Bleeding in early pregnancy

Bleeding in early pregnancy is very distressing but it does not always mean that you are having a miscarriage. Miscarriage occurs in 10 to 20% of clinical pregnancies.

When your pregnancy progresses after bleeding it does not affect your baby.

If the bleeding is caused by a miscarriage, no treatment or therapy can stop the miscarriage from occurring.

Despite this, it is very important to be seen by a health professional because:

• You may require blood tests. Treatment for some blood groups is required.
• You may need urgent care if your bleeding is very heavy and you have cramps and pain.
• There may be an ectopic pregnancy, which is when the pregnancy is growing outside the uterus, often in the fallopian tube. This should be suspected when you have pain and bleeding in early pregnancy and is a serious condition which means you should see your doctor immediately or go to an emergency department (ED). Only around 1% of pregnancies are ectopic. If you have bleeding and pain it needs to be excluded.

Other causes for early bleeding

Often the cause for the bleeding is not found and the pregnancy will continue normally.

Bleeding can occur at implantation (when the fertilized egg attaches to the uterus wall) and evidence of this may be found at ultrasound.

Causes not immediately related to the pregnancy can also lead to bleeding such as benign polyps and problems of the cervix.

Generally, if the bleeding stops and the ultrasound of the foetus is normal no further tests are required. Ongoing bleeding may require further examinations and tests.

What will happen in the ED?

You will be assessed when you arrive in the ED and your pulse and blood pressure will be taken. You must tell the clinicians you see about what you know of your pregnancy and your symptoms, such as pain and how much bleeding you have had.

What tests are offered will depend a lot on the age of your pregnancy and your symptoms but some or all of the following tests may be done.

This can be a very distressing time for any woman and her family, therefore it is important to have support and talk about your concerns with your loved ones. If you are in the department by yourself and feel overwhelmed talk to the staff in the ED who can help.

Tests which may be done

Internal examination

This may be useful in some circumstances to check for:

• visible causes for bleeding.
• obvious cause for pain (such as a clot in the cervix).
• to assess size of uterus against known gestational age by dates.

Blood tests

Blood tests are done to measure if the pregnancy hormone (HCG) level is appropriate for your stage of pregnancy (based on the time of your last period). Often the test has to be repeated in a few days to check whether the hormone levels are rising normally.

Ultrasound

The ultrasound scan is useful most often after about six weeks. First, it tells us if the pregnancy is in the uterus and not ectopic which can be a serious problem. The baby’s heart can usually be seen from around six weeks when a vaginal probe is used. This does the baby no harm. The vaginal probe is put inside the vagina, which feels similar to an internal examination, as it gives a better view than using it on the abdomen.

You may also need a blood test to check your blood group. If you know your blood group then tell clinical staff.

Urine test

Urinary infections are common in pregnancy and can cause traces of blood in the urine.

After the tests what might happen?

Initially, the most important aspect of your emergency care will be based around ensuring you are safe and stable and that your pain is under control if you have any.

Your follow up care depends a lot on your particular circumstances.

When the pregnancy is thought still viable:

• If your tests are normal or inconclusive and bleeding has stopped or is minimal then no treatment or changes to normal daily activities are required, with the exception of avoiding strenuous activity.
• It is advised not to use tampons during or after a miscarriage or threatened miscarriage because of a small risk of infection.
• It is OK to have sex if you feel comfortable. Having sex after an episode of bleeding or pain has not been shown to increase the risk of miscarriage.

When a complete or incomplete miscarriage is diagnosed:

• If you have had a complete or incomplete miscarriage your doctor or nurse will advise you on the options you have. You will be provided with information to enable you to make an informed decision.

Referred to EPAS?

• Dedicated outpatient early pregnancy assessment services (EPAS) operate in most larger and medium sized NSW hospitals. You are usually seen in the next one-two days.

When you should see a doctor or go to an ED

Whatever your circumstances, you must be prepared for things to change. Heavy bleeding and crampy pain make it likely you are having a miscarriage. Go to your ED when:

• bleeding gets heavy (two pads soaked per hour and/or large clots, 50ȼ piece size)
• severe or crampy abdominal pain particularly if widespread and in your shoulders
• you feel generally unwell and have a fever or are shaking (chills)
• you feel faint or dizzy
• an offensive vaginal discharge is present.

Your distress is important

Pregnancy and problems of pregnancy can make you feel very distressed and this is normal.

Bleeding may be the first indication of a pregnancy and you will have to deal with both the news of the pregnancy and the potential loss. These are complex thoughts and feelings and you should ask for and be offered emotional and psychological support.

If you have concerns after you leave the ED then ask your general practitioner to refer you to help.

Seeking help

In a medical emergency call an ambulance – dial triple zero (000). If you have any concerns, see your local doctor or healthcare professional. If this is not possible return to the emergency department or urgent care centre.

For more information

Ask your local doctor or healthcare professional. You can also call healthdirect 24 hours a day on 1800 022 222 or visit healthdirect.gov.au.