Bleeding in early pregnancy could be distressing, especially for a first timer or for women who have had such experience in the past with unfavourable outcome. Many factors may be responsible for this. They include: implantation bleeding, infection, impending miscarriage or ectopic pregnancy — that is pregnancy outside of the womb.
Bleeding in early pregnancy may be in form of spotting, moderate flow, or heavy bleeding, even with clots. It could also be associated with or without pain.
Implantation bleeding occurs around the time a woman is expecting her normal menstruation. It is the time the newly-formed embryo is just getting implanted or attached to the womb. The process usually starts about six to seven days after the fertilisation of the egg, and the fertilised egg penetrates or burrows into the wall of the womb.
It is usually a light bleeding, much lighter than the normal flow, usually either brownish or pink, with no associated pain, up till between 24 and 48 hours; and, in very few cases, up to 72 hours or more. Only few women experience implantation bleeding, though.
Infection of the vagina or the cervix (neck of the womb) can also cause bleeding in early pregnancy. Vaginal infection (candidiasis), bacterial vaginosis, and also sexually transmitted infections like gonorrhoea, chlamydia and trichomonasis may cause irritation and inflammation of the cervix. Consequently, light bleeding may occur after sexual intercourse.
Ectopic pregnancy occurs when a fertilised egg gets implanted in any other place outside of the womb, commonly in the tube. When this happens, it is referred to as tubal pregnancy. It can also get implanted in the abdominal cavity, ovary, cervix, etc. When this happens, it is referred to as abdominal pregnancy, ovarian pregnancy or cervical pregnancy respectively).
More than 90 per cent of ectopic pregnancies occur in the tube. This could result into pain in the pelvic or abdominal region, follow by bleeding from the vagina when the pregnancy in the tube bursts. Medically, this phenomenon is referred to as ruptured ectopic pregnancy. Because the tube is narrow for a growing embryo, the tube gets distended, this gives pain, and when the tube is overdistended, it bursts.
Bleeding from the burst tube flows into the abdominal cavity and also into the vagina through the uterus. The bleeding into the abdominal cavity could be heavy enough to irritate some nerves in the abdominal cavity and patient may even present with shoulder or neck pain.
The pain is usually sharp and stabbing, depending on the degree of the internal or external bleeding. Patient may collapse and even faint.
Bleeding in early pregnancy may occur without a miscarriage; but miscarrige could occur in 15-20 per cent of pregnancies. In most cases, the amount of bleeding is proportional to the risk of miscarriage. The greater the bleeding in early pregnancy, the higher the chance of miscarriage; especially when there is associated clots.
Again, if bleeding is associated with abdominal pain, the risk of miscarriage will be high.
At that point, miscarriage could either be threatened or inevitable.
Threatened miscarriage: Here, the bleeding is light, there may be spotting, which may also stop after a few days. The cervix remains closed, with slight or no pain. When ultrasound scan is done, findings are usually normal.
Inevitable miscarriage: Bleeding is continuous, not subsiding, and it comes with heavy bleeding with clots, starting with low back ache, low abdominal pain. The pain increases in intensity, contraction is associated, and the cervix is open. In this case, miscarriage is sure.
Other conditions that can cause bleeding in early pregnancy include sexual intercourse. In early pregnancy, some women may experience slight bleeding during sexual intercourse. Bleeding may be heavy if there is coital laceration. Pelvic examination will reveal the bleeding is coming from the vaginal wall and not from the womb or the baby.
The presence of cervical polyps, a benign growth from the womb or the cervix, may also cause slight bleeding, which usually subsides on its own in most cases.
Also, very rare causes of bleeding in early pregnancy is cancer of the cervix. It usually presents as contact bleeding, maybe after sexual intercourse or vaginal examination.
Investigating bleeding in early pregnancy starts from simple pregnancy test to ascertain that the woman is really pregnant, because some women sometimes have delayed menstruation which they interpret as pregnancy, especially those that have fertility problem. If the pregnancy test is positive, then ultrasound scan is performed to see where the pregnancy is located — whether in the womb or outside of the womb.
Also, to know if the foetus is alive, ultrasound scan will help to predict if the pregnancy will continue or may lead to miscarriage. The findings from the ultrasound scan will determine the next line of management. If the pregnancy goes beyond 20 weeks, over 90 per cent of the baby will survive.
Pregnancy that are associated with heavy bleeding in early stage may have increased risk of premature labour, early rupture of membrane or risk of placenta abruption (separation of the placenta)
A woman bleeding in early pregnancy must see her doctor for proper assessment of the underlying cause of the bleeding and management.