For bleeding in early pregnancy caused by ectopic pregnancy, the pregnancy will not survive. If you have such a pregnancy, the possibilities of future ectopic pregnancies depend on the location, timing, and management of the condition. Most women with ectopic pregnancies who had no prior fertility issues later have successful pregnancies (about 70%).
• Threatened abortion: You will have an entirely normal pregnancy and birth 50% of the time. Alternatively, you may progress to have a spontaneous abortion or miscarriage. If you have an ultrasound at the time of your evaluation, which shows a fetus with a heartbeat in the uterus, there is a 75%-90% chance of having a normal pregnancy.
• Complete abortion or miscarriage: For women with recurrent miscarriages, the possibility of having a successful pregnancy is still high. Even after two or more miscarriages, your chances for delivering a child are still high.
• Molar pregnancy: After having a molar pregnancy, the risk of molar pregnancy in a later conception is about 1%. In addition, the overall risk of a certain form of cancer in women who have had a prior molar pregnancy has been estimated at 1,000 times higher than that of women who have not had a molar pregnancy.

Late pregnancy bleeding

Placenta Previa: The risk of maternal death is less than 1%, but other complications, such as massive hemorrhage requiring a blood transfusion or a hysterectomy, can also occur.

• Rarely, the placenta attaches abnormally deep into the uterus. This is called a placenta accreta, increta, or percreta, depending on the depth. Many women who have this condition have such massive bleeding that a hysterectomy (removal of the uterus) is required to save the woman's life.
• Up to 8 of every 100 babies with placenta previa die, usually because of premature delivery and lack of lung maturity. Other problems for the baby include size smaller than expected, birth defects, breathing difficulties, and anemia requiring blood transfusion.

Placental Abruption: The risk of maternal death is low, but major blood loss may require transfusions.

• The risk of death for the baby with placental abruption is about 1 in 500. This accounts for 15% of all newborn deaths.
• If the baby survives, about 15% have neurological and behavioral problems as a result of decreased oxygen to the brain. This occurs because placental blood vessels spasm and reduce the flow of oxygen to the baby before delivery.
• As the placenta separates from the womb, amniotic fluid and some placental tissue may enter the woman's bloodstream and cause a reaction. Her blood may become very thin and not clot well, which worsens the hemorrhage. She may require additional blood products to help her clot.

Uterine Rupture: This is a very dangerous condition for both the woman and the baby.

• The greatest risks to the woman are hemorrhage and shock.
• An increased rate of transfusion occurs with uterine rupture, and 58% of women require more than 5 units of blood transfused.
• The risk of death for the woman is less than 1%. However, if left untreated, the woman will die.
• The risk to the fetus is extremely high. The death rate is about one in three.
• Fetal bleeding is extremely dangerous for the baby. The risk of death for the baby is 50% and is increased to 75% if the membranes rupture (water breaks).

Congenital Bleeding Disorders: The risk of complications for the woman is quite low. The most concerning is hemorrhage. The risk to the infant is very low. The largest risk to the baby, especially if it is a male, is inheritance of the bleeding disorder.

The best way to prevent any complication in pregnancy is to have a good relationship with your health care professional and to maintain close contact throughout your pregnancy. This is especially important if you have had prior pregnancies complicated by third trimester bleeding.

Avoid bleeding in pregnancy by controlling your risk factors, especially the use of tobacco and cocaine. If you have high blood pressure, work closely with your healthcare professional to keep it under control.