Bleeding or pain during pregnancy

Bleeding in pregnancy, and to a lesser degree pain, are common symptoms in the early stages of pregnancy.

The most likely outcome of bleeding or pain is a normal viable pregnancy; however, these symptoms should always be investigated.

Investigations required for women with pain and bleeding in early pregnancy are hCG level (accurate pregnancy hormone test), blood group typing and an ultrasound scan.

An ultrasound scan is only useful if the pregnancy is big enough to be seen (usually about one week after missing a period). It is only able to confirm that the pregnancy is viable (or healthy) by seeing a fetal heart beat, and this can be seen approximately two weeks after missing a period. Ultrasounds prior to this often give an ‘equivocal’ result, meaning it needs to be repeated after one week to check that the pregnancy is growing or for the presence of a heart beat.

Bleeding and pain may be due to miscarriage

Miscarriage can present with any combination of pain and bleeding, or indeed no signs at all, so these symptoms should always be investigated. While it can occur at any stage in the first trimester, the more advanced your pregnancy is, the less likely you are to have a miscarriage. Once a fetal heart has been seen on ultrasound, the chance of miscarriage is only about 1%. Overall, miscarriages are common and account for about 20% of all known pregnancies.

Possible miscarriage is diagnosed with a pregnancy hormone level and an ultrasound scan. Occasionally, these don’t tell the whole story and an additional blood test two days later or ultrasound scan a week later is needed.

The treatment for miscarriage includes doing nothing and waiting for the pregnancy to pass, or an operation (curette). There are advantages and disadvantages to both, and we will discuss your options. Ultimately, most women choose a curette because it is timely, reduces the risk of infection and bleeding, and follows a more predictable course.

Following a single miscarriage, the chance of future miscarriage is low and comparable to other women in the general population of the same age, so does not usually need any special investigations.

Pain or bleeding can signal an ectopic pregnancy

Like miscarriage, ectopic pregnancy can present with bleeding or pain or both. Most ectopic pregnancies occur in the fallopian tube, but can very rarely occur in other places. The danger of ectopic pregnancies is that they can rupture, causing potentially life-threatening haemorrhage. This typically does not occur until about 6 weeks of pregnancy, but ideally ectopic pregnancies should be diagnosed as early as possible to prevent rupture and allow for choice of treatment.

Ectopic pregnancies are uncommon, occurring in just 1% of pregnancies. Some women are at higher risk, and should automatically have a pregnancy ultrasound at 5 weeks pregnancy. These include women with a previous ectopic pregnancy or damaged tubes for any reason, and conception with an IUD or while using progesterone contraception (minipill, implanon etc).

Ectopic pregnancy is diagnosed with a combination of ultrasound and pregnancy hormone blood test results. Sometimes, like with miscarriage, serial testing is needed.

The gold standard for treatment of a tubal ectopic pregnancy is laparoscopic (keyhole) removal of the entire tube. Removing the tube reduces the chance of another ectopic pregnancy because the damaged tube is removed. Many women fear that removing one tube will halve their fertility; this is absolutely not the case. Fertility is reduced by about 1/6 because it is possible to ovulate from one ovary and the egg travel down the opposite tube.

An alternative treatment for small ectopic pregnancies is an injection of methotrexate. Methotrexate is a chemotherapy drug that successfully treats 85% of ectopic pregnancies. The remaining 15% need the tube removed at laparoscopy because of rupture, suspected rupture, or persistence of the pregnancy. The response to injection is monitored by frequent blood tests (once to twice weekly), and future pregnancy needs to be delayed at least three months because of the persistent effect of methotrexate on a new pregnancy.

Always seek help for pain and bleeding in early pregnancy

Pain and bleeding in early pregnancy always needs to be investigated.

• In the event of very severe pain, haemorrhage or collapse, call 000 for an ambulance immediately.
• In the event of persistent heavy bleeding or severe pain, go to the Epworth Richmond Emergency Department.
• For bleeding and pain that is mild to moderate, it is OK to call my rooms for advice on (03) 9418 8299. For severe symptoms after hours, contact my paging service on (03) 9387 1000.
• For bleeding or severe pain prior to 20 weeks, contact my rooms on (03) 9418 8299 or my paging service on (03) 9387 1000 OR alternatively attend the Epworth Richmond Emergency Department.
• For bleeding or severe pain after 20 weeks, call your hospital and they will give you instructions on what to do.