Bleeding during the first trimester (first 12 weeks of pregnancy) is fairly common and is usually no cause for alarm. However, in some cases, it can be a sign of something serious and it is important to seek medical attention to ensure that both you and your baby are healthy. Approximately 25% of pregnant women will experience some amount of spotting or bleeding in the first few weeks during pregnancy and among the 25%, half will end up with a miscarriage.
Normal First Trimester Pregnancy
One of the first findings in pregnancy is the presence and elevation of the human chorionic gonadotropin (hCG) hormone which is produced by the placenta after the blastocyst has implanted. The implantation happens at about day 23 of gestation, which is approximately eight days after conception. Home pregnancy test kits can detect very low hCG levels making it possible to diagnose a pregnancy even before a missed period. These hCG levels increases in a predictable way by 80 percent every 2 days the first four to eight weeks of pregnancy. Inadequate or unexpectedly high levels of hCG usually indicate an abnormal pregnancy.
An ultrasound can also be used to detect and confirm the pregnancy. A normal pregnancy in the uterus has a central blastocyst that is surrounded by two rings which are the chorionic villi and decidua. By the sixth week, the yolk sac becomes visible. At the end of the sixth week, the embryo becomes visible allowing it to be measured. This is the best way to date the pregnancy (telling how old it is and estimating when you will be delivering the baby). Once the embryo has grown over 5mm in length, cardiac activity starts. All of these milestones are through the transvaginal ultrasound. If transabdominal ultrasound is used, since it is less sensitive, all the mentioned landmarks can only be seen a week later.
Common Causes of Bleeding in The First Trimester
Some of the possible causes of first trimester bleeding are:
There may be some spotting in the first 6-12 days after conception. It occurs when the blastocyst implants into the uterine lining. There are many women who think of this as a light period and do not realize that they are pregnant. Generally, the bleeding is light and brief, lasting from several hours up to a few days. One of the discriminatory findings is the thickening of the decidua that can be seen through a transvaginal ultrasound.
Miscarriage occurs most frequently in the first trimester. When first trimester bleeding occurs, one of the most dreaded concerns is the possibility of a miscarriage. However, not every case of first trimester bleeding means that a miscarriage will occur. In 90% of cases with first trimester bleeding, as long as a heartbeat can be identified on ultrasound, it is unlikely that a miscarriage will occur. Some of the other signs and symptoms of miscarriage include strong cramps in the lower part of the abdomen and passing of tissue through the vagina. A miscarriage can be confirmed through an ultrasound. Once products of conception (tissue) are passed out coupled with an absence of cardiac activity, it signifies that the miscarriage is inevitable.
An ectopic pregnancy occurs when the implantation of a fertilized embryo occurs outside the uterus. There are several sites of implantation for ectopic pregnancy such as the fallopian tube (commonest) and rectouterine pouch. As the embryo continues to grow, it can cause the fallopian tube to enlarge and burst. This can be life threatening to the woman. While potentially fatal, ectopic pregnancy only occurs in approximately 2% of pregnancies. In the United States, ectopic pregnancy accounts for 6 percent of maternal deaths. Ectopic pregnancy should be suspected if the levels of hCG are higher than usual. If both the hCG levels are high and the gestational sac (embryo) cannot be seen through a transvaginal ultrasound, there is a high possibility of ectopic pregnancy. Ectopic pregnancy an occur when there is blockage in the tube. Early diagnosis is crucial to preventing maternal deaths and preserving fertility.
Also known as gestational trophoblastic disease, this is a rare condition where there is abnormal tissue growth in the uterus instead of a fetus. It can be identified through ultrasound that shows a “snowstorm” appearance. Surgery to remove it should be done as soon as possible along with close follow up as there is risk of metastatic disease (cancerous and has the potential to spread to other parts of the body). Some of the symptoms of molar pregnancy include nausea and vomiting with a uterus that enlarges rapidly.
Sub chorionic hemorrhage
Sub chorionic hemorrhage or sub chorionic hematoma is a common cause of first trimester bleeding. An ultrasound shows an area that is adjacent to the gestational sac and can be mistaken for a twin gestational sac. It is in fact a collection of blood. The outcome of the pregnancy ultimately depends on the size of the hematoma, the gestational age of the fetus, and the mother’s age. The rates of miscarriage are higher if the size of the hematoma is bigger and in mothers who are more advanced in age.
Other causes of 1st trimester bleeding
Some of the other causes of first trimester bleeding are changes in the cervix and infection. When pregnancy occurs, there is extra blood flow directed to the cervix. It therefore has a higher tendency to bleed especially if there is contact with the cervix through intercourse of pap smear. This bleeding is mostly harmless and should not be of any concern. Infection of the cervix, vagina, and/ or contracting a sexually transmitted disease (chlamydia, gonorrhea, herpes, etcetera) can also be a potential cause of first trimester bleeding.
Management of First Trimester Bleedin
One of the most reassuring signs is the detection of cardiac activity on ultrasound as it rules out ectopic pregnancy and is associated with only 2% of pregnancy loss in women who are 35 years or younger. The rates increase to 16% in women above the age of 35 years. In sub chorionic hemorrhage, the likelihood of losing the pregnancy is 9 percent and increases if the mother is older than 35 years old or if the hematoma is big. The outlook in this situation is not positive and continued bleeding is expected with the possibility of miscarriage.
While most miscarriages occur completely without intervention, there are certain cases where the passing of tissue is incomplete. In these cases, dilatation and curettage (removal of leftover tissues of conception) is usually the treatment of choice. However, several studies have proven that misoprostol can be more effective and safer for the mother. Although the findings support that misoprostol is beneficial, it is not approved by the United States Food and Drug Administration to be used for the treatment of miscarriage.
In ectopic pregnancy, an early diagnosis is favorable. The mother is managed through medical and laparoscopic (minimally invasive surgery) management. Expectant (wait and see) management is reserved for those with declining hCG levels as it could mean that the ectopic pregnancy might terminate on its own. Open surgery is for emergency cases where there is tubal rupture and hemoperitoneum (the fallopian tube has ruptured due to the growth of the ectopic pregnancy causing internal bleeding).
For follow up care, there are several issues that must be addressed. Anti D immune globulin is administered to women who have Rhesus negative blood. Contraception is also important as pregnancy should not be attempted until the body has a chance to recuperate. There is no evidence that suggests the ideal interval between miscarriage and attempt at getting pregnant again but if there are future plans of pregnancy, the mother to be should be started on folic acid supplements. The psychological impact due to the loss of pregnancy can be devastating to the couple and grief counseling should be recommended.
How to Stop or Reduce First Trimester Bleeding and What to Do
The methods to stopping or reducing first trimester bleeding depends on the cause of the bleeding. If you experience first trimester bleeding, it is best to seek medical attention with your doctor or nearest emergency center immediately. Once you notice the bleeding, start keeping track of the amount and color of the blood you lose as it can help your doctor with a possible diagnosis. Take note if there are any clots or tissue that are passed out, you may want to collect these to show your doctor. In cases where your doctor has established that it is not serious, get plenty of bed rest and avoid heavy or strenuous work for up to two weeks until the bleeding stops. It is recommended to avoid intercourse, tampons, and douching until your doctor says it is okay. It is also important to stay hydrated to ensure you make up for the volume loss. Should your symptoms worsen or you start experiencing new symptoms (such as cramps, dizziness, fever, etcetera), seek medical attention immediately.