When You See Red, Don’t Panic: First Trimester Bleeding

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     There is nothing more disconcerting than looking down and seeing red. Whether it’s dark or bright, light or heavy, it can make you hold your breath and start praying. Blood is viewed as the harbinger of very bad things to come. (For all of you Game of Thrones fans, it’s like winter is coming!) But the reality is that blood, be it red or brown, with or without cramping, does not mean this pregnancy is case closed. It could mean absolutely nothing at all.

     And while we get that this is hard to believe and even harder not to panic over, bleeding in early pregnancy is incredibly common. In fact, it is the most common call an OB/GYN gets. It occurs in up to 40% of all pregnancies! It is so common that we can recite the list of dos and don’ts, shoulds and shouldn’ts, whys and why nots in our sleep (which is good, because these calls usually come in the middle of the night!).

     First things first, bleeding in pregnancy is not always pregnancy related. Pregnant women still have intestines, vaginas, and cervices that will bleed irrespective of that baby on board. So while the first finger everyone points is towards your belly, we need to make sure that the uterus is really where things are coming from. Things like cervical polyps, cervical irritation, vaginal tears, and vaginal warts can cause vaginal bleeding. While they are not harmful for you or your pregnancy, identifying them early can ease anxiety and allow us to treat them. In very rare cases, such bleeding can be indicative of a cervical or vaginal cancer, so a good look inside by your OB is important.

     On a slightly different note, the rectum can bleed for a number of reasons during pregnancy. Pregnancy is marked by constipation, pressure, and changes in our bathroom habits. This can exacerbate or lead to things like hemorrhoids, anal fissures, and polyps (not fun). And not only can they cause pain, itching, and discomfort, but they can also bleed. Rectal blood is often mistaken for vaginal blood. While no blood is good blood, rectal bleeding has nothing to do with the health of the pregnancy.

     The big three of early bleeding in pregnancy are the following—miscarriage, ectopic, implantation or physiologic bleeding (a.k.a. nothing to worry about). How we differentiate between the three usually requires both a good chat and a good check. During the chat part, we will ask you questions about timing, quantity, pain, and the events that preceded the bleeding (intercourse, activity, etc.). We will also want to know when your last period was, if you took fertility medications, and if you have recently seen an OB. This will allow us to narrow down the culprit. The “check” part will include both a pelvic exam (who doesn’t love that speculum?) as well as an ultrasound and blood work.

What we are looking for are things like:

  • Is the cervix open?
  • Can we see a pregnancy in the uterus?
  • Is there blood surrounding the pregnancy (subchorionic hematoma) or in the pelvis?
  • Is your pregnancy hormone appropriately elevated?
  • What is your blood type?

These checkpoints, combined with a good chat, will clear the way for a diagnosis (and hopefully a cease fire to this bleeding).

     Sometimes the reason behind bleeding in pregnancy isn’t so clear. And while we certainly don’t want to torture you, it can take a few visits and even a couple of weeks to answer the questions where it is coming from and if this pregnancy is going to be a go. Oftentimes, we need to take a second or third look with the ultrasound and at the pregnancy hormone before we can comfortably call it. During this time, we may ask you to take it easy (no exercise, no intercourse), stay close to home (no major travel), and keep us on speed dial. We want to know what’s going on, as this may get us to make the diagnosis quicker.

     Bleeding in pregnancy not only brings women anxiety but also guilt and blame (almost all of which we point towards ourselves). However, whether bleeding happens for no identifiable reason or because of a miscarriage, in neither case is it a result of something you did, something you ate, or something you didn’t do. Bottom line, it is not your fault. Say that in your head ten times over until you truly believe it. Unfortunately, sh–t happens. And while that may not be eloquent, it is the truth.

     Although you probably found us through a Google search, an Instagram post, or a Tweet, the Internet can be a dangerous place (particularly in the middle of the night when it comes to bleeding and pregnancy). And while we too have our “Google MDs” (in everything non-OB/GYN related) and like to browse and self-diagnose, we caution you from putting a lot of stock into what you read and what you see. It may do nothing more than make you crazy and keep you from getting a good night’s sleep (which every expecting mother needs)!
     To put it bluntly, we have seen women soak their beds with bright-red blood who go on to deliver healthy babies and those who notice one spot of dark-brown blood who go on to miscarry. Nothing is predictive. So doctor’s orders (after you read this): close your computer. Pull out a good book, or put on a funny movie. Getting your mind off of what’s going on below is the best way to pass the time. Laughter certainly won’t make matters worse. Let your doctor focus on the detective work.