Bleeding During Pregnancy

 

What is it?

          Vaginal bleeding in pregnancy can range from spotting to profuse bleeding.  Any vaginal bleeding accompanied by abdominal pain is potentially serious and could indicate an impending miscarriage.  Consult this section for evaluation of bleeding, light or heavy, anytime during pregnancy.  This can be a serious problem, especially in the later stages, and should always be reported to your doctor promptly.  This often involves a problem with the placenta (afterbirth).  Normally the placenta is located on the upper portion of the wall of the uterus.  Sometimes, though, the placenta lies very low in the uterus, so that the opening of the uterus is partially or completely covered.  This is called placenta previa, and vaginal bleeding is the most common symptom.

           

 

Causes of Vaginal Bleeding?

	Placenta abruption
	Placenta previa
	Threatened miscarriage or tubal pregnancy
	Vaginal spotting

 

 

Placenta Abruption

            Placenta abruption refers to the premature separation of the placenta from the uterine wall (womb).  The incidence of this complication occurs in less than 1% of all pregnancies in the United States. 

            The cause of abruption is unknown, but has been associated with chronic high blood pressure, preeclampsia (toxemia of pregnancy), diabetes (during pregnancy), and abdominal injuries.  Multiple pregnancies, abnormally short umbilical cord, prior history for abruption, advanced maternal age, and sudden loss of amniotic fluid are considered risk factors for placental abruption.  Smoking and alcohol consumption have also been identified as risk factors.

            Placental abruption is seen in the third trimester of pregnancy (after 25 weeks gestation).  When this problem occurs, it is considered as absolute emergency. 

            Common symptoms include abdominal pain, back pain, and vaginal bleeding in the female that is 25 weeks, or more, into her pregnancy.

            Evaluation will involve immediate assessment of the mother and fetus.  Pregnancy ultrasound has been helpful in the diagnosis of this condition.  A complete blood count will be required in all patients with placental abruption.  Some placental abruptions may be associated with blood clotting abnormalities (DIC), so coagulation studies are often routinely performed.  Serum fibrogen levels may also be measured in some patients.

            Treatment is based on the extent of placental separation.  Most cases result in immediate delivery of the child by cesarean section.  Complications such as DIC and shock, if present, must also be addressed.  An OB-GYN physician is the expert in the treatment of this serious obstetrical complication.

            Maternal death rates in placental abruption are approximately 1%.  Fetal death rates range from 50 to 80%.

 (Picture credit to theMedclip Clinical OB/GYN, 1997)

 

 

 

Placenta Previa

            Placenta previa is one of the most common, serious causes of vaginal bleeding during the third trimester of pregnancy  (over 25 weeks gestation).

            Normally, the fertilized ovum implants itself in the upper portion of the uterus.  If the implantation occurs in a lower position in the uterus (toward the opening of the uterus or the cervix), there exists a possibility of the placenta covering the cervix.  When this occurs, it is referred to as placenta previa.

            Common symptoms include painless, heavy vaginal bleeding in the female who is in the third trimester of pregnancy.  The usual pattern is intermittent bleeding (over a 1-2 week period) that progressively increases.

            Evaluation includes pregnancy ultrasound, which can identify the location of the placenta.

            Treatment usually involves medications that will impede labor if the pregnancy is too early.  These babies are delivered by cesarean section, to avoid the complications of fetal anoxia (low oxygen to the baby during delivery).  The OB-GYN physician is the expert in the treatment of this serious pregnancy complication.

*Placenta previa occurs in approximately 1 of 200 births.  The high-risk group for placenta previa is advanced maternal age and previous cesarean section. (See F.Y.I. below)

 

(Picture credit to the Mayo Clinic, 2001)

 

Tubal Pregnancy

            Tubal pregnancy refers to the abnormal (ectopic) placement of the developing fetus in the fallopian tube, which connects the ovary to the uterus.  Tubal pregnancy becomes a medical problem (symptomatic) between the third and eighth week of gestation, as the fetus reaches a critical size.  Tubal pregnancy, also known as ectopic pregnancy, is an absolute emergency requiring immediate surgical correction.  Maternal death from internal bleeding and hemorrhagic shock is possible without definitive treatment.  Fetal survival is not possible in tubal pregnancy.

            Common symptoms include abrupt onset of one-sided lower abdominal pr pelvic pain.  This may be accompanied by faintness or fainting (particularly upon standing).  Some patients may also have vaginal bleeding.  Any female of reproductive age with lower abdominal pain must have this diagnosis considered.

            Evaluation will include history and physical examination.  Pelvic examination will guide he physician toward the appropriate diagnosis.  Additional studies include pelvic ultrasound.  This test allows the physician to “see” the internal anatomy (and, hopefully, the location of the fetus) using a painless sound wave test.  Blood pregnancy test and blood counts will also be performed.

            For confirmed cases, treatment is surgical.  In some cases, a limited removal of the fetal tissue can be accomplished allowing the fallopian tube to be salvaged.  Other cases may necessitate complete removal of the fallopian tube on that side.

 

 

 (Picture credit to adam.com)

 

 

Vaginal Spotting

          Vaginal spotting is a possibility.  Spotting, or very light vaginal bleeding without pain can be seen approximately in 40% of all pregnancies in the first weeks of development.  Any bleeding accompanied by clots or pain must be evaluated by your doctor immediately.  Persistent spotting should also be evaluated.

 

*Bedrest and avoidance of aspirin are important to reduce spotting.  Discuss this situation with your doctor.

 

 

F.Y.I.

          Many studies have been completed in the last 10 years to try to determine the etiology of bleeding during pregnancy and to establish ways to prevent this daunting occurrence.  Overtime they have concluded that sometimes trauma, such as injuries from an auto accident, or high blood pressure can cause this problem.  In early pregnancy, the most common problems are miscarriage and ectopic pregnancy.  More than one-quarter of all pregnancies end in miscarriage before the 20^th week, with most occurring during the first ten weeks.  A cohort study out of Great Britain was completed in 1997 to estimate the miscarriage rate of pregnant women and the final outcome of pregnancy.  Out of 550 of the women who were studied, 117 experienced bleeding before the 20^th week, which is 21% of the pregnancies.  Out of these 117 bleeding occurrences, 67 ended in miscarriage.  In this study the majority of cases of vaginal bleeding in pregnancy were of unknown origin and were usually slight.  In conclusion of this study, bleeding in pregnancy is associated with an increased perinatal morbidity and mortality.  (Everett, 1997).

            Although one study concluded that there is no positive correlation between cigarette smoking during pregnancy and placenta previa (Ananth, 1996), others estimate that cocaine use plays as a risk factor for the placenta previa.  However placenta abruption is closely associated with cigarette smoking during pregnancy.  A case study was reported from reviewing hospital records and prenatal charts for the ratio of maternal cocaine use and other potential risk factors for placenta previa.  Maternal cocaine use was reported through urine tests or self-report.  The association between cocaine use and placenta previa was studied by controlling for other variables and results showed that cocaine use is an independent risk factor.  Prior cesarean section, prior elective abortion, and multiple births were also associated (Macones, 1997).  In relation, another studied noted a strong correlation between women with a history of spontaneous or induced abortion, or caesarean birth with placenta previa.  The conclusion of this study stated that this is sufficient reasoning to reduce the number of c-sections. (Macones, 1997).

 

·Placenta previa occurs in 1 out of 200 pregnancies.  (Miller, 1997)  

    

·Women who have had a c-section delivery and/or abortion have an increased risk for placenta previa.  (Ananth, 1997)

 

·Increased risk of a separating placenta (abruptio) is associated with smoking and aspirin use late in pregnancy.  These are controllable ways to prevent this occurrence.  (Ananth, 1996)

 

 

     

In Conclusion…

          Many women with bleeding in pregnancy are found to have minor conditions and need no treatment.  At other times, bleeding can be the first sign of a problem.  For this reason, it is very important that bleeding anytime-early or late—be reported to your health care provider.  Your health and the health of the baby depends on getting prompt treatment.