About one out of three pregnant women will experience some vaginal bleeding in the 1st three months of their pregnancy.  In virtually all cases, this raises alarm over the possibility of a miscarriage. And when bleeding occurs in women who have conceived following infertility treatment, the alarm often turns into panic. In most such cases, the bleeding soon stops and the pregnancy proceeds without incident to the birth of a healthy baby.

Some cases of bleeding do unfortunately end in miscarriage, and usually only time will tell how things will ultimately resolve. When we see these early signs of potential miscarriage, we use the term “threatened miscarriage” to describe the status. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty.” An “incomplete miscarriage” refers to cases where some products are retained in the uterus.

Causes of Bleeding in Early Pregnancy

Mild painless vaginal bleeding (often referred to as “spotting”) is usually due to hormonally induced eversion of the glandular cells that line the inner cervical canal, such that erosion develops on the outer part of the cervix that protrudes onto the vagina. The everted glandular tissue is fragile and susceptible to contact trauma, brought about sexual penetration or the insertion of vaginal suppositories. Since such local bleeding does not involve the developing conceptus located inside the uterus, it is almost always innocuous.

The diagnosis of a local cause of bleeding requires visual inspection of the vagina and cervical inlet via speculum examination. Thereupon, provided that the pregnancy has advanced beyond 5-6 weeks, a sonogram can confirm the presence of an unaffected pregnancy. Patients are advised to be more careful in inserting vaginal suppositories and to avoid sexual penetration until the bleeding has stopped for at least 1 week.

Sometimes bleeding occurs behind the conceptus inside the uterus (retrochorionic bleeding). Some blood will usually track down through the cervix and into the vagina. A speculum examination will often reveal blood tracking into the vagina through the cervical canal and a sonogram will reveal the presence of a retrochorionic blood clot. Although such bleeding can in some cases progress to an inevitable miscarriage, it often abates, and over time, the blood clot in the uterus absorbs and the pregnancy continues normally. Treatment involves careful observation, avoidance of aspirin and other non steroidal anti-inflammatory medications (NSAIDs), bed rest, and avoidance of vaginal penetration until the condition stabilizes.

While mild painless vaginal bleeding is usually innocuous, bright red bleeding that increases in amount and is accompanied by escalating pain is another matter altogether. It often suggests an impending miscarriage.

Before the 7th week of pregnancy a normally rising blood hCG (pregnancy hormone) titer is a comforting indicator that the pregnancy is more than likely progressing normally. Likewise, the detection of a normal heartbeat by ultrasound examination done after the 7th week of pregnancy is a very reassuring finding. However, even these indicators don’t exclude the possibility of an inevitable miscarriage.

The causes of a miscarriage are multiple and diverse. However in most cases it is due to the developing conceptus being chromosomally/genetically abnormal. However, early miscarriages that recur more than twice in a row (Recurrent Pregnancy Loss [RPL]) often suggest of an underlying implantation problem that could be due to a poorly developed uterine lining (endometrium) or immunologic dysfunction involving activated immune cells known as uterine natural killer (NK) and/or T-cells. Treatment requires an accurate diagnosis of the cause and selective therapy.

Indicators of an Ectopic Pregnancy

Bleeding in the first 2-3 months of pregnancy, especially if associated with the sudden onset of acute abdominal pain that is aggravated by movement and is accompanied by right shoulder tip pain, light headedness, or fainting could point to a bleeding ectopic pregnancy (one that is located in a Fallopian tube, outside the uterus) . The condition can be life endangering and warrants an immediate trip to the hospital as it often requires emergency surgery.

Patients with a vaginal bleeding are often told to stay in bed. While this might reduce visible blood loss, there is no tangible evidence that it will prevent a miscarriage. Unfortunately, there is no definite treatment for this kind of bleeding in the early stages of pregnancy. Alas, in most cases only time will provide the answer.