It is the most common phone call I get late at night. And it is the most frantic one I get. I can remember during OB/GYN residency when the other residents would complain about this frequent night time call from fertility patients. I never minded that call and appreciated the opportunity to help a patient in need- this was when I knew I was made to be a doctor in the field of reproductive endocrinology and infertility.

The call goes something like this…”I started bleeding, red, and I’m pregnant. I thought everything was going alright. I didn’t do anything differently. What do I do?”

Well, first, take a big breath and hang in there. Know that this is very common and most of the time it turns out ok.
Yes, vaginal bleeding can be a problem. It is often the first sign of a miscarriage. But there are also things that will not be a miscarriage that can cause the bleeding.

Steps to take:

1.  Call the on call doctor for advice.
2. Stop any baby aspirin or blood thinners until you speak with your doctor.
3. Get off your feet and rest.
4. Drink water- rehydrate more than you think is necessary.
5. Check your activity log: did you have intercourse? Did you exercise more today? Did you carry something heavy? Are you constipated and it happened after a bowel movement?
6. Check to make sure you did not miss any medicine—are you still on progesterone?

Vaginal bleeding can come from 3 places:

1. The uterus where the placenta is attached.
2. The cervix, where there are blood vessels on the outside that can be irritated by vaginal medicine and by intercourse. And vessels on the inside that can bleed if the cervix is trying to open prematurely.
3. The vaginal sidewalls that can get irritated from vaginal medicine/applicators or intercourse.

Bleeding can also come from the bladder (urinary infections) or the rectum (hemorrhoids) and It is important to know if it is from one of these 2 other places.

Bleeding that is coming from the uterus/placenta is often caused by a blood vessel tearing. This blood fills in the space between the placenta and the uterus and eventually drips down through the vagina. It can be caused by:

1. A growing or contracting uterus that shears off the placenta and tears a vessel
2. Trauma to the uterus
3. Weak vessels
4. Thin blood
5. Weak hormones that should be supporting the baby’s growth

This bleeding will usually stop and be pushed out as old brown blood or absorbed by the body’s immune system. It is usually not harmful (but is very scary!). If your blood type is NEGATIVE (Rhesus factor) then you need to get a shot of medicine called RhoGam to help prevent your body from making antibodies to the baby if your baby might be POSITIVE.

If you lose a lot of blood or spotting continues you may become anemic and need extra iron or a transfusion in severe cases. But most often, the doctor needs to figure out why you are bleeding to try to prevent it from happening again. We will often perform an ultrasound the next day (it is important to rest off your feet at first to allow the bleeding to stop if you are not hemorrhaging). A progesterone test may be performed to make sure you have enough hormone support. Sometimes an HCG test or estrogen test will be performed, especially if the pregnancy is so early that the ultrasound doesn’t tell us anything. If the baby is growing well and has a heartbeat, then usually the bleeding has been minor and you can heal without fear of miscarriage. However, if the baby is not growing well, then the placenta may not be strong and the bleeding may be the first sign of an impending miscarriage.

Subchrorionic hemorrhage is the term used when blood is seen on ultrasound between the placenta and the uterus. Second and third trimester subchorionic hemorrhages (SCH) are handled differently than ones in the first trimester. A recent prospective study supported the long held belief that SCH’s don’t increase the miscarriage risk. Of 1,115 women in early pregnancy 142 (13%) had ultrasound documented SCH. Dr. Nicole Stamatopoulos found no statistical association between SCH and miscarriage if the baby had a heartbeat. Bleeding earlier (before the heart has been established) is still of uncertain significance.

So, while bleeding in early pregnancy is always scary, it is not always a bad sign. Make sure to call your doctor and take the recommended steps.