What does first trimester bleeding mean?
Vaginal bleeding in early pregnancy is not uncommon but should always be taken seriously. Miscarriage is possible and this is known as a threatened abortion. It is important to differentiate abnormal vaginal bleeding from an implantation bleed which is normal. An implantation bleed occurs anywhere between 1 to 2 weeks after conception. It occurs when the fertilized egg attaches to the lining of the uterus.
Although many women mistaken this implantation bleed for a period, it is not the same. Menstruation does not occur in pregnancy. An implantation bleed is normal but may not be seen in every pregnancy. In fact only about 1 in 4 women notice an implantation bleed. Any other vaginal bleeding in pregnancy is abnormal and needs to be investigated immediately as the pregnancy may be at risk.
How is first trimester bleeding treated?
The first step is for the pregnant woman to be assessed by a medical professional, preferably a gynecologist-obstetrician (OBGYN). Prompt evaluation is necessary because it can pregnancy-related bleeding can lead to shock if the bleeding is profuse and excessive. Initially the evaluation will commence with a case history and physical examination (including a pelvic examination). This will be followed by laboratory tests and ultrasonography.
What does your doctor want to know?
The case history is a very important first step in evaluating any condition. It is imperative that accurate and correct information is given to the practitioner. Some of the points that a doctor will want to know about first trimester vaginal bleeding may include:
- When did the bleeding start?
- Is the bleeding continuous or intermittent?
- How much of blood is being lost based on the number of soaked pads?
- Are there any clots or pieces of tissue in the blood which could be the products of conception?
- Is there any pain with the bleeding?
Apart from pain, the presence of other symptoms also needs to be reported. This may include:
- Vaginal discharge.
- Fever and chills.
What will the doctor check?
Vital signs such as temperature (fever), increased pulse rate and low blood pressure will give an indication about blood loss, shock and infection.
- Abdominal examination is done to assess uterine size and evaluation of pain.
- A Doppler ultrasound probe can be used to check for fetal heart sounds.
- Pelvic examination is necessary to assess the amount of bleeding, pelvic pain, identify any products coming out and to check if the os (opening of the cervix) is closed or open (this will determine the type of abortion).
Tests and Scans
- Urine pregnancy test to confirm pregnancy.
- Urinalysis to check for urine infection.
- Blood count, blood grouping and Rh typing. Rh testing will determine if Rho(D) immune globulin will need to be given (if the woman is Rh Negative with an Rh Positive fetus).
- Cross matching of blood is done in case of heavy bleeding where blood transfusion may become necessary.
- Quantitative beta-hCG (beta subunit of human chorionic gonadotropin) measurement, in conjunction with ultrasound results, can help to identify an ectopic pregnancy.
– A beta-hCG level of > 1500 mIU/mL with no intrauterine pregnancy on ultrasonography will point to a diagnosis of ectopic pregnancy.
– If no intrauterine pregnancy is seen on ultrasonography but the beta-hCG level is < 1500 mIU/mL, intrauterine pregnancy may still be possible.
– Serial beta-hCG level (which usually doubles every two days in early pregnancy) may show lower than normal levels in cases of ectopic pregnancy or miscarriage.
- Cervical cultures – where septic abortion is suspected.
– Transvaginal pelvic ultrasonography will determine the state of the pregnancy and fetus.
– Ultrasound can also help to diagnose the type of abortion, ectopic pregnancy, molar pregnancy or a ruptured corpus luteum cyst.
What are the treatment options?
Depending upon the diagnosis, there are several different treatments that may be necessary. This varies on the type of underlying problem that is causing the vaginal bleeding during the first trimester. In all of these cases, there is a risk of a miscarriage. This is also known as a spontaneous abortion and should not be confused with an induced abortion whereby a woman chooses to terminate her pregnancy.
This is where a miscarriage is very likely with the presence of vaginal bleeding in the first trimester. The patient may be managed at home with the appropriate advice and medication.
- Bed rest (till bleeding and pain stops).
- Adequate fluid intake.
- Avoid intercourse (for 3 weeks).
- Tampons should not be used.
- Avoid douching.
- Mild sedatives.
- Drugs containing progesterone (opinion varies regarding benefit of progesterone in threatened abortion).
Incomplete and Inevitable Abortion
This is where a miscarriage has occurred but the products of conception have not bee completely expelled from the uterus. A dilation and curettage (D and C) or a suction curettage will need to be done to ensure that all the products of conception have been removed from the uterus. The drug misoprostol is an alternative to surgical treatment.
This is where a miscarriage has occurred and all the products of conception have been expelled. No treatment may be necessary if expulsion of all the products of conception is confirmed by examination and ultrasound.
This is where a miscarriage has occurred but the products or conception or the fetal remains has not been expelled. Women may not be aware that they have miscarried as there may be no vaginal bleeding. A D&C may be done or the patient sent home and monitored for spontaneous expulsion of the products. Misoprostol may be used as an alternative method.
This is where an infection of the placenta and fetus has compromised the viability of the pregnancy. Intravenous antibiotics is usually necessary. Immediate evacuation of the uterus to remove the infected products.
This is where the cells that form the placenta form an abnormal mass and no embryo or fetus will develop. A D&C is necessary. Follow up is important to test beta-hCG levels at regular intervals and check for choriocarcinoma.
A ruptured ectopic pregnancy is the most dangerous cause of vaginal bleeding in the first trimester of pregnancy and is potentially life-threatening for the mother. An immediate laparoscopy or laparotomy becomes necessary in these cases.
For unruptured ectopic pregnancy :
- Medical therapy – methotrexate.
- Surgery – to remove the ectopic pregnancy and conserve as much of the tube as possible (salpingotomy), especially in women who desire further pregnancies. Removal of the fallopian tube (salpingectomy) may become necessary in some cases. Laparoscopic surgery is preferred but laparotomy may be done.