There are many causes of bleeding in pregnancy, some are not of vaginal or uterine origin, and are due to lesions in the anus (anal fissures, hemorrhoids) or even the urinary tract (urinary tract infection). Even when bleeding is vaginal, it is important to know that often the blood is of maternal origin and not properly the developing fetus. Thus, some characteristics of bleeding, associated symptoms, physical examination and ultrasonography will guide the doctor to a more accurate diagnosis.
Attention: When bleeding is bulky or accompanied by colic or intense pain the pregnant woman should seek the referral hospital immediately!
Firstly the pregnant woman herself may try to observe if the bleeding actually comes from the vagina. Most often, when the source is anal, as in cases of hemorrhoids, there is difficulty and pain to evacuate and bleeding occurs at the time of evacuation. When there is a urinary infection, such as in cystitis, there may be pain or burning when urinating and an increase in the frequency of urination.
Some external lesions on the vulva (outside of the female genital organ) also cause bleeding. These are usually related to trauma such as sexual intercourse or waxing. In case of vaginal bleeding, it is necessary to observe the quantity, if small or intense; color, whether red-hot or darker; if it is constant or intermittent and if there is pain or colic associated.
Depending on the time of gestation the causes of bleeding will be different. Therefore, they will be divided as first or second half of pregnancy. In this text we will address bleeding at the beginning of pregnancy, to be more accurate, in the first half of pregnancy. The bleeding that occurs at the end of pregnancy (in the second half) will be covered in a text to be published in the coming weeks.
In the first trimester, 20 to 40% of the pregnant women present with vaginal bleeding. The main causes are:
1. Due to miscarriage
2. Implantation of gestation in the womb (implantation of the fertilized ovum in the uterus may cause minor bleeding)
3. Ectopic pregnancy (outside the womb, as in cases of tubal pregnancy)
4. Pathology of the cervix, vagina or uterus (trauma, inflammation/infection, polyps)
Many times the doctor can not determine the cause of the bleeding. The main goal is to exclude diagnoses that may have negative repercussions for the ongoing pregnancy.
The most common causes are those resulting from abortion, whether it is only a threat or unavoidable. Pregnancy outside the uterine cavity, as in the tube, is the most important diagnosis to be excluded. In this situation, there is a risk of rupturing the tube and causing intense bleeding, which could threaten the life of the pregnant woman. In general, the more intense the bleeding and colic, or abdominal pain, the greater the chance of being one of these causes and the more urgent the clinical evaluation should be.
Pregnant women who have had two or more abortion episodes are at increased risk of another episode. Similarly, patients who have had an ectopic pregnancy or who have risk factors such as pelvic inflammatory disease, IUD use at childbirth, or previous pelvic surgery, are more likely to have a new pregnancy out of the womb.
It is important to tell the doctor if an ultrasound has been performed that has demonstrated pregnancy inside the uterus, which makes the diagnosis of ectopic gestation unlikely. If you do not have it, the dosage of Beta-HCG confirming the pregnancy should be presented.
b) Physical examination
Complete physical examination is most important in the evaluation of bleeding. First, blood pressure and heart rate will be evaluated. The examination of the abdomen may lead the healthcare professional to think of causes that are not gynecological or obstetrical for abdominal pain, such as appendicitis.
Up to 12 weeks' gestation, the uterus can not be palpated by the abdomen, and fetal heart rate (FHR) is not evaluated with Doppler sonar. When the pregnant woman has more than 12 weeks of gestation, the uterus is palpable and the FHR perceived is reassuring. It ensures that abortion did not happen and virtually excludes the diagnosis of ectopic pregnancy.
Then the vulva and anal region are examined for lesions that may be a bleeding site. Specular examination will diagnose cervical conditions: lacerations, polyps, inflammatory / infectious processes (vaginal discharge), ectopia (cervical fragility), warts or tumors. The vaginal touch will assess the size of the uterus, if compatible with the time of pregnancy, evaluate the adnexal regions looking for signs of gestation outside the uterus and whether the cervix is open or closed.
c) Ultrasonography
Transvaginal ultrasonography is the main method of evaluating bleeding in pregnancy, especially when it has not been performed in the current pregnancy. It confirms the pregnancy inside or outside the uterus, evaluates the number of fetuses and the presence of heartbeats.
It is important to note that pregnancies with less than five weeks of evolution can not be evaluated by ultrasonography and the best way to evaluate them at this stage is by measuring the Beta-HCG. When the Beta-HCG level is compatible with the time of pregnancy we should wait up to 6 or 7 weeks to perform the ultrasound. When smaller than expected may mean miscarriage or ectopic pregnancy. This dosage can be serial, when the Beta-HCG level falls this is abortion, when it rises slowly suggests the pregnancy outside the uterus.
Treatment will depend on the cause of the bleeding. Many causes do not require specific treatment.
Important: whenever suspected bleeding due to abortion or ectopic pregnancy, pregnant women with Rh-negative blood type should receive anti-Rh immunoglobulin.
When we can not identify the cause, the bleeding does not endanger the life of the pregnant woman, the clinical examination is normal and the ultrasound confirms the well-being of the pregnancy, general guidelines are made, mainly to observe the appearance of new symptoms. These cases usually have a favorable evolution and the bleeding usually stops spontaneously.
Bleeding from implantation of gestation in the uterus and most lesions of the vulva, vagina or cervix do not require treatment, unless the bleeding is severe or the cause is, for example, a tumor in the cervix.
In the case of threatened abortion it is difficult to evaluate the effectiveness of some type of treatment because when seen in pregnancy in the uterus and embryo with FHR the chance of success without any specific measure is 90 to 96% in gestations between 7 and 11 weeks and bigger still with more time. Many physicians opt for clinical observation.
In-progress or incomplete abortions can be treated expectantly, with medications or by surgical methods. This evaluation is individual and at the discretion of the physician with the patient.
Complete abortion also does not require specific action.
In most cases, ectopic pregnancy is a medical emergency, requiring emergency surgery. Sometimes it is possible to choose with medication treatment or by clinical observation.
