This pamphlet tells you about:

The causes of bleeding Signs of problems What can be done

Early Pregnancy

Many women have vaginal spotting or bleeding in the first 12 weeks of pregnancy. If you are bleeding in early pregnancy, your doctor may do a pelvic exam. A blood test may be done to measure human chorionic gonadotropin (hCG). It is a substance produced during pregnancy. You may have more than one test because hCG levels increase as the pregnancy progresses.

Ultrasound may be used to find the cause of the bleeding. Sometimes the cause is not found.

If you have bleeding during pregnancy, you may need special care. You have a higher chance of going into labor too early (preterm labor) or having an infant who is born too small.

Miscarriage

Bleeding doesn't mean that miscarriage is certain, but it can occur. About half of the women who bleed do not have miscarriages. If there is a problem with the pregnancy, fetal death usually results in the passage of tissue, and the pregnancy ends.

Miscarriage can occur at any time during the first half of pregnancy. Most occur during the first 12 weeks. Miscarriage occurs in about 15-20% of pregnancies.

Signs of miscarriage include:

• Vaginal bleeding
• Cramping pain felt low in the stomach (often stronger than menstrual cramps)
• Tissue passing through the vagina

Many women who have vaginal bleeding have little or no cramping. Sometimes the bleeding stops and pregnancy goes on. At other times the bleeding and cramping may become stronger. Then miscarriage occurs.

If you think you have passed fetal tissue, take it to the doctor's office so it can be examined. If some tissue stays in the uterus, bleeding often continues. The tissue that remains may be removed by a procedure called dilation and curettage (D&C). The tissue also may be removed by a suctioning device. This is called suction curettage.

Most miscarriages cannot be prevented. They are often the body's way of dealing with a pregnancy that was not normal. There is no proof that exercise or sex causes miscarriage. Having a miscarriage doesn't always mean that you can't have more children or that something is wrong with your health. If you have two or three miscarriages in a row, your doctor may suggest that some tests be done to look for a cause.

Ectopic Pregnancy

Another problem that may cause pain and bleeding in early pregnancy is ectopic pregnancy. If pregnancy occurs in a fallopian tube, it may burst. There may be internal bleeding also. Blood loss may cause weakness, fainting, or even shock. A ruptured ectopic pregnancy needs prompt treatment.

Ectopic pregnancies are much less common than miscarriages. They occur in about 1 in 60 pregnancies. Women are at a higher risk if they have had:

• An infection in the tubes (such as pelvic inflammatory disease)
• A previous ectopic pregnancy
• Previous tubal surgery

Molar Pregnancy

A rare cause of early bleeding is molar pregnancy. It is also called gestational trophoblastic disease (GTD) or simply a "mole." It is the growth of abnormal tissue instead of an embryo. A molar pregnancy may require treatment with suction curettage or with drugs.

Late Pregnancy

The causes of bleeding in the second half of pregnancy differ from those in early pregnancy. Common conditions that cause minor bleeding include an inflamed cervix or growths on the cervix.

Late bleeding may pose a threat to the health of the woman or the fetus. It may require treatment in a hospital. Heavy vaginal bleeding usually involves a problem with the placenta. The two most common causes of bleeding in late pregnancy are placental abruption and placenta previa. Preterm labor can also cause vaginal bleeding.

Placental Abruption

The placenta may detach from the uterine wall before or during labor. This may cause vaginal bleeding. Only 1% of pregnant women have this problem. It usually occurs during the last 12 weeks of pregnancy. Stomach pain often occurs, even if there is no obvious bleeding.

When the placenta becomes detached, the fetus may get less oxygen. This can pose a danger to the fetus.

Those at high risk include women who:

• Have already had children
• Are over 35
• Have had abruption before
• Have sickle cell anemia

Placental abruption has been linked to:

• High blood pressure
• Blows or other injuries to the stomach
• Cocaine use
• Smoking

Placenta Previa

When the placenta lies low in the uterus, it may partly or completely cover the cervix. This is called placenta previa. It may cause vaginal bleeding. Placenta previa is serious and requires prompt care.

Placenta previa occurs in 1 woman in 200. It is more common in women who have had more than one child, who have had a cesarean birth or other surgery on the uterus, or who are carrying twins or triplets. Bleeding often occurs without pain.

Labor

Late in pregnancy, vaginal bleeding may be a sign of labor. A plug that covers the opening of the uterus during pregnancy is passed just before or at the start of labor. A small amount of mucus and blood is passed from the cervix. This is called "bloody show." It is common. It is not a problem if it happens within a few weeks of your due date. If it happens earlier, you may be going into preterm labor. You should talk to your doctor right away.

Other signs of preterm labor include:

• Vaginal discharge
  • Change in type (watery, mucus, or bloody)
  • Increase in amount
• Pelvic or lower abdominal pressure
• Low, dull backache
• Stomach cramps, with or without diarrhea
• Regular contractions or uterine tightening

Taking Action

Call your doctor if you have bleeding in late pregnancy. You may need to be admitted to the hospital to find its cause. Ultrasound may be advised. You may have to stay in the hospital for a few weeks. A blood transfusion may be required.

Conditions that cause bleeding in late pregnancy pose a risk to both mother and fetus. They may be serious enough to require early delivery of the baby, sometimes by cesarean birth.

Finally...

Many women with bleeding in pregnancy have minor conditions that need no treatment. At other times, bleeding can be a sign of a serious problem. Bleeding anytime in pregnancy—early or late—should be reported to your doctor. The health of you and your baby may depend on getting prompt treatment.

Glossary

Cesarean Birth: Delivery of a baby through an incision made in the mother's abdomen and uterus.

Dilation and Curettage (D&C): A procedure in which the cervix is dilated and tissue is gently scraped or suctioned from the inside of the uterus.

Ectopic Pregnancy: A pregnancy in which the fertilized egg begins to grow in a place other than inside the uterus (usually in the fallopian tubes).

Human Chorionic Gonadotropin (hCG): A hormone produced during pregnancy. Its detection is the basis for most pregnancy tests.

Miscarriage: The loss of a pregnancy before the fetus can survive outside the uterus.

Placenta: Tissue that connects mother and fetus and provides nourishment to and takes waste away from the fetus.