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Unexpected Bleeding During Pregnancy
Understanding this common problem

Many pregnant women visit the doctor because of unexpected bleeding. Fortunately, most of the time it turns out to be no risk to either the mother-to-be or the unborn baby. However, to be sure that all is well, a history and a physical exam (sometimes including special tests) must be done.

Pregnancy is divided into three stages called trimesters. Each trimester is about 13 weeks long, and each carries risks for particular bleeding problems.

First trimester bleeding

In the first trimester, unexpected bleeding is surprisingly common. Up to a quarter of pregnant women may experience bleeding. However, only about 15 per cent of known pregnancies end in miscarriage. At this stage, abdominal cramps with bleeding are much more cause for alarm than bleeding or cramping alone.

The first time bleeding occurs, the doctor will usually do an internal exam. This exam may determine if a miscarriage is going to happen or may rule out ectopic pregnancy or diseases of the cervix as the cause. An ultrasound may be ordered to help diagnose the problem. If no reason for bleeding can be found, the doctor will reassure the woman. Bleeding for no apparent reason in the first trimester is called a threatened miscarriage.

No specific treatment exists for a threatened miscarriage. Bed rest and refraining from sexual intercourse have been suggested. However, research has not shown these to make much difference. Nothing a mother does or does not do is likely to change what is going to happen. Knowing this can help many women who have lost a baby to avoid unnecessary guilt over what more they might have done.

If ultrasound reveals the baby is no longer living but is still inside the uterus, this is called a missed abortion. The woman may be given the option of waiting to see what happens naturally, taking medication to cause the miscarriage to be completed or have a D&C. This is a day hospital procedure used to complete the miscarriage.

About 1.5 per cent of all pregnancies are ectopic. In an ectopic pregnancy, the baby grows outside the uterus. This usually happens in the fallopian tube (tubal pregnancy), but can also happen elsewhere in the pelvis. The expectant mother may bleed from the vagina (birth canal) and feel sudden severe pelvic pain a few weeks after her missed period. Diagnosis can often be made by examination, but sometimes ultrasound or fibre-optic surgery (laparoscopy) is needed. The pregnancy cannot be saved. To prevent the mother from bleeding severely, emergency surgery is done.

Second and third trimester bleeding

Bleeding in the second and third trimester is much less common. It happens in less than five per cent of pregnancies. Most of the time, no cause is known, although problems with the placenta (the baby’s life support system) may be found.

Placenta previa is the medical term given to a placenta attached low in the uterus and too close to or over the top of the cervix (the opening of the uterus into the birth canal). This condition affects about one in 250 pregnancies and has risks for both mother and baby. While very common in the second trimester, 95 per cent of cases correct themselves by the end of the pregnancy. It may help to know that, of such placentas found by ultrasound, only five per cent are still low by the time of birth. The placenta seems to move up and out of the way as the uterus grows. As a result, at this stage a low-lying placenta with no bleeding problems is not a cause for alarm!

If placenta previa does cause a problem, it usually begins with painless, bright red bleeding from the vagina in the third trimester. Diagnosis is made after a physical exam and ultrasound. Bleeding caused by placenta previa is usually treated in hospital by caesarean section close to the due date.

With placental abruption, the placenta partly or fully detaches from the wall of the uterus. This affects nearly one in 200 pregnancies and usually happens for no known reason. It may be associated with cigarette smoking, cocaine use, or a blow to the abdomen.

Symptoms may begin with cramping and painful bleeding from the vagina. The bleeding may be dark because it usually has been concealed behind the placenta for some time. Placental abruption is diagnosed by an examination and ultrasound.

Treatment varies. It depends on how gravely ill mother or child appear to be, and how close the pregnancy is to the due date. Delivery through the vagina is preferred, but a caesarean section may be done if the baby is at risk or if severe bleeding occurs.

Other causes of bleeding in the second and third trimesters are quite rare. These include erosions of the cervix, dilated veins of the vagina, premature labour and normal changes to the cervix late in pregnancy.

Can bleeding during pregnancy be prevented?

A mother-to-be can help herself have the healthiest pregnancy possible by eating a balanced diet. She should consider taking a supplement with the vitamin folate. She can also avoid smoking, illicit drugs, drinking and injury to her abdomen. Regular prenatal visits with her doctor are important including at least one routine ultrasound examination to determine the position of the placenta. A pregnant woman should wear a seat belt in the car and the lap belt should be low on her hips.

Considering these measures before becoming pregnant will give the most benefit. Most other factors that place women at higher risk of bleeding cannot currently be changed.

Bleeding in pregnancy is a common and distressing problem affecting a quarter of all pregnancies. Fortunately, for most there are no long term consequences. However, for some women, a stay in hospital or even loss of the pregnancy may result.

If you are bleeding in pregnancy, see your doctor. If your pregnancy does not end successfully, you may feel sad and angry. These feelings are very natural. Sit down with your doctor and ask the questions that are troubling you. Often, understanding what happened can help you deal with your feelings. Talk with your spouse or a trusted friend. You may be able to ease the pain and sort out your feelings by putting them into words.