First Trimester Bleeding: How serious is it?

 

Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.

Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus.

Miscarriage: Mild painless vaginal bleeding (often referred to as “spotting”) is usually due to hormonally induced eversion of the glandular cells that line the inner cervical canal, such that erosion develops on the outer part of the cervix that protrudes onto the vagina. The everted glandular tissue is fragile and susceptible to contact trauma, brought about sexual penetration or the insertion of vaginal suppositories. Since such local bleeding does not involve the developing conceptus located inside the uterus it is almost always innocuous. The diagnosis of a local cause of bleeding requires visual inspection of the vagina and cervical inlet a speculum examination. Thereupon, provided that the pregnancy has advanced beyond 5-6 weeks, a concomitant sonogram could confirm the presence of an unaffected pregnancy. Patients are advised to be more careful in inserting vaginal suppositories and to avoid sexual penetration until the bleeding has stopped for at least 1 week.

Sometimes bleeding occurs behind the conceptus inside the uterus (retrochorionic bleeding). Some blood will usually track down through the cervix and into the vagina. A speculum examination will often reveal blood tracking into the vagina through the cervical canal and a sonogram will reveal the presence of a retrochorionic blood clot. Although such retrochorionic bleeding can become an inevitable miscarriage, it often abates and over time the blood clot in the uterus absorbs, and the pregnancy continues normally. Treatment involves careful observation, avoidance of aspirin and other non steroidal anti-inflammatory medications, bed rest and avoidance of vaginal penetration until the condition stabilizes, is essential.

While mild painless vaginal bleeding is usually innocuous, bright red bleeding that increases in amount and is accompanied by escalating pain is another matter altogether. It often suggests an impending inevitable miscarriage.

Before the 7th week of pregnancy a normally rising blood hCG (pregnancy hormone) titers is a comforting indicator that the pregnancy is more than likely progressing normally. Likewise, the detection of a normal heartbeat detected by ultrasound examination done after the 7th week of pregnancy is a very reassuring finding. However, even such findings by no means exclude the possibility of an inevitable miscarriage.

The causes of a miscarriage are multiple and diverse. However in most cases it is due to the developing conceptus being chromosomally/genetically abnormal. However, early miscarriages that reoccur more than twice in a row (Recurrent Pregnancy Loss-RPL) often suggest of an underlying implantation problem that could be due to a poorly developed uterine lining (endometrium) or immunologic dysfunction involving activated immune cells known as uterine natural killer (NK) and/or T-cells. Treatment requires an accurate diagnosis of the cause and selective therapy.

An ectopic pregnancy must be excluded: .Bleeding in the first 2-3 months of pregnancy especially if associated with the sudden onset of acute abdominal pain that is aggravated by movement and is accompanied by right shoulder tip pain, and light headedness or fainting could point to a bleeding ectopic pregnancy (one that is located in a Fallopian tube, outside the uterus) . The condition can be life endangering and warrants an immediate trip to the hospital as it often requires emergency surgery.

Molar pregnancy: Molar pregnancies are due to rapid overgrowth of the trophoblastic tissue that forms the placenta. Although infrequent they can cause early vaginal bleeding in pregnancy. Bleeding from molar pregnancies is often present with typical bleeding which resembles “red currents floating in a red jelly”. Bleeding from a molar pregnancy can either painful or painless. The condition is often associated with severe vomiting in early pregnancy, disproportionate enlargement of the uterus, and very elevated blood levels of hCG. Ultrasound evaluation, often reveals a rather characteristic snow-storm like image.

Patients with a vaginal bleeding are often told to stay in bed. While this might reduce visible blood loss, there is no tangible evidence that it will prevent a miscarriage. Unfortunately, there is no definite treatment for this kind of bleeding in the early stages of pregnancy. Alas, in most cases only time will provide the answer.

2 Comments

Lili

Dr Sheer,
Your help and opinion is needed.
I sadly miscarried and I my local ER didn’t want to check for potential causes
🙁

I had a Frozen embryo transfer and was 6 weeks 5/7

All went so fast. I was at my doc office, waited a long long time. At one point I decided to stand up and walk, I was really annoyed of all the waiting. As soon as I stand, a big huge amount of liquid got out of me. I run to the bathroom and that was a carnage : I had blood everywhere to the knees !! I did knock on my doc door saying I was in trouble. She lay me down on her table and got the ultrasound machine. Baby was there, heartbeat, measuring right on time.
She said to rest for the rest of the day and that it will stop.
I went back home, took a shower (very needed!) and got to bed. I continue bleeding a river with cloths and everything.
On mid afternoon that was awful, I decided to go to the ER. Doc said she couldn’t see, that there was a tsunami in my uterus because the bleeding and the cloths.
She gave me an apointment the next day in radiology. There was nothing to be seen, not even the sac

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Dr. Geoffrey Sher

There is nothing more stressful to patients and to caring physicians than dealing with recurrent early pregnancy losses (RPL). There is also no greater imperative in such cases, than to carefully identify the underlying cause that without which successful treatment is far less likely.

In about 80% of cases, early pregnancy loss (whether due to miscarriage or chemical pregnancy) is due to embryo abnormalities which are usually (but not invariably) related to chromosomal irregularities (aneuploidy) originating in the egg (rather than the sperm). In the remaining 20% of cases, the cause is implantation dysfunction which can result from anatomical (lining), immunologic implantation dysfunction (IID) or molecular biochemical abnormalities.

Since egg and embryo aneuploidy occur so frequently as a variant of normal reproductive performance, it follows that early pregnancy loss is likewise normal to the human condition. Moreover, since egg chromosomal irregularities increase with age advancement beyond 34y, starting at about 1:2 eggs/embryos ty about19; 20 (5%) by age 45y. the incidence of embryo aneuploidy will likewise increase as the woman gets older.

Depending upon how early the pregnancy loss occurs, it might manifest as a positive pregnancy test, prior to the emergence of clinical or ultrasound evidence of a pregnancy (a chemical pregnancy) or later after clinical or ultrasound evidence of an established pregnancy has become evident.

The incidence of early pregnancy loss rises dramatically as the women age beyond 40 years such that by the mid 40’s it is greater than 50%. This is largely due to the age-related increase in egg aneuploidy. Such chromosomal early pregnancy losses occur randomly and sporadically so that a woman might have a baby, lose one or two and then have another healthy pregnancy. In other words, they rarely occur repeatedly (>2 in a row). In contrast, early pregnancy losses that are due to implantation dysfunction (i.e. attributable to surface lesions in the uterine cavity, a thin uterine lining or due to IID) tend to be recurrent in nature. In summary, while miscarriages most commonly occur as a result of chromosomal egg-related embryo abnormalities, these rarely present as recurrent losses and thus when recurrent pregnancy loss (RPL) occurs, it is important to consider and rule out implantation dysfunction problems as the primary cause, before proceeding to another IVF attempt.

Women who have repeated IVF failures thus need to be evaluated thoroughly for both embryo competency and implantation dysfunction before and/or in the course of their next IVF attempt. Implantation problems should be evaluated before proceeding to the next IVF cycle. The tests needed include:
1. Evaluation of the anatomical integrity of the uterus. This necessitates performance of a sonohysterogram (saline sonogram), a hysteroscopy or a pelvic MRI (rarely is it necessary to go this far). A hysterosalpingogram (HSG), also known as a dye x-ray, is inadequate because it involves injecting a radio opaque substance into the uterine cavity which can obscure small lesions due to scarring, polyps or fibroids protruding into the uterine cavity.
2. Assessment of endometrial thickness. This can be determined by ultrasound examination around the time of normal ovulation or can be determined based on endometrial thickness as measured in previous cycle. A lining of > 9 mm in thickness is ideal. Less than 8 mm is poor and between 8 – 9 mm in thickness is “intermediate”. In my opinion, embryos should not be transferred into a uterus where the lining measures < 8 mm. The administration of vaginal Viagra (sildenafil) suppositories for at least 72 hours prior to the hCG trigger will often dramatically improve a “thin lining”. 3. Autoimmune and alloimmune causes of immunologic implantation dysfunction should be assessed. Since both allo-and autoimmune implantation dysfunction ultimately are linked to Natural Killer Cell activation, you can start by doing a Natural Killer Cell activity (NKa) test using the K562 target cell test and/or endometrial cytokine analysis, and only proceed to more detailed evaluations if this turns out to be abnormal. Numerous blog articles on this site provide more details on IID and the use of immunotherapy that address/reverse such problems. 4. Testing molecular and biochemical factors in the endometrium. There has been a growing interest in measurement of various endometrial factors as a method to assess implantation potential, including the endometrial receptivity assay (ERA) and other molecular assessments. Frankly, I personally do not share enthusiasm for most such tests which by and large lack concrete evidence of efficacy. Recent advances in egg and embryo karyotyping using Preimplantation Genetic Screening (PGS)- technologies have improved the our ability to identify “competent” chromosomally normal embryos for transfer. This requires biopsying the advanced embryo (blastocyst) and testing its DNA for aneuploidy. When the so tested, embryo transfer must be deferred until a subsequent hormone replacement cycle (staggered IVF) so as to allow enough time for the results of the testing to become available. In such cases the embryos can be vitrified (ultra rapidly frozen) and stored for subsequent dispensation without prejudice. Aside from the above, there are other less common causes of embryo incompetency (e.g., unbalanced embryo chromosomal translocations) and implantation dysfunction (bacterial and parasitic infections, etc.). ADDENDUM: PLEASE READ!! INTRODUCING SHER FERTILITY SOLUTIONS (SFS) Hitherto I have personally performed IVF- treatment and related procedures on patients who, elected to travel to Las Vegas to be managed by me. However, with the launching of Sher-Fertility Solutions (SFS) in April 2019, I have taken on a new and expanded role. Now, rather than having hands-on involvement I confine my services to providing hour-long online Skype consultations to an ever-growing number of patients (emanating from >40 countries), with complex Reproductive problems, who seek access to my input, advice and guidance. All Skype consultations are followed by a detailed written report that meticulously describes and explains my recommendations for treatment. All patients are encouraged to share this report with their personal treating doctor(s), with whom [subject to consent and a request from their doctor] I will, gladly discuss their case with the “treating Physician”.
Through SFS I am now able to conveniently provide those who because of geography, convenience and cost, prefer to be treated at home or elsewhere by their chosen Infertility Physician.
“I wish to emphasize to all patients with whom I consult, that in the final analyses, when it comes to management, strategy, protocol and implementation of treatment, my advice and recommendations are always superseded by that of the hands-on treating Physician”.

Anyone wishing to schedule a Skype consultation with me, can do so by: Calling my concierge (Patti Converse) at 1-800-780-7437 (in the U.S.A or Canada) or 702-533-2691, for an appointment. Patients can also enroll online on my website, http://www.SherIVF.com, or email Patti at concierge@SherIVF.com .
I was very recently greatly honored in receiving an award by the prestigious; International Association of Top Professionals (IAOTP). For more information, go to the press release on my website, http://www.sherIVF.com .

PLEASE HELP SPREAD THE WORD ABOUT SFS!

Geoff Sher

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