What do we need to know about bleeding in early pregnancy? Firstly, we know it's an anxious time for a couple because one of the possibilities for bleeding in early pregnancy is early miscarriage. This is often where our mind goes to first.
Thankfully most of the time when there's bleeding in early pregnancy it's not a miscarriage.
Patrick [00:00:36] This is Dr. Pat. I'm here with Brigid. And today it's bleeding in early pregnancy. Bleeding and spotting an early pregnancy can be really frightening. We've got our own experience of Brigid having a big bleed when she was seven weeks pregnant and it came as such a shock and I remember feeling anxious and thinking we lost the baby and even with my expert knowledge, being really scared. This episode is about giving you the knowledge so you know what to ignore and what to have investigated and to help give you that sense of calm as you try and navigate the waters of early pregnancy.
Brigid [00:02:56] So, we are talking about bleeding in early pregnancy, which is a really anxious time when you have a spot or you might have a bright red bleed, or you know there's so many variations that you get. You know there's a lot of discharge, isn't there when you're in early pregnancy. So Paddy, I'm going to talk about what a woman might experience. Her period's late. She's had her pee on a stick and it's come back positive but she's got some spotting. What's what's going on there.
Patrick [00:03:27] So that's a really common situation that we see it at work a lot. And it's an anxious time for the couple because one of the possibilities is early miscarriage and that's where our mind goes to first. Thankfully most of the time when there's bleeding in early pregnancy it's not a miscarriage actually. But we need to keep an eye on that situation until we can reliably reassure that woman that things are fine. So some of the possibilities are that it's something called an implantation bleed.
Patrick [00:03:57] Remember the egg comes out of the ovary it's picked up by the trumpet end of the fallopian tube and about halfway down the tube it makes up with the sperm coming up the other way. Fertilisation, where the sperm penetrates the egg, happens in the tube and then the tube will push the fertilised egg down back into the body of the uterus where it implants and all of that takes time. So somewhere around that sort of 4 to 5 week mark in early pregnancy - four or five weeks since that last period, the fertilised egg is literally implanting into the into the lining of the uterus which has got all thick to be ready to receive it. And that process can cause bleeding and sometimes that's all the bleeding is.
Brigid [00:04:41] And you know, we get a bit obsessed with the type of bleeding. So what sort is that, just like brown spotting or is it like bright red or what should a woman expect from implantation bleeding?
Patrick [00:04:53] That's usually pink, spotting pink.
Patrick [00:04:55] Yeah and but any bleeding needs some attention because we just don't know whether it's a miscarriage, it could be implantation bleed or nothing or whatever.
Patrick [00:05:04] So the appropriate things to do is to catch up with your local doctor. You might be seen in hospital emergency department after hours and they'll check you over and make sure that you're basically well and then it's to work out what's going on with the pregnancy. And of course the appropriate test is ultrasound. If the ultrasound shows pregnancy that's in the uterus with a heartbeat, regardless of the cause of the bleed, we I think all is well. And if it shows an empty uterus or if the woman's very unwell with pain or there is dozen different possible scenarios. Then each of those has got their appropriate further testing and investigation.
Brigid [00:05:41] I love that image that you've just put in my mind of the egg, you know on its journey down the fallopian tube and you know everything being pulsed towards to meet the sperm and you know even the image of the fertilised egg sort of burrowing in to the uterus lining like that. It's just such beautiful imagery. It's a beautiful thought. And sometimes though it doesn't quite go to plan does it?
Patrick [00:06:07] The fertilized egg might just hang around too long in the fallopian tube and try and implant in the fallopian tube and that's an ectopic pregnancy. And that's one of the things that needs to be seriously considered when there's bleeding in early pregnancy. So with a combination of ultrasounds and some quantitative beta hCG levels the one that gives the number the blood test we can work it out.
Brigid [00:06:29] So the blood test will tell us whether it's an ectopic will it?
Patrick [00:06:33] Not all by itself.
Patrick [00:06:34] Yeah but it's about building a picture where we say okay, what can we see on ultrasound what's the blood test telling us. And there's almost a flowchart that helps you with the answer.
Brigid [00:06:44] Yeah and if we're investigating an ectopic pregnancy is there a prime time for an ectopic pregnancy.
Patrick [00:06:52] Will usually only come to light when it either bursts out of the tube, that might happen at seven eight or nine weeks pregnancy or when it's trying to implant somewhere where it shouldn't implant it causes bleeding and the bleeding tracks down through the cavity and out the vagina.
Brigid [00:07:13] And that could be earlier at a 6 or seven week.
Patrick [00:07:15] Yes exactly.
Patrick [00:07:17] And that might happen so early even before the ectopic pregnancy has got an obvious appearance on ultrasound.
Brigid [00:07:24] Okay. So if you have had a suspected ectopic pregnancy how is that treated?
Patrick [00:07:29] Well briefly if an ectopic pregnancy has been proven there are a couple of different types. There might be a pregnancy that's sitting in the fallopian tube and it's known to be there through the testing but it hasn't burst out the tube and they can often be treated. Sometimes they will miscarry by themselves and sometimes that's a process that just needs to be observed and the blood hormone levels followed back to zero. They can be treated with medication these days, a medication that works a little bit like chemotherapy and goes in there and dissolves the cells and that can avoid an operation in some situations. But if the ectopic pregnancy has burst out of the tube and it's bleeding and the woman is very unwell then obviously that needs to be treated with her an emergency keyhole operation to go in through the belly button and fix the bleeding and often remove the tube.
Brigid [00:08:23] It's dreadful we've had a very good friend who has had an ectopic pregnancy and she looked dreadful. It's obvious isn't it.
Patrick [00:08:31] Most people with a burst ectopic look very unwell. And that is a hospital emergency department type scenario.
Brigid [00:08:39] Yes an over what sort of what period of time? If you feel like symptoms are coming along, where are you feeling symptoms a ruptured ectopic.
Patrick [00:08:48] Yes. Well I think that that needs to be considered by patients and by doctors of anyone who's known to be pregnant and has a bleeding and and severe pelvic pain.
Brigid [00:08:57] Okay. So it's not specifically one sided or it's just incredible pain.
Patrick [00:09:03] So pain, bleeding and known to be pregnant. Yeah. And we would look into that.
Brigid [00:09:07] So there's lots of reasons why somebody might bleed. That doesn't lead to a miscarriage. But what are some of those reasons.
Patrick [00:09:14] Well the in the early pregnancy what's happening is that a million little blood vessels are connecting up between the pregnancy and the lining of the mother's uterus and the. And it's a miracle that they don't bleed all the time and it probably does, and we just don't see most of them. So a lot of that bleeding is harmless. An ultrasound can be used in that setting to show people that the pregnancy is carrying on fine that the source of the bleeding can't be seen. There's not enough blood to show up on ultrasound and that the baby is fine. And that's what usually happens if a woman presents to a hospital emergency department leading an early pregnancy as one of the reasons why we'd like to have a scanner in the department so we can scan people on the spot and say you're fine.
Brigid [00:09:56] Yes, you can go home. Yeah I know this because you know, we're in the same household. But you get some questions, some phone calls at different times of the day and night where someone's had a bright red bleed after sex.
Patrick [00:10:11] Yep some bleeding after sex in pregnancy worries people as well because they again think it's a miscarriage, it's usually not.
Patrick [00:10:19] But it might be. So bleeding after sex in pregnancy needs an ultrasound to investigate. So if everything's fine then we usually advise those couples to steer clear of sex for a couple of weeks, wait for everything to settle down. Then reintroduce sex again and see how they go.
Brigid [00:10:37] And you know we do play the blame game a little bit. If by chance we do then go on and have a miscarriage we look back on all those things that caused miscarriage. And do you think that sex does cause miscarriage?
Patrick [00:10:49] No. No I think that's very clear that it doesn't. We don't know what causes a lot of miscarriages but we do know that it's usually got something to do with the sperm and the egg not coming together properly in the first place.
Patrick [00:11:03] So if we think about the all the DNA from the sperm and all the DNA from the egg they have to come together and be connected up like a giant Zip. And as that zip goes up mistakes can happen. The wrong bits of DNA hook up with the wrong bits of DNA and we wind up with a with an early pregnancy that's capable of surviving until five or six or seven weeks but not beyond that. And that's the cause of most early pregnancy loss. And whilst it's very sad there's nothing that can really be done to prevent those ones.
Brigid [00:11:38] And I think that's really important point to make because a lot of women sort of blame themselves or their situation or their stress at work or whatever it might be. But actually you know there's no control over how that DNA might zip up. That's a really good analogy I like.
Patrick [00:11:53] That's right. There is no control over that and I think it's super important that people understand that miscarriage isn't their fault. So this beautiful thing on the internet somewhere once just the one hand holding up a sign that said presumably to her caregivers. "Thank you for saying that the miscarriage wasn't my fault". And she just needed to be told that because we're human beings and we tend to blame ourselves for things.
Patrick [00:12:19] Yeah and look for causes and yes it's one it can be very frustrating to people when a clear cause of their pregnancy losses and found so then they start saying well it must have been something I did or didn't do.
Brigid [00:12:31] That's right. And miscarriage is pretty common isn't it?
Patrick [00:12:34] Yeah absolutely so. First trimester of pregnancy loss is extremely common. And when I see a couple with their first miscarriage they will tell their family and friends and at that point their family and friends will say that happened to us as well. And thankfully most people recover from it very well and most people who were in good psychological health will accept that the pregnancy loss happened. They will feel very sad about it and a great sense of disappointment at the start but that passes in as little as two weeks. And I see people two weeks later for that very reason because I want to make sure that they're on the right track to emotional recovery and people at two weeks very different. Most people are improving day by day. They've been able to contextualize the early pregnancy loss is something that's very sad but they're already hopeful for the future and almost ready to start trying again.
Brigid [00:13:35] And I've heard you say before you've got a nice little phrase which is something like you might always remember...
Patrick [00:13:41] Oh yeah yeah yeah. Well I just say to people that the pregnancy loss is something that will be with you forever. So if you're a grandma and your granddaughter has a miscarriage you'll say to her. I had a miscarriage too. So you'll it will be with you your whole life. But it won't hurt for very long, people are extremely resilient.
Brigid [00:14:02] Yeah. And those that perhaps do need help like it will be a trigger where they need to sort of seek help from a psychologist or you know.
Patrick [00:14:11] Yeah. So a certain number of people that might be the the mental health straw that you know goes a bit too far. And of course we're talking about people with isolated first trimester pregnancy loss. If you've got recurrent pregnancy loss that's a different scenario and it's very sad. It's difficult to treat. When people have a first trimester miscarriage most people think that they're going to be that person, that it's going to keep on happening. I'll never have a baby. And of course that's not true for most people most people get pregnant again few months later when they finally. Yes. So if you've had about three miscarriages in a row or you've had a miscarriage that are suspicious, like they happened really late, then we have to start investigating those people and treating those people. But for most people it doesn't need investigational treatment, they're not recurrent miscarriages so it's an isolated thing.
Brigid [00:15:08] All right. So someone's experienced a bleed in pregnancy every single bleed needs to be investigated. Is there anything that also happens once you have a bleed in terms of their blood grouping?
Patrick [00:15:20] Yes so by groups relevant at this point so that if a woman's a negative blood group and has had bleeding in pregnancy then each one of those needs to be looked at. That's a part of an issue called Rhesus disease which will cover another day but. Sometimes a bleed in pregnancy is of a sufficient volume that we need to treat the woman with with some stuff called Anti.D. which will neutralise any positive blood cells which might have escaped from a miscarriage into the mother's system.
Brigid [00:15:49] I'm very familiar with having my A.D. shot on a rhesus negative so you know many Anti.D. shots along the 16 years of having babies. Yeah sounds like I've got a lot but there's only 4 in there. Alright so pat. A woman's had a bleed. What's the next step?
Patrick [00:16:08] I think the next step is is for her to be assessed by her doctor for an ultrasound to be to be done to look at the wellness of the pregnancy and if she's a negative group for that to be taken into consideration as well.
Brigid [00:16:24] And there's a pregnancy it's all going well. She goes home and she just carries on her life. But the doctor thinks that she's had a miscarriage. So what are the next steps.
Patrick [00:16:35] Okay so if we know it's a miscarriage and we know that for sure, then there are a few different possibilities. It may be that the pregnancy ends by itself and comes out by itself and that can take time but it's certainly nature's way of just emptying the uterus and some people are happy to wait for that to happen. There are other situations where the bleeding might be very heavy or painful or the miscarriage has happened a bit later in the first trimester and there's a lot of material from the pregnancy to come out and in that suction curette can be a better thing to do. This is a little operation to drain the contents of the uterus using suction and someone's under general anesthetic.
Patrick [00:17:13] And which of those is appropriate is a matter for discussion with the doc based on the clinical scenario and how unwell the woman is and what her and what her preferences are.
Brigid [00:17:26] Well everyone I know that this has been a very heavy topic. It's normal to feel anxious listening to issues around early pregnancy and and feeling like well, what if this happens to me. If you feel like this anxiety is really causing a change to your daily life and impacting on how happy you feel during your daily life then I think it's time for you to seek some more help. And first stop is probably the perinatal anxiety and depression Australia website. It's panda.org.au. They've got a really great mental health checklist and you can do this checklist just to see whether it's time for you to seek some help.
Brigid [00:18:05] All right. Please go and download our pregnancy knowledge check up on our website.
Brigid [00:18:11] And if you haven't already go to our iTunes account and subscribe to our podcast and please tell a friend. We really want our information out there for every woman to have a pregnancy that box.
Patrick [00:18:24] Bye for now. See you next time.