Trigger warning: This article discusses pregnancy loss.
For expecting moms everywhere, bleeding during pregnancy, whether it’s light spotting one time or a continual occurrence, is one of the biggest causes of anxiety. Yet, 1 in 4 women experiences some kind of bleeding throughout a healthy pregnancy for a wide variety of reasons.
Dr. Mark Yassa said, “It could be nothing, or it could be something, but either way, we want to ensure that we’re helping you navigate both physical hurdles and the associated emotional difficulties.”
Yassa, an OB-GYN at Novant Health Coastal OB/GYN, is here to provide insight on why women experience bleeding during pregnancy, the different causes of bleeding during the trimesters, and when we should be concerned.
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We know there’s a lot of variation in how pregnancy goes for each woman. What are the common types of bleeding in pregnancy and what might cause them?
The most crucial factor we consider when you’re experiencing bleeding is how far along you are in your pregnancy. How common the bleeding is and how risky it is will vary significantly based on the trimester. First-trimester bleeding can be extremely common. There are several different causes for that first-trimester bleeding:
- Ectopic pregnancy
- Miscarriage
- Implantation bleeding
- Irritation of the cervix or vagina
- A cervical polyp
With second or third trimester bleeding, we do worry if there are more serious concerns at play that could impact a pregnancy. These may include:
- Placental abruption
- Placenta previa
- Preterm labor
- Early cervical dilation
- Cervical insufficiency
These are all conditions we’ll want to screen for, depending on when the mother experiences the bleeding. There isn’t always an identifiable cause of bleeding.
When there’s no apparent cause of the bleeding, how do you work with patients to process the emotions they may be experiencing?
Common causes of bleeding during pregnancy, defined.
Ectopic pregnancy – a pregnancy that occurs outside the uterus.
Miscarriage – an end to pregnancy before the embryo or fetus can survive outside of the womb
Implantation bleeding – light spotting when the fertilized egg implants into the uterine wall, a week and a half to two weeks after fertilization. This typically occurs around the time of a missed period and may be mistaken for the start of a menstrual cycle.
Cervical polyp – an outgrowth of cervical tissue on the cervix, usually benign.
Placental abruption – the separation of the placenta from the uterus.
Placenta previa – when the placenta moves into a position that blocks the cervix, which is the baby’s pathway out of the body. Most cases of placenta previa result in a C-section before full-term.
Preterm labor – labor that begins before 37 weeks of pregnancy.
Cervical insufficiency – when the connective tissue of the cervix can’t hold the cervix itself together, resulting in early cervical dilation. Uncommon, but treatment options exist.
Subchorionic hematoma – when blood collects under the tissue that connects the sac the baby is in (the amniotic sac) to the wall of the uterus. Many subchorionic hematomas go away on their own.
Once I’ve determined there’s no clear cause of the bleeding – I’ve run down that list above – and ensured there is nothing life-threatening to either the mom or the baby going on, then it’s time to reassure the patient that everything is OK. If anxiety levels are higher now that something has happened, which may have shaken the pregnant patient up, I can offer the option to do increased monitoring throughout the pregnancy. That way, we can confirm via ultrasound more often that everything really is OK.
Bright red bleeding – rather than brown or pinkish spotting – can be alarming. Are there times when the sight of bright red blood is not dangerous?
It is always concerning when you experience new, bright red bleeding without a noted cause, but it’s not necessarily a worst-case scenario.
First, talk to a member of your prenatal care team. My main advice would be that if your prenatal care team is not very concerned, that's usually a reassuring finding. They know what a scary amount of bleeding would be and what the reasons would be in those situations, and they know what’s not a cause for concern.
There are a few other common reasons for bright red bleeding that are not miscarriage. These include a cervical polyp that’s been irritated or intercourse that irritated your cervix or vaginal canal. This is what we call provoked bleeding.
It’s common for women to consult “Dr. Google” when they experience something scary like bleeding during pregnancy. Do you think this is helpful or harmful?
It’s extremely common now for patients to come in with things they’ve seen or read on TikTok or an article they found online. If a concern arises that I don’t often hear, I’ll ask the patient where they heard it, and most of the time, it is from social media.
On one hand, I urge my patients to do their research, and I appreciate that my pregnant patients not only have more access to information but are trying to be active participants in their care by researching what’s happening with their bodies. On the other hand, there’s misinformation out there that can either reassure you when you think something serious could be going on, or worry you when there's nothing to worry about.
Realistically, information around pregnancy has always been from secondhand sources – this isn’t something new for OB-GYNs. Before it was social media, it was advice your mom gave you or old wives' tales – like if I stand on my head, the baby won’t be breech (feet toward the vaginal canal).
It’s essential to continue collaborating with your care team, whether you’re inquiring about something you heard from a family member or an influencer. The relationship goes both ways: as medical professionals, it’s our job to listen to our patients’ concerns, discuss them and not dismiss them. The role of the patient in this 40-week collaboration is to hold up their end of the relationship by trusting their care team over secondhand, non-vetted sources.
What are the early warning signs of both miscarriage and an ectopic pregnancy?
Miscarriage
The most common signs of miscarriage are early pregnancy bleeding, pelvic pain and cramping. It's going to feel like menstrual cramps. Usually, both the bleeding and the cramping get worse and worse with heavy clots. A patient may need to change their pad or tampon every hour. Sometimes, depending on how far along the pregnancy is, you may also see the passage of tissue or clots.
It’s easy to assume any bleeding is a miscarriage, but that is not always the case. That’s why I like to educate patients on what else to look for if they’re worried a miscarriage is occurring.
Ectopic Pregnancy
Ectopic pregnancies account for 2% of all pregnancies, so they’re relatively common. With an ectopic pregnancy, you’ll also have early pregnancy bleeding, pain and cramping that can occur. While the symptoms aren’t exactly the same, they can feel and look very similar. We rule out an ectopic pregnancy when we've confirmed that the pregnancy is inside the uterus during your first ultrasound.
An ectopic pregnancy occurs when an egg is fertilized somewhere that is not the uterus. That could be the fallopian tube or an ovary, for example. Implantation will then happen in that location, and since your fallopian tubes and ovaries are not made to carry a pregnancy, a rupture will occur if the pregnancy isn’t caught first.
Because of the location of the pregnancy, you’ll likely experience pain on one side of the body. You may also experience what feels like bloating, nausea, dizziness and you could pass out.
If any of these symptoms occur and you’re filling up a pad or more every hour or two, you should be evaluated in the emergency room.
These symptoms can show up anywhere from five to nine weeks. The longer the ectopic pregnancy goes untreated, the riskier it is for the pregnant woman. So if you have any early signs or worries about an ectopic pregnancy, don’t hesitate to bring them up with your care team.
Are there any causes of bleeding that are not as commonly discussed, or just not as common?
Yes, there are a few we didn’t cover, cervical insufficiency and cervical cancer.
Cervical insufficiency occurs when the connective tissue of the cervix fails to hold the cervix closed throughout pregnancy. Usually, you’ll experience this as painless dilation of the cervix, and you may see some bleeding or abnormal vaginal discharge.
Your doctor may decide to do an exam to look at the cervix. We’re looking to see if it’s open and if it’s short. The cervix should remain closed until the mom is in labor and the baby is ready to be born. It should also stay at its normal length of 3 centimeters until just before labor.
Based on exam findings, we may make the diagnosis of cervical insufficiency. It’s completely treatable in the second trimester with a procedure called cervical cerclage, where we suture the cervix closed. This is not very common.
Cervical cancer is obviously more serious. That’s why we always check to ensure pregnant patients have an up-to-date Pap test, or we perform one at their first prenatal visit with us. If there’s any concern that there is a pre-cancerous or cancerous lesion or mass that needs to be removed before it’s time for delivery, we’ll do a biopsy of the area through a nonsurgical procedure called a colposcopy. The findings from that will help us decide our next steps.
How do you help your patients process why bleeding happened or is happening, especially when there’s no clear cause?
I get questions like this all the time – “Why did this happen to me?” I try to reassure my patients that there’s nothing they did that caused it. It’s not that the dog jumped on your belly too hard. It wasn't that you had that one cup of coffee the other day. It wasn't that you walked the trail too long with your partner.
The only known causes of bleeding that are patient-induced are pelvic irritation, usually by intercourse or insertion of a tampon. In that case, I advise pelvic rest – don’t do anything that may irritate the vaginal canal or cervix.
This is an important conversation we have around miscarriage and pregnancy loss, too, because almost always the mindset is, I must have done something to cause this. In case of a pregnancy loss, the most common finding is just that the fetus was genetically abnormal to the point where the baby wasn’t going to continue to grow or form the way your body expects it to. The body recognizes that, and miscarriage occurs. So even if patients don’t ask me, I will try and reassure them it’s nothing that they did.
What's your advice for women who want to advocate for themselves when they notice spotting or bleeding, and they feel like their concerns are being dismissed?
First, bring it to the attention of a member of your care team. Let them know you’re still worried. As caregivers, it can be easy to overlook the underlying reason why a patient asked a question. It’s easy to answer most questions; it’s harder to understand where the questions are coming from. Is there anxiety, worry or fear here? While we strive to be very attuned to what might be happening beneath the surface, we won’t get it every time.
When I encounter a patient with a lot of questions – someone who has done their research – I might pause the conversation and ask, “Is there something you’re concerned about you’d like to address?” If we can get to the bottom of that, then I can try to alleviate your concerns.
You can always tell a member of your care team, however, something like, “I know you said this is fine, but I’m still worried.” Be as clear as possible with your concerns and your expectations. That way, we can give you your options, and both you and your care team can be satisfied with the relationship.
If you’re on the fence about voicing your concerns, consider that stress is not something we want you to experience a lot of during pregnancy. Anything your care team can do to help relieve that stress is something they’re probably willing to do as long as it’s not harmful to you.
Is there anything we may not be aware of when it comes to bleeding during pregnancy?
This is something most people tend to be very vigilant about. The one thing most patients just don’t consider until they need to is their blood type. If you have any kind of negative blood type (O-, B-, A-), you’ll need RhoGAM at some point. If you experience vaginal bleeding, your blood type should be discussed with your care team. Rhogam is an injection that prevents you from developing any kind of immune response to the pregnancy.
What type of follow-up care or monitoring can patients expect if they do have bleeding during their pregnancy?
The follow-up is based on two things. One is the underlying cause, if we’ve identified one. Based on the cause, we can do follow-up ultrasounds to ensure everything's going well, but these are usually individualized based on other risk factors for the patient. It’s also based on a shared decision-making process with the patient. Sometimes, if you have prolonged bleeding throughout your first or second trimester, you'd probably go see our maternal fetal medicine specialists as well for a consultation with them.
What would you want every pregnant patient to know about bleeding, especially if you’re a first-time mom?
If you experience bleeding, please reach out to your OB-GYN or midwife – whoever is providing you with prenatal care. If you don't have that, vaginal bleeding during pregnancy still needs to be evaluated.
I urge people to seek care. We want to assess any vaginal bleeding during the first, second or third trimester to ensure there isn’t anything serious going on. If you do not have access to routine prenatal care, you can visit the emergency department, an urgent care near you, or a triage unit for evaluation.
