Bleeding During Pregnancy: Causes and Treatment

Overview of Vaginal bleeding during pregnancy

Bleeding and spotting during pregnancy are one of the most common conditions seen in pregnant women. Approximately 1 out of 4 women experience bleeding or spotting during pregnancy. A female experiencing bleeding or spotting does not mean she is having signs of miscarriage or any other complications. There are various causes of bleeding during pregnancy.

Causes of vaginal bleeding during pregnancy

There are various causes of vaginal bleeding during pregnancy. Based on the trimester during which vaginal bleeding has occurred and the exact cause of the bleeding, the gynecologist can tell the severity of the condition. The causes of vaginal bleeding during pregnancy are:

• Vaginal bleeding during the first trimester
  • Ectopic pregnancy: During this condition, the fertilized egg implants and grows outside the uterus, resulting in severe bleeding, pain abdomen, and miscarriage of the fetus. It can cause serious complications including death if left untreated.
  • Miscarriage: The chances of having a miscarriage are high during the first trimester (first 12 weeks of pregnancy).
  • Implantation bleeding: It occurs 10-14 days after conception when the fertilized egg implants in the lining of the uterus. Most of the females do not realize they are pregnant because they mistake vaginal bleeding for a light menstrual period. Usually, the bleeding is very minimal and will last for a few hours to a few days.
  • Cervical infections, inflamed cervix, or growth outside the cervix.
  • Molar pregnancy: It is also called gestational trophoblastic disease. During this condition, an abnormally fertilized egg implants into the abnormal tissue resulting in causing bleeding PV (per vaginal).
  • Cervical polyps: They are the non-cancerous growth on the cervix, which bleeds during pregnancy due to the high estrogen levels.
• During the second and third trimesters
  • Cervical incompetency: During this condition, the premature opening of the cervix will result in causing a preterm baby.
  • Preterm labor: During this condition, the child is delivered early before the completion of gestation, resulting in dull backache, an increase in pelvic pressure, and vaginal bleeding due to pelvic contractions.
  • Miscarriage: The chances of miscarriage are usually high during the first 12 weeks of pregnancy. However, the chances of marriage during the second and third trimesters are possible.  
  • Placenta previa: A condition where the placenta covers the cervix resulting in causing severe vaginal bleeding. However, placenta previa occurrence is very rare in the late third trimester, occurring in only 1 in 200 pregnancies.  A bleeding placenta previa, which is painless is usually an emergency condition, which must be treated immediately.
  • Placenta abruption: A condition where the placenta supplies oxygen and nutrients to the fetus and separates itself from the wall of the uterus. The incidence is about 1% in pregnant females. Placenta abruption is a critical condition where the mother and the child both are in danger if not treated immediately.  It is a very rare and life-threatening condition where the uterus tears open along the scar line from a previous c-section.
  • Preterm labor: The vaginal bleeding during the end of pregnancy is an indication of the delivery of the baby. A few days or weeks before labor begins, the mucus plug that covers the opening of the uterus will pass out of the vagina, and it will usually have a small quantity of blood which is called a “bloody show.” If these signs are seen before 37 weeks of pregnancy, then it is termed preterm labor.
• Normal vaginal bleeding at the end of delivery: Vaginal bleeding during the end of the pregnancy is an indication of the delivery of the baby. A bloody show is often a sign that the body is preparing for labor.
• Injuries to the genital tract: Any injuries to the genital tract due to trauma can cause vaginal bleeding during pregnancy.
• Varicose veins in the vulva and vagina
• Subchorionic hematoma: Subchorionic hematoma is usually a self-resolving condition, where the bleeding from one of the membranes that surround the embryo inside the uterus.

Women who are at high risk for bleeding during pregnancy

The women who are at high risk for bleeding during pregnancy are listed below:

• Women who are pregnant at the age of 35 years and above
• History of miscarriage
• History of placenta previa, placenta abruption
• Women diagnosed with sickle cell anemia
• Trauma or injury to the abdomen
• Women who had a history of cocaine abuse
• Women who have undergone uterine surgeries or c-sections in the past.

Signs and symptoms associated with bleeding during pregnancy

The signs and symptoms that may be associated with bleeding during pregnancy are listed below:

• Cramping and severe abdominal pain
• Vomiting
• Discharge of fluid or tissue from the vagina
• Absence of fetal heart sound
• Low or dull backache
• Fever associated with chills
• Dizziness

Diagnosis of bleeding during pregnancy

Whenever the pregnant female notices any of the above-mentioned symptoms associated with bleeding per vagina. The patient should consult the doctor immediately. The doctor initially will examine the patient thoroughly to look for any signs of abnormalities ( advise the patient on a couple of tests which include):

• The history of the patient should be evaluated

  • Any history of trauma?
  • History of medications that are taken by the patient which include blood thinners, etc
  • History of sexual intercourse followed by vaginal bleeding during pregnancy
  • History of drug abuse or tobacco intake
  • History of bleeding disorders, or liver problems
  • Previous history of miscarriage, or any other abnormalities detected during pregnancy
• Physical examination:During the physical examination, the doctor will palpate the abdomen to look for any tenderness in the abdomen (pain), check the size of the uterus, and check the fetal heart of the patient.
• Pelvic examination
• Laboratory tests:They include complete blood count, urine pregnancy test, urinalysis done to check if there is urinary tract infection, serum quantitative bhCG (blood hormone maker of pregnancy)
• Ultrasound examination of the abdomen and pelvis: Ultrasound examination of the abdomen and pelvis includes ultrasonography of the abdomen, to check if the fetus is healthy or not, and diagnose ectopic pregnancy, placenta abruption, and placenta previa.
• Speculum examination: It will help in diagnosing abnormalities in the lower genital tract

Treatment for vaginal bleeding during pregnancy

Depends on the diagnosis and underlying condition and severity. The treatment options advised for bleeding during pregnancy are:

• Complete bed rest
• Avoid sex during pregnancy
• Avoid traveling and avoid lifting heavy objects
• Medications if required
• Iv fluids and blood transfusion in case of severe blood loss
• Hospitalization and surgery in case of severe vaginal bleeding

Prevention for vaginal bleeding during pregnancy

• Although vaginal bleeding during pregnancy cannot be prevented completely, however, there are a few risk factors that can minimize the risk of causing vaginal bleeding during pregnancy. They are listed below:
• Avoid lifting heavy objects during pregnancy
• Avoid taking drugs or tobacco intake
• Control high blood pressure during pregnancy
• Avoid doing heavy workouts during pregnancy
• Avoid smoking 
• Avoid sexual intercourse in the first trimester 

Complications associated with vaginal bleeding

The complications associated with vaginal bleeding during pregnancy if left untreated, are:

• Fetal death
• Severe bleeding causing anemia
• Sepsis
• Shock in case of ectopic pregnancy
• Life-threatening complications including death

What is the difference between vaginal spotting and vaginal bleeding during pregnancy?

Spotting (light bleeding) is a condition where there are only a few drops of blood seen on the panty, whereas vaginal bleeding is a condition where the blood flow is heavier. Spotting is often brownish or pink in color, whereas bleeding is usually bright red in color.

FAQs

1) What are the causes of bleeding during early pregnancy?
A) Almost 20% of the females experience a minimal amount of vaginal bleeding during their early pregnancy (first 12 weeks of gestation). The causes of vaginal bleeding during early pregnancy are listed below:

• Implantation bleeding- women who have undergone implantation might experience vaginal bleeding during the first 6 to 12 days after they conceive, since the fertilized egg implants itself in the lining of the uterus.
• During sexual intercourse- a few females might complain of a small amount of vaginal bleeding during or after intercourse.
• Miscarriage- it is one of the most common causes of vaginal bleeding during the first 12 weeks of gestation and tends to be one of the biggest concerns with early pregnancy bleeding.
• Molar pregnancy- is also known as gestational trophoblastic disease. It is a very rare condition, during which abnormal tissue grows inside the uterus instead of fetus growth. In very cases, this abnormal tissue can become cancerous and can spread to other parts of the body.
• Ectopic pregnancy- it accounts for about 2% of all pregnant females. During this condition, the fertilized embryo implants outside the uterus, most commonly in the fallopian tube, resulting in causing severe pain in the abdomen, vomiting, and vaginal bleeding. It is one of the most dangerous conditions which will result in causing life-threatening complications including death if left untreated.
• Cervix or vaginal infections such as gonorrhea, chlamydia, etc can cause vaginal bleeding during early pregnancy.
• Cervical changes during pregnancy- during pregnancy, there is an extra amount of blood flow into the cervix, which will result in causing bleeding during sexual intercourse or during a pap smear test.

2) Define ectopic pregnancy
A) Ectopic pregnancy is also known as extrauterine pregnancy. During this pregnancy, the fertilized egg grows outside the uterus. An ectopic pregnancy most often occurs in the fallopian tube (a tube that carries eggs from the ovaries to the uterus). Ectopic pregnancy can occur in other parts of the body which include- the ovary, abdominal cavity, or the lower part of the uterus (cervix), which connects the vagina.

3) Define miscarriage
A) Miscarriage is the spontaneous loss of pregnancy before 20 weeks of gestation. It accounts for about 10-20% of females having miscarriages during their pregnancy. The most common cause of miscarriage during the first trimester is due to malformation of the development of the fetus.

4) What are the complications and loss of blood during the first trimester?
A) The complications and loss of blood during the first trimester are listed below:

• Severe bleeding will result in causing anemia
• Sepsis in case of retained part of the fetus inside the uterus during miscarriage
• Shock in case of ectopic pregnancy if left untreated
• Death of the mother and fetus in a few cases

5) What are the complications and loss of blood during the second and third trimesters?
A) The complications and loss of blood during the second and third trimesters are:

• Premature delivery of the fetus
• Premature delivery of the fetus with undeveloped lungs or surfactant deficiency
• Severe anemia
• Infection
• Severe pain abdomen

6) How common is bleeding during early pregnancy?
A) Bleeding during early pregnancy (first 12 weeks of gestation) accounts for about 15-25 in 100 pregnancies.

7) Does bleeding during pregnancy always indicates that there is a problem?
A) There are several causes for which vaginal bleeding can be seen during pregnancy. The outcome of this condition depends upon the cause of vaginal bleeding. Some are serious, while others are not. Vaginal bleeding during pregnancy can occur during early or late pregnancy stages. However, one should consult the OBG doctor immediately whenever they notice any kind of abnormal discharge from the vagina.

8) How to prevent miscarriage?
A) Although miscarriage cannot be prevented completely, there are a few steps that will help in minimizing the risk of causing miscarriage. They are listed below:

• Avoid lifting heavy objects during pregnancy

• Stop smoking and drinking alcohol

• Eating a healthy balanced diet

• Avoid getting certain infections such as rubella, trichomonas, chlamydia, etc.

• Avoid drug abuse

• Maintain a healthy weight during pregnancy

• Have a regular follow-ups with the doctor and follow the instructions suggested by the doctor

• Avoid certain food items that will harm the mother and the fetus.

• Keep blood pressure, sugars, and thyroid under control. 

References

1. https://www.marchofdimes.org/find-support/topics/pregnancy/bleeding-and-spotting-vagina-during-pregnancy

2. https://www.mayoclinic.org/symptoms/bleeding-during-pregnancy/basics/causes/sym-20050636

3. https://americanpregnancy.org/healthy-pregnancy/pregnancy-complications/bleeding-during-pregnancy/

4. https://www.emedicinehealth.com/pregnancy_bleeding/article_em.htm

5. https://my.clevelandclinic.org/health/symptoms/22044-bleeding-during-pregnancy

6. https://www.emedicinehealth.com/pregnancy_bleeding/article_em.htm