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Symptoms and Signs of Pregnancy, Bleeding

Doctor's Notes on Bleeding During Pregnancy (Light, Heavy) Causes, Symptoms, and Pictures

Vaginal bleeding during the first trimester of pregnancy is fairly common, occurring in up to 20% of pregnancies. In most cases, vaginal bleeding during early pregnancy is not a cause for concern. Implantation bleeding is light bleeding that occurs at the time of implantation of the fertilized egg in the uterine lining. Other causes for early bleeding in pregnancy are changes in the cervix and vaginal infections.

In some cases, vaginal bleeding can be a sign of a serious problem such as impending miscarriage or ectopic pregnancy. Symptoms associated with a miscarriage can include abdominal or back pain. Abdominal or pelvic pain is also a symptom associated with ectopic pregnancy. If a vaginal infection is the cause of bleeding during pregnancy, a vaginal discharge may be present. It is appropriate to seek medical advice any time you experience bleeding during pregnancy.

Medical Author:
Medically Reviewed on 3/11/2019

Bleeding During Pregnancy (Light, Heavy) Causes, Symptoms, and Pictures Symptoms

It is helpful for your health care professional to know the amount and the quality of the bleeding that you have. Keep track of the number of pads used and passage of clots and tissue. If you pass a clump of tissue and are going to see your doctor, bring the tissue with you for examination.

Other symptoms you may experience are increased fatigue, excessive thirst, dizziness, or fainting. Any of these may be signs of significant blood loss. You may notice a fast pulse rate that increases when you stand up from lying down or sitting. Moreover, dizziness may worsen when you stand up.

With late-pregnancy bleeding, you may have these specific symptoms:

  • Placenta previa: About 70% of women have painless bright red blood from the vagina. Another 20% have some cramping with the bleeding, and 10% have no symptoms.
  • Placental abruption: About 80% of women have dark blood or clots from the vagina, but 20% have no external bleeding. More than one-third have a tender uterus. About two-thirds of women with placental abruption have the classic "pain and bleeding." Over half of the time, the baby shows signs of distress. Most abruptions occur before labor begins.
  • Uterine rupture: Symptoms are highly variable. Classic uterine rupture is described as intense abdominal pain, heavy vaginal bleeding, and a "pulling back" from the birth canal of the baby's head. The pain may initially be intense, then get better with rupture, only to worsen as the lining of the abdomen is irritated. Bleeding can range from spotting to severe hemorrhage.
  • Fetal bleeding: This condition may show up as vaginal bleeding. The baby's heart rate on the monitor will first be very fast, then slow, as the baby loses blood.

Bleeding During Pregnancy (Light, Heavy) Causes, Symptoms, and Pictures Causes

Vaginal bleeding in the first trimester of pregnancy can be caused by several different factors. Bleeding affects 20% to 30% of all pregnancies. , and many women wonder how much bleeding during pregnancy is normal. Implantation bleeding is a form of bleeding that takes place when the fertilized egg is implanted in the wall of the uterus, around the time of the expected menstrual period. Implantation bleeding is typically lighter than a usual menstrual period.

Bleeding increases the risk of having a miscarriage (lose the baby). Of even more concern, however, is that about 2% of all pregnancies are ectopic in location (the fetus is not inside the uterus), and vaginal bleeding can be a sign of an ectopic pregnancy. An ectopic pregnancy may be life-threatening. All bleeding, but particularly heavy or period-like bleeding during early pregnancy should prompt a call to your health care professional for immediate evaluation.

  • Implantation bleeding: There can be a small number of spots associated with the normal implantation of the embryo into the uterine wall, called implantation bleeding. This is usually very minimal but frequently occurs on or about the same day as your period was due. This can be very confusing if you mistake it for simply a mild period and don't realize you are pregnant. This is a normal part of pregnancy and no cause for concern.
  • Threatened miscarriage: You may be told you have a threatened miscarriage (sometimes also referred to as threatened abortion) if you are having some bleeding or cramping. The fetus is definitely still inside the uterus (based usually on an exam using ultrasound), but the outcome of your pregnancy is still in question. This may occur if you have an infection, such as a urinary tract infection, become dehydrated, use certain drugs or medications, have been involved in physical trauma, if the developing fetus is abnormal in some way, or for no apparent reason at all. Other than these reasons, threatened miscarriages are generally not caused by things you do, such as heavy lifting, having sex, or by emotional stress.
  • Completed miscarriage: You may have a completed miscarriage (also called a spontaneous abortion) if your bleeding and cramping have slowed down and the uterus appears to be empty based on ultrasound evaluation. This means you have lost the pregnancy. The causes of this are the same as those for a threatened miscarriage. This is the most common cause of first trimester bleeding.
  • Incomplete miscarriage: You may have an incomplete miscarriage (or a miscarriage in progress) if the pelvic exam shows your cervix is open and you are still passing blood, clots, or tissue. The cervix should not remain open for very long. If it does, it indicates the miscarriage is not completed. This may occur if the uterus begins to clamp down before all the tissue has passed, or if there is an infection.
  • Blighted ovum: You may have a blighted ovum (also called embryonic failure). An ultrasound would show evidence of an intrauterine pregnancy, but the embryo has failed to develop as it should in the proper location. This may occur if the fetus were abnormal in some way and not generally due to anything you did or didn't do.
  • Intrauterine fetal demise: You may have an intrauterine fetal demise (also called IUFD, missed abortion, or embryonic demise) if the developing baby dies inside the uterus. This diagnosis would be based on ultrasound results and can occur at any time during pregnancy. This may occur for any of the same reasons a threatened miscarriage occurs during the early stages of pregnancy; however, it is very uncommon for this to occur during the second and third trimesters of pregnancy.
  • Ectopic pregnancy: You may have an ectopic pregnancy (also called tubal pregnancy). This would be based on your medical history and ultrasound and in some cases laboratory results. Bleeding from an ectopic pregnancy is the most dangerous cause of first trimester bleeding. An ectopic pregnancy occurs when the fertilized egg implants outside of the uterus, most often in the Fallopian tube. As the fertilized egg grows, it can rupture the Fallopian tube and cause life-threatening bleeding. Symptoms are often variable and may include pain, bleeding, or lightheadedness. Most ectopic pregnancies will cause pain before the tenth week of pregnancy. The fetus is not going to develop and will die because of lack of supply of nutrients. This condition occurs in about 3% of all pregnancies.
    • There are risk factors for ectopic pregnancy. These include a history of prior ectopic pregnancy, history of the pelvic inflammatory disease, history of Fallopian tube surgery or ligation, history of infertility for more than two years, having an IUD (birth control device placed in the uterus) in place, smoking, or frequent (daily) douching. Only about 50% of women who have an ectopic pregnancy have any risk factors, however.
  • Molar pregnancy: You may have a molar pregnancy (technically called gestational trophoblastic disease). Your ultrasound results may show the presence of abnormal tissue inside the uterus rather than a developing fetus. This is actually a type of tumor that occurs as a result of the hormones of pregnancy and is usually not life-threatening to you. However, in rare cases the abnormal tissue is cancerous. If it is cancerous it can invade the uterine wall and spread throughout the body. The cause of this is generally unknown.
  • Postcoital bleeding is vaginal bleeding after sexual intercourse. It may be normal during pregnancy.
  • Bleeding may also be caused by reasons unrelated to pregnancy. For example, trauma or tears to the vaginal wall may bleed, and some infections may cause bleeding.

The most common cause of late-pregnancy bleeding is a problem with the placenta. Some bleeding can also be due to an abnormal cervix or vagina.

Placenta previa: The placenta, which is a structure that connects the baby to the wall of your womb, can partially or completely cover the cervical opening (the opening of the womb to the vagina). When you bleed because of this, it is called placenta previa. Late in pregnancy as the opening of your womb, called the cervix, thins and dilates (widens) in preparation for labor, some blood vessels of the placenta stretch and rupture. This causes about 20% of third-trimester bleeding and happens in about 1 in 200 pregnancies. Risk factors for placenta previa include these conditions:

  • Multiple pregnancies
  • Prior placenta previa
  • Prior Cesarean delivery

Placental abruption: This condition occurs when a normal placenta separates from the wall of the womb (uterus) prematurely and blood collects between the placenta and the uterus. Such separation occurs in 1 in 200 of all pregnancies. The cause is unknown. Risk factors for placental abruption include these conditions:

  • High blood pressure (140/90 or greater)
  • Trauma (usually a car accident or maternal battering)
  • Cocaine use
  • Tobacco use
  • Abruption in prior pregnancies (you have a 10% risk it will happen again)

Uterine rupture: This is an abnormal splitting open of the uterus, causing the baby to be partially or completely expelled into the abdomen. Uterine rupture is rare, but very dangerous for both mother and baby. About 40% of women who have uterine rupture had prior surgery on their uterus, including Cesarean delivery. The rupture may occur before or during labor or at the time of delivery. Other risk factors for uterine rupture are these conditions:

  • More than four pregnancies
  • Trauma
  • Excessive use of oxytocin (Pitocin), a medicine that helps strengthen contractions
  • A baby in any position other than head down
  • Having the baby's shoulder get caught on the pubic bone during labor
  • Certain types of forceps deliveries

Fetal vessel rupture: The baby's blood vessels from the umbilical cord may attach to the membranes instead of the placenta. The baby's blood vessels pass over the entrance to the birth canal. This is called vasa previa and occurs in 1 in 5,000 pregnancies.

Less common causes of late-pregnancy bleeding include injuries or lesions of the cervix and vagina, including polyps, cancer, and varicose veins.

Inherited bleeding problems, such as hemophilia, are very rare, occurring in 1 in 10,000 women. If you have one of these conditions, such as von Willebrand disease, tell your doctor.

The medical evaluation begins with a thorough history and physical exam. Depending on the setting (medical office or hospital) and the seriousness of your symptoms, laboratory and ultrasound tests may be performed. For bleeding in the early part of pregnancy, the doctor's main goal will be to make sure you don't have an ectopic pregnancy. That is what the evaluation will focus on. For late-pregnancy bleeding, the doctor first will make sure you are stable.

Medical history: Your health care professional will ask you a lot of questions: If early in pregnancy, your pregnancy history will be reviewed regarding the certainty of the dates of your pregnancy. If you think you are pregnant, you usually are. You may be asked about recent trauma or sexual intercourse and whether you have abdominal pain or contractions. Your medical history will be reviewed, with emphasis on bleeding disorders, liver problems, and drug or tobacco use. You will be asked about prior pregnancies, Cesarean deliveries, preterm labor, placenta previa, or placental abruptions.

Physical exam: Regardless of where you are being treated, the first thing that should be established is how sick you are as a result of the bleeding. This is done by evaluating vital signs (pulse and blood pressure), and by a quick physical assessment of volume of blood loss by looking to see if you are pale or if you have abdominal tenderness. If you have lost a significant amount of blood, you will be treated with IV fluids and you may need surgery.

  • Your abdomen will be examined to see if you are tender and to check the size of your uterus.
  • You will be checked for bleeding from other sites, such as the nose or rectum.
  • The results of the pelvic exam may or may not be very helpful in differentiating between ectopic pregnancy and threatened miscarriage: 10% of women with an ectopic pregnancy will have a completely normal pelvic exam. How enlarged the uterus is on examination may help, because in less than 3% of ectopic pregnancies is the uterus enlarged to greater than 10 cm. In some cases, especially late in the pregnancy, the pelvic examination might not be performed until an ultrasound is available.
  • Quantity and quality of abdominal pain and vaginal bleeding is important for the doctor to know. Pain is seen in most women with ectopic pregnancy (up to 90%) and vaginal bleeding (50% to 80%).
  • Late in pregnancy, you will have an abdominal ultrasound prior to a vaginal exam to see if you have a placenta previa. If ultrasound does not show previa, you will have a sterile speculum vaginal exam to evaluate you for injury to the lower genital tract. If the vaginal exam is normal, you will have a digital exam to check for cervical dilation. You will have monitors attached to your abdomen to check for contractions and for the baby's heart rate.
  • Symptoms and physical examination diagnose uterine rupture. The symptoms that suggest rupture are sudden onset of severe abdominal pain, abnormality of the size and shape of the uterine contour, and regression of the baby's head up the birth canal.

Lab tests: Several lab tests are routinely obtained. They include a urine pregnancy test, a urinalysis, a blood type and Rh, and a complete blood count (CBC). Serum quantitative bhCG, which is a blood hormone marker of pregnancy, is also frequently obtained.

  • The urine pregnancy test is extremely sensitive for diagnosing pregnancy at or about the same time you miss your period, or possibly a few days before. A urinalysis can diagnose urinary tract infections, regardless of whether you have symptoms of this type of infection. This is because infections, specifically of the urinary tract, are a cause of miscarriage. Also, a urinary tract infection with no symptoms is relatively common in pregnancy, occurring in 2% to 11% of pregnant women. Up to a fourth of these women will go on to have kidney infections.
  • Your blood type will be checked. You are being screened for whether your type is Rh negative or positive. If you are negative and the father of the baby is positive, your body may make antibodies against the baby's blood cells. If this occurs without treatment, the next time you are pregnant, these antibodies will appear again and harm that baby. If this is discovered during the first pregnancy and treatment with an injection called RhoGAM is given, this prevents the antibodies from forming.
  • A blood count is routinely obtained to have an estimate of how much bleeding has already occurred.
  • The bhCG level is a measure of the volume of living tissue associated with the developing pregnancy. Both ectopic and intrauterine pregnancies (IUP) produce bhCG, although there is usually a difference in the rate at which the quantitative bhCG level increases. Although a single value of bhCG isn't useful for differentiating between a normal or abnormal pregnancy or an ectopic pregnancy, a variation in the expected rate of rise of the bhCG level can be helpful. The real value of the quantitative bhCG for diagnosis of ectopic pregnancy is when it is used in correlation with the results of a pelvic ultrasound.

Ultrasound: Ultrasound can often determine if the fetus is healthy and growing inside the uterus. Ultrasound is a form of imaging using sound waves, not X-rays. It is a test that is often able to identify a pregnancy and estimate the age of the fetus. However, a pregnancy may be too early to be seen on ultrasound.

  • Ultrasound may be able to identify an ectopic pregnancy growing outside of the uterus. It also may be used to look for blood in the pelvis, a very serious complication that can occur when the ectopic pregnancy has ruptured the Fallopian tube.
  • Late in pregnancy, placenta previa is diagnosed almost exclusively by abdominal ultrasound, which can detect it 95% of the time.
  • Placental abruption is diagnosed by excluding other causes. It often cannot be confirmed until after delivery when the placenta is found to have a blood clot attached to it. An ultrasound is performed to make certain that the bleeding is not from a placenta previa. Ultrasound at best is only able to detect about half of placental abruptions.
  • Fetal bleeding can be distinguished from maternal bleeding by performing a special test on the blood present in the vagina. Also, a special type of ultrasound (Doppler) may be used to see the blood flow within the blood vessels.
  • Lower genital tract problems can easily be diagnosed with a speculum examination. It is important that an ultrasound rule out placenta previa prior to any vaginal exam.

The medical evaluation begins with a thorough history and physical exam. Depending on the setting (medical office or hospital) and the seriousness of your symptoms, laboratory and ultrasound tests may be performed. For bleeding in the early part of pregnancy, the doctor's main goal will be to make sure you don't have an ectopic pregnancy. That is what the evaluation will focus on. For late-pregnancy bleeding, the doctor first will make sure you are stable.

Medical history: Your health care professional will ask you a lot of questions: If early in pregnancy, your pregnancy history will be reviewed regarding the certainty of the dates of your pregnancy. If you think you are pregnant, you usually are. You may be asked about recent trauma or sexual intercourse and whether you have abdominal pain or contractions. Your medical history will be reviewed, with emphasis on bleeding disorders, liver problems, and drug or tobacco use. You will be asked about prior pregnancies, Cesarean deliveries, preterm labor, placenta previa, or placental abruptions.

Physical exam: Regardless of where you are being treated, the first thing that should be established is how sick you are as a result of the bleeding. This is done by evaluating vital signs (pulse and blood pressure), and by a quick physical assessment of volume of blood loss by looking to see if you are pale or if you have abdominal tenderness. If you have lost a significant amount of blood, you will be treated with IV fluids and you may need surgery.

  • Your abdomen will be examined to see if you are tender and to check the size of your uterus.
  • You will be checked for bleeding from other sites, such as the nose or rectum.
  • The results of the pelvic exam may or may not be very helpful in differentiating between ectopic pregnancy and threatened miscarriage: 10% of women with an ectopic pregnancy will have a completely normal pelvic exam. How enlarged the uterus is on examination may help, because in less than 3% of ectopic pregnancies is the uterus enlarged to greater than 10 cm. In some cases, especially late in the pregnancy, the pelvic examination might not be performed until an ultrasound is available.
  • Quantity and quality of abdominal pain and vaginal bleeding is important for the doctor to know. Pain is seen in most women with ectopic pregnancy (up to 90%) and vaginal bleeding (50% to 80%).
  • Late in pregnancy, you will have an abdominal ultrasound prior to a vaginal exam to see if you have a placenta previa. If ultrasound does not show previa, you will have a sterile speculum vaginal exam to evaluate you for injury to the lower genital tract. If the vaginal exam is normal, you will have a digital exam to check for cervical dilation. You will have monitors attached to your abdomen to check for contractions and for the baby's heart rate.
  • Symptoms and physical examination diagnose uterine rupture. The symptoms that suggest rupture are sudden onset of severe abdominal pain, abnormality of the size and shape of the uterine contour, and regression of the baby's head up the birth canal.

Lab tests: Several lab tests are routinely obtained. They include a urine pregnancy test, a urinalysis, a blood type and Rh, and a complete blood count (CBC). Serum quantitative bhCG, which is a blood hormone marker of pregnancy, is also frequently obtained.

  • The urine pregnancy test is extremely sensitive for diagnosing pregnancy at or about the same time you miss your period, or possibly a few days before. A urinalysis can diagnose urinary tract infections, regardless of whether you have symptoms of this type of infection. This is because infections, specifically of the urinary tract, are a cause of miscarriage. Also, a urinary tract infection with no symptoms is relatively common in pregnancy, occurring in 2% to 11% of pregnant women. Up to a fourth of these women will go on to have kidney infections.
  • Your blood type will be checked. You are being screened for whether your type is Rh negative or positive. If you are negative and the father of the baby is positive, your body may make antibodies against the baby's blood cells. If this occurs without treatment, the next time you are pregnant, these antibodies will appear again and harm that baby. If this is discovered during the first pregnancy and treatment with an injection called RhoGAM is given, this prevents the antibodies from forming.
  • A blood count is routinely obtained to have an estimate of how much bleeding has already occurred.
  • The bhCG level is a measure of the volume of living tissue associated with the developing pregnancy. Both ectopic and intrauterine pregnancies (IUP) produce bhCG, although there is usually a difference in the rate at which the quantitative bhCG level increases. Although a single value of bhCG isn't useful for differentiating between a normal or abnormal pregnancy or an ectopic pregnancy, a variation in the expected rate of rise of the bhCG level can be helpful. The real value of the quantitative bhCG for diagnosis of ectopic pregnancy is when it is used in correlation with the results of a pelvic ultrasound.

Ultrasound: Ultrasound can often determine if the fetus is healthy and growing inside the uterus. Ultrasound is a form of imaging using sound waves, not X-rays. It is a test that is often able to identify a pregnancy and estimate the age of the fetus. However, a pregnancy may be too early to be seen on ultrasound.

  • Ultrasound may be able to identify an ectopic pregnancy growing outside of the uterus. It also may be used to look for blood in the pelvis, a very serious complication that can occur when the ectopic pregnancy has ruptured the Fallopian tube.
  • Late in pregnancy, placenta previa is diagnosed almost exclusively by abdominal ultrasound, which can detect it 95% of the time.
  • Placental abruption is diagnosed by excluding other causes. It often cannot be confirmed until after delivery when the placenta is found to have a blood clot attached to it. An ultrasound is performed to make certain that the bleeding is not from a placenta previa. Ultrasound at best is only able to detect about half of placental abruptions.
  • Fetal bleeding can be distinguished from maternal bleeding by performing a special test on the blood present in the vagina. Also, a special type of ultrasound (Doppler) may be used to see the blood flow within the blood vessels.
  • Lower genital tract problems can easily be diagnosed with a speculum examination. It is important that an ultrasound rule out placenta previa prior to any vaginal exam.

Early Signs & Symptoms of Pregnancy Slideshow

Early Signs & Symptoms of Pregnancy  Slideshow

A missed menstrual period is often the first recognizable sign of a possible pregnancy, but there are other signs and symptoms of early pregnancy as well. Not all women have all symptoms or experience them in the same way. The most common first trimester symptoms are discussed in the following slides.

REFERENCE:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

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