Antenatal bleeding, or bleeding in pregnancy, is one of the most frightening things that can happen to expectant parents. Bleeding in the first trimester, when your risk of miscarriage is highest, is especially worrying. While bleeding in pregnancy does not always indicate a serious problem, it is always a serious symptom. This article is concerned with vaginal bleeding. Nosebleeds and bleeding gums are common in pregnancy and usually caused by an increase in your blood volume and hormonal activity, especially in the late second and third pregnancy. Reporting them to your midwife is important, as is seeing your dentist and dental hygienist for check-ups in pregnancy. Never ignore vaginal bleeding in pregnancy. Always report it to your doctor, midwife, or nearest hospital and get it checked out as soon as possible.

The following are potential causes of vaginal bleeds in pregnancy, as well as when they tend to happen, what they may look like, and how they are treated.

Implantation Bleeding

Implantation bleeding may happen before you even know you are pregnant (within 12-14 days after fertilisation) and looks like light spotting. You may not have noticed a missed period yet and could easily mistake it for that. Implantation bleeding happens when blood vessels break as a result of a fertilised egg embedding in the lining of your womb. It isn’t usually a problem and does not usually require treatment. Similarly, if it does not happen, it does not indicate that there’s something wrong with your pregnancy.

Miscarriage

Miscarriage is extremely common; it is thought that more than one in five pregnancies in the UK ends in miscarriage, but the data is not completely accurate because not all miscarriages are reported or even recognised. Most miscarriages happen in the first twelve weeks of pregnancy. Less than two percent happen in the second trimester, which is known as a late-term miscarriage (miscarrying between 13-24 weeks in the UK, or 13-20 weeks in the US), and losing a baby after this may be referred to as foetal loss or stillbirth. The most common reason for a miscarriage is a chromosomal abnormality, and the most common first sign is vaginal bleeding. The way the bleeding presents is not the same for every woman—it may look like spotting or be large amounts of blood, and the colour can range from bright red to dark red and light brown. You may or may not see clots or experience pain. Some women who describe the experience report instinctively knowing a miscarriage is happening. There is nothing anyone can write to make this experience less awful, but even if you know exactly what is happening, you need to seek medical help as soon as possible. Psychological and emotional support is also extremely important for anyone who has lost a baby. A pregnancy can sometimes be saved when you are showing signs of miscarriage. It is possible to experience extremely heavy bleeding and see clots during pregnancy and still remain pregnant and carry your baby to term, which is another reason seeking medical care immediately is so crucial.

There are three treatments for miscarriage. You can allow the tissue to pass by itself or be prescribed medication that encourages this. There’s also a surgery that happens inside the vagina and won’t leave visible scars. You will usually be allowed to choose the treatment you prefer. It is important to seek mental health support if necessary.

Ectopic pregnancy (tubal pregnancy)

Ectopic pregnancy is one of the causes of miscarriage and extremely dangerous for the mother, as it can make you bleed internally and even kill you. Ectopic pregnancy happens when a fertilised egg implants outside the womb. Symptoms usually show up between five and twelve weeks of pregnancy, which is a pretty significant time period, as most of us just think our period is late at five weeks, whereas you are nearing the end of your first trimester and will hopefully have had at least one scan by week twelve. An ectopic pregnancy causes pregnancy tests to show positive results and makes your periods stop. Vaginal bleeding is a very common symptom, but the blood you see can vary from light pink to dark red, brown, or even black. Other symptoms include period-like cramps, nausea, and vomiting, though these can easily be confused with regular early pregnancy symptoms. Some ectopic pregnancies have no symptoms. You may have been warned you’re at greater risk of a tubal pregnancy if you’ve had surgery on your fallopian tubes or pelvic inflammatory disease in the past, if you smoke, or if you have a history of ectopic pregnancy. Some research suggests that assisted reproductive technologies like IVF increase your risk of ectopic pregnancy, though there is such variation between methods and practices in different clinics and across different countries that your comparative risk among ART procedures is hard to interpret. You need to have an ultrasound scan to have an ectopic pregnancy diagnosed.

An ectopic pregnancy cannot be saved, unfortunately, and treatment can involve medication or allowing you to pass the pregnancy tissue naturally (you will be carefully monitored while this happens). You may also have surgery recommended to you. Again, mental health support is an important part of your recovery.

A bleeding placenta

Bleeding from your placenta will be bright red and probably painless. It is associated with a low-lying placenta (placenta praevia) and the third trimester of pregnancy, though this isn’t always the case. It’s important that this sort of bleeding is reported as soon as possible. You can also go directly to the hospital, as you will almost certainly be told to come in for an assessment when you call about it.

Placental abruption

This means your placenta, your baby’s lifeline in pregnancy, has come away from the wall of your womb. There are degrees of severity to placental abruption; you and your baby can survive it, but it is considered very dangerous to you both and can cause premature labour. The most common symptom is dark red blood. It can happen in the third trimester and during labour. You may also feel abdominal or back pain and experience contractions. Placental abruption can be diagnosed through a physical examination or testing and is treated with close monitoring or an emergency delivery. The most important thing to do if you suspect abruption has happened is to get medical help.

Cervical sensitivity/erosion

Bleeding from the cervix is relatively common in pregnancy and often isn’t a problem. More blood vessels are developing in this area when you’re growing a baby, and it tends to be more delicate and prone to bleeding after sex or pelvic examinations. Genuine cervical injuries can impact future pregnancies, and it’s important to fully understand any you may have and share this information with anyone looking after you while you are pregnant.

Cervical polyps or fibroids

Polyps and fibroids are growths inside the body and are typically benign, though they can bleed. Fibroids form from muscle tissue in the uterus, while polyps can form anywhere in the body, but when they form in the uterus, they are made from the endometrium. You can develop both of these growths in pregnancy if you did not have them before, and they can also grow or shrink as a result of pregnancy. Their causes and changes are not well understood but may be hormonal. Beyond bleeding, cervical polyps can increase your risk of miscarriage and premature birth. Hormonal medication can improve them but is less likely to be recommended in pregnancy, as it can impact the baby and the polyps can grow back if you stop taking it. You may simply have your polyps monitored closely, which means extra antenatal appointments for you! Fibroids can increase your risk of developing a low-lying placenta and of having a breech birth or a premature birth. They may be treated with anti-inflammatory and pain medication, though please do not take anything while pregnant without a doctor’s advice, even if it’s been prescribed to you previously. Both polyps and fibroids can be treated surgically, but it is unlikely that surgery will be recommended during your pregnancy unless your healthcare team believes the benefits outweigh the risks. Bleeding from polyps and fibroids can vary from light spotting to resembling a heavy period, and it is important to get it checked out as quickly as possible.

Cervical incompetence

This is another potential cause of premature labour. It sounds kind of mean, right? Your cervix is working so hard to support your baby; why call it incompetent? Really, it’s just a medical term to explain that the cervix has dilated and become effaced (get pliable and prepare for birth) before your baby is fully developed. The blood might look like light spotting, and you may also see vaginal discharge and feel pressure in your vagina. The diagnosis will usually happen through a physical examination. Depending on how long you’ve been pregnant, you may be given a surgical stitch to strengthen the cervix, medication to prolong your pregnancy, or an emergency induction or caesarean section.

Molar pregnancy

A molar pregnancy happens when something goes wrong at the moment of fertilisation. As with ectopic pregnancy, your periods stop and pregnancy tests show positive results in molar pregnancies. Unlike an ectopic pregnancy, a molar pregnancy does embed in the womb; however, it is essentially a tumour rather than a growing baby. A molar pregnancy can’t survive and will usually end on its own, through miscarriage, within the first three months, though it can also be removed surgically. The blood will look dark brown or red. You may also experience nausea and vomiting, though these are hard to distinguish from regular early pregnancy symptoms. Molar pregnancy can also occur without any symptoms you’re aware of until you have your first scan. It’s important to seek mental health support as part of your recovery if necessary.

Sex

Bleeding after sex in pregnancy is not always a problem, but it is still important to have yourself assessed to ensure the cause isn’t something more serious. Sex in pregnancy is generally considered safe; you don't need to avoid it unless you don’t want to have any or your doctor specifically tells you to do so. If you are actively bleeding or suspect your waters have broken, you should avoid having sex until you’ve been checked out at the hospital.

Subchorionic Haemorrhage

Bleeding in the first trimester is never normal, but it is common, happening in 20 to 40 percent of pregnancies. One of the potential causes is subchorionic haemorrhage, which is blood that collects between the wall of the uterus and your forming placenta. It doesn’t always result in bleeding through the vagina, though the internal blood will probably be spotted in your first pregnancy scan. There’s nothing that you did or didn’t do that caused an SH. Your pregnancy will likely survive, and SH, they usually resolve themselves within weeks of formation. It’s a bit more common with IVF pregnancies. There is no treatment, and you can usually continue with your regular activities unless advised otherwise. The impact SH has on early pregnancy is disputed; some studies suggest that it increases your risk of miscarriage, and others suggest that it does not increase your risk of miscarriage or any later pregnancy complications. As there really isn’t a specific treatment, you may like to use the time an SH takes to resolve itself to work on developing coping mechanisms that will help you in other moments of pregnancy stress, such as a lengthy early labour or an induction.

Urinary Tract Infections (UTIs)

Infections can cause inflammation that makes pregnancy bleeding more likely. They may or may not be a cause for concern; some infections are linked to premature labour. They are typically treated with vaginal pessaries and antibiotics, though it is important to wait for your doctor’s diagnosis and advice rather than attempting to self-treat, even if you are familiar with UTIs and have successfully self-treated before. Always avoid sex while you are bleeding, or if you know you have been bleeding and haven’t yet seen a doctor.

Can I tear my vagina to the point of bleeding when I’m pregnant?

Yes, vaginal tearing is possible during pregnancy as well as during childbirth. You can cause it yourself during shaving or waxing, and it can happen through friction while cycling or horseback riding. The most common cause of vaginal tearing in pregnancy is sex. Some vaginal tearing can cause bleeding, and any vaginal bleeding in pregnancy should be checked out. Don’t worry about it being embarrassing; your doctor or midwife will definitely have heard and seen worse.

Can I get my period when I’m pregnant?

No, bleeding in pregnancy cannot be a period. Your period is your uterine lining being shed and flushed out through your vagina each month because your body doesn’t need it to get thicker and start growing the placenta that will support your developing baby. An unfertilised egg either disintegrates and is absorbed within your body or leaves your body along with your period. Neither of these things happen when you’re pregnant. Pain that feels like period pain should be reported to your doctor or midwife and checked out, as this can be an early sign of labour.

For more advice on taking care of yourself in pregnancy, labour, and birth, check out Unii’s Antenatal Classes, with prenatal video episodes taught by senior NHS midwives, an award-winning obstetrician and gynaecologist, and six other leading healthcare experts. Only at unii.com.

For more information on caring for yourself in pregnancy, check out Unii’s Pregnancy Journey video course with Dr. Shree Datta.

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