Vaginal Bleeding or Spotting during Pregnancy

When the reason behind vaginal bleeding or spotting isn’t clear, it is always a reason for worry. This may turn into a serious concern when you are pregnant and experience spotting. However, the best way to get through this is to educate yourself about the causes, consequences, and remedies of vaginal bleeding during pregnancy.

Video: Vaginal Bleeding or Spotting During Pregnancy

Is Vaginal Bleeding or Spotting Normal?

Light spotting or bleeding is common during pregnancy. It usually happens during the early stages (1st trimester). Around 25% of women experience spotting or bleeding. (1) (2) (3) (5) Although it is normal to experience spotting or vaginal bleeding, you should always consult your doctor if it happens. 

It is a good idea to undergo some tests and ultrasound to ensure that the baby is fine and to rule out any complications.

Difference Between Spotting and Vaginal Bleeding

The answer to what bleeding and spotting in pregnancy are in the colour and quantity of blood. (1) (4) If the blood stain is somewhat brown, like what you see at the end of periods, it is spotting, and if it is red in colour, then it is bleeding. (4) The amount of blood is also a differentiator, spotting does not soak the sanitary pad, and bleeding does. (3)

What Are the Causes of Spotting

There are a few reasons that could cause spotting: (1) (3) (4) (6)

1. In the 1st Trimester

• Implantation bleeding – This bleeding happens during the earliest part of pregnancy. The implantation of the embryo in the wall of the uterus causes spotting. It usually occurs sometime before (or around the same time) as your period or approximately at about 6 to 12 days after pregnancy. Spotting is lighter (light pink to brown coloured) than the periods and lasts for a few days.

2. In the 3rd Trimester

Spotting in the 3rd trimester occurs when you lose your mucus plug.

• Sexual intercourse or internal pelvic exam – Pregnancy causes the cervix to become tender and swell with blood vessels, and any minor bumping (sex or internal exam) may irritate the cervix, causing it to bleed. This type of bleeding happens anytime during pregnancy and mostly does not indicate any problem.
• Vaginal infection (bacterial vaginosis) or cervix – If you have a vaginal infection, your cervix is inflamed during this time, and thus, you might experience little spotting.
• Subchorionic bleed – Accumulation of blood in the folds of the outer fetal membrane next to the placenta or between the uterus and placenta can cause spotting. It usually resolves on its own.

Causes of Vaginal Bleeding

Heavy bleeding during pregnancy is not a benign sign because it can be accompanied by some other complications. Here are a few reasons for bleeding during pregnancy: (1) (3) (4) (6)

1. In the 1st Trimester

Ectopic pregnancy is where the fertilized egg implants outside the uterus. This requires immediate medical attention. Ectopic pregnancy may cause heavier bleeding with severe abdominal pain, sometimes with rectal pressure, light-headedness, and fainting. (5)

Molar pregnancy is a rare condition. In this, the placenta becomes a mass of cysts accompanied by a deformed embryo. This will cause bleeding (bright red to dark brown), and you will experience severe nausea, vomiting, and cramps.

Miscarriage (loss of pregnancy before the 20th week) is often caused due to a chromosomal or genetic disorder of the embryo. It can be caused by hormonal factors too. In this, there is heavy vaginal bleeding with clotting similar to having a period. This may be accompanied by severe cramping in the abdominal area.

Other reasons:

• Your cervix may be irritated.
• There is a chance that you have fibroids.
• You may have an inherited disorder known as Von Willebrand Disease, which makes clotting of blood difficult.

If you have a miscarriage, it does not predict that you are unfit to carry a healthy baby to term later. According to research, 40% of pregnancies end in miscarriage.

2. In Late Pregnancy

The most common reason for bleeding in late pregnancy is a problem with the placenta. In some cases, it might also be due to some abnormality in the cervix. (1) (2) (5)

• Placenta previa – The placenta connects the baby to the uterine wall. It can cover the cervical opening partially or completely. Bleeding because of this is called placenta previa. During later stages of pregnancy, the walls of the cervix are dilated, preparing for labour. Some of the placental blood vessels get ruptured. This is the cause of vaginal bleeding in the 3rd trimester 20% of the time. The risk of placenta previa is high when –

1. 1. There have been multiple pregnancies
   2. Prior C-Section delivery
   3. Prior placenta previa

• Placental abruption – In this medical condition, the placenta is separated from the wall of the uterus, and blood fills up between the placenta and the uterus. This condition occurs in 1 out of 200 pregnancies. The cause for this is unknown. The risk of this condition occurs when –

1. 1. Blood pressure is high (140/90 or more)
   2. Trauma
   3. Use of cocaine or tobacco
   4. Abruption in prior pregnancies

• Uterine rupture – This is a rare condition but is very dangerous. In this, the uterus splits open, which causes the baby to be expelled into the abdomen. It occurs mostly in women who have had a uterine rupture or prior surgery of the uterus. The rupture could happen either before or during delivery. Other risk factors for uterine rupture are:

1. 1. More than four pregnancies
   2. Trauma
   3. Excessive use of oxytocin(Pitocin)
   4. When the baby is in any position other than head down
   5. When the baby’s shoulder gets stuck on the pubic bone during labour

• Fetal vessel rupture – The blood vessels from the umbilical cord can get attached to the membranes in place of the placenta. The baby’s blood vessels are passed on to the entrance of the birth canal. This condition is called vasa previa.

Some of the lesser common causes of bleeding during late pregnancy are injuries in the cervix, cancer and varicose veins.

What Should You Do When You Notice Vaginal Bleeding or Spotting?

About 50% of women who have bleeding during pregnancy have a healthy pregnancy and healthy baby. When you notice spotting or vaginal bleeding, you should consult your doctor immediately to discuss the symptoms. If the bleeding is heavy, similar to bleeding during periods, then you should make sure that there is no other complication by consulting your doctor. (1) (6) Heavy bleeding during the later part of pregnancy may cause harm to the baby.

Diagnosis

A woman who has vaginal bleeding during pregnancy should be examined thoroughly and promptly. Certain causes of bleeding, like ectopic pregnancy, can lead to hemorrhagic shock. Hemorrhagic shock occurs when you lose more than 20% of the blood from your body. The loss of blood makes it difficult for the heart to pump blood into the body leading to organ failure. Your doctor may conduct (5) – 

• A thorough check of the vital signs for fever and signs of hypovolemia.
• Pelvic and abdominal examinations. Doppler ultrasound probe to check on the fetal heartbeats. The pelvic examination would include an inspection of external genitals, speculum examination, and bimanual examination. An inspection of the cervix should be done to check for discharge and dilation lesions.

Treatment

Treatment for vaginal bleeding and spotting differs on the basis of the duration of pregnancy.

Treatments in the First Trimester

• If you have been diagnosed with an ectopic pregnancy by ultrasound, you may be given medication(Methotrexate) or taken into surgery. Surgery is conducted for women who do not meet certain criteria for receiving treatment with methotrexate and for those who are too sick to wait for the methotrexate to work.
• If you are diagnosed with a threatened miscarriage, your doctor will give you instructions on how to carry out precautions and return for follow-up check-ups.
• If there has been an incomplete abortion, then you will have to be admitted to the hospital to remove the fetal tissue that has been left behind. This process is known as dilation and curettage and prevents complications such as haemorrhage or infection.
• If there has been a missed abortion, you may be admitted to the hospital for a D&C or monitored at home so that the tissue is passed without surgery. This depends on the age and size of the fetus.
• If there has been complete abortion, you may be sent home after the fetal tissue has completely passed out.
• In the case of molar pregnancy, an immediate D&C is necessary, along with obtaining a check for B-hCG level to check for chronic carcinoma, a type of cancer.

 Treatments in the Second and Third Trimesters

In the case of bleeding during late pregnancy, monitoring for loss of blood and signs of shock should be done. Your baby will be monitored for signs of distress. Treatment will depend on the bleeding, condition and the baby’s age.

A) Placenta Previa

• C-section delivery is the preferred method if you and your baby are in danger of severe bleeding.
• If you have contractions, then you may be given IV medicine to slow or stop them.
• If your pregnancy is less than 36 weeks and the bleeding is not that severe, you will be admitted to the hospital for observation. If your pregnancy is more than 36 weeks, then the doctor will monitor the baby’s lungs to check if they are mature. If they are mature, then you may go in for a C-section.
• In this case, all deliveries will be C-section deliveries.

B) Placental Abruption

• Vaginal delivery is always the preferred delivery method.
• C-sections will be done only in case of emergency.
• If the baby is more than 36 weeks, then you will have a controlled vaginal delivery. IV medication is prescribed to help contractions.
• If your pregnancy is less than 36 weeks and the bleeding is not that severe, you will be admitted to the hospital for observation. The baby’s heart rate will be monitored, and blood will be checked for anaemia.

C) Uterine Rupture

• If there is a high chance of the uterus rupturing, you will have to undergo a C-section delivery.
• Chances are that your uterus may be removed.
• The doctors may be able to repair the uterus if your condition is stable.
• If there is a high suspicion of rupture of the uterus, you will have an immediate C-section delivery.
• A lot of blood transfusion is required.
• Fetal bleeding is treated by performing an immediate C-section delivery.

Prevention

There are a few things you can do to prevent bleeding and spotting in pregnancy (1) (7) :

• Getting plenty of bed rest until the bleeding stops.
• While you are bleeding, use pads and not tampons.
• Avoid sex while you are bleeding. 
• Light medication like paracetamol to relieve you from the pain if required.
• Report any changes in your condition to your doctor immediately.
• If the bleeding and cramping are severe, then you should drink only fluids.
• Do light physical activities like a walk around the house or do light chores.
• Keep your feet at an elevated level whenever possible.
• Avoid lifting items that weigh more than 10 pounds.

Will It Harm Your Baby?

Spotting or light bleeding is generally harmless. Hence your baby is likely to be fine. Many pregnancies complete term despite bleeding problems.

Although bleeding and spotting are generally harmless, they can be a sign of miscarriage when accompanied by stomach cramps and if the bleeding is getting heavier. The spotting or bleeding usually tends to stop on its own. However, it is advised that you consult your doctor if bleeding occurs.

References/Resources:

1. Bleeding and spotting from the vagina during pregnancy: March of Dimes, https://www.marchofdimes.org/find-support/topics/pregnancy/bleeding-and-spotting-vagina-during-pregnancy, Last reviewed April 2020

2. Bleeding During Pregnancy: ACOG, https://www.acog.org/womens-health/faqs/bleeding-during-pregnancy, Last reviewed: August 2022

3. John D. Jacobson. et al.: Vaginal Bleeding in Early Pregnancy: MedlinePlus Medical Encyclopedia, https://medlineplus.gov/ency/patientinstructions/000614.htm, Last Reviewed: May 2020

4. Reem Hasan et al.; Patterns and predictors of vaginal bleeding in the first trimester of pregnancy: NCBI,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884141/, 2011

5. Bleeding during pregnancy: Pregnancy Birth and Baby,  https://www.pregnancybirthbaby.org.au/bleeding-during-pregnancy, January 2023

6. E.: Bleeding during pregnancy: American Pregnancy Association, https://americanpregnancy.org/healthy-pregnancy/pregnancy-complications/bleeding-during-pregnancy/, January 2023

7.  Editorial staff, F. E., Rice, A., & staff, Alex Rice, F. E. (2017, September 20). Bleeding During Pregnancy – What’s Normal?: familydoctor.org, https://familydoctor.org/bleeding-pregnancy-whats-normal/, December 2022