Women Talk: Bleeding during pregnancy

During pregnancy, especially in the first few weeks, women notice some brownish discharges, or even frank bleeding. Old folks often reassure them that this is normal, and call this “pagbabawas.” 

 

However, vaginal bleeding during pregnancy is never normal. Barring medical conditions and local lesions in the vagina and cervix (tumors or lacerations), we usually divide the pregnancy into halves, the first and the last, to look at the causes for these bleeding. 

 

First half

 

Most common obstetrical causes of bleeding during the first half of pregnancy  include threatened abortion, ectopic pregnancy, and H-mole.

 

Threatened abortion may be brought about by separation, or near-separation of the fetus’ attachments to the mother’s uterus, which could lead to a miscarriage. Crampy pain in the lower abdomen may be felt, as the uterus contracts, hence the pain is not unlike that of dysmenorrhea. A pelvic ultrasound may show a “subchorionic hematoma” which is a pool of blood below the attaching membranes. These may spontaneously be resorbed by the body and the pregnancy continue normally. Or it may grow larger until the attachments are peeled off, causing fetal demise, because nutrients could no longer be received by the fetus. 

 

An obstetrical consult is needed when vaginal spotting or bleeding occurs. Medications may be given, or bed rest is advised. Some epidemiologists say that there is no evidence that bed rest works, but avoiding the stress of work and rushing around could calm the mother. Staying at home and taking it easy, according to most of my patients, helped them a lot.

 

An ectopic pregnancy is an abnormal pregnancy outside the uterus. Because the body detects a pregnancy, the lining walls of the uterus are also transformed into a thick and lush structure as if the pregnancy is a normal one. When the ectopic pregnancy starts to have problems with its blood supply, there will be decrease in pregnancy hormones. Support for the lining walls of the uterus decreases, and superficial layers may start to slough off, and the result is vaginal bleeding. Again, some pain may be felt, as the uterus contracts, or when the bleeding irritates the peritoneum.

A pelvic ultrasound may be of help to diagnose the ectopic pregnancy.

 

A molar pregnancy (hydatidiform mole) is an abnormal pregnancy where instead of a fetus, large grape-like, cystic structures are formed from the cells of the placenta. Many times, the first clue is when the size of the uterus is not compatible with the dates of the last menses.

An ultrasound will be very helpful, and after the diagnosis is done, the H-mole is evacuated, usually by suction and sharp curettage. Many times, prophylactic medicines are given after the curettage, depending on the monitored levels of HCG (human chorionic gonadotrophin, a hormone of pregnancy).

It is important to know that some molar pregnancies could turn malignant (choriocarcinoma) so a diligent follow-up with your doctor in the succeeding months is very important. Some patients neglect to do so, especially because after the curettage everything seems to be fine. But the spectre of a malignancy is always there.

 

Second half

 

During the second half of pregnancy, the most common causes of vaginal bleeding include placenta previa, abruptio placenta, and preterm labor.

 

The normal placenta is implanted high in the fundus (uppermost part of the uterus), away from the cervical opening. However, some placenta are implanted low, and could even cover the cervical opening, making normal delivery of the baby impossible without incurring massive bleeding. This is because the placenta is a very vascular structure, with large blood vessels criss-crossing it. Diagnosis is done by ultrasound. Many times however, the placenta “moves” slowly upwards (placental migration) away from the cervical opening, as the pregnancy progresses; and a normal delivery is possible. 

 

No actual cause could be given for placenta previas, but some researches invoke previous CS scars where the placenta could attach themselves, low in the uterus. Sonologists also measure the distance between the placental edge and the cervical opening, and deem 2.5 cm as a cut-off for saying it is a previa; otherwise it becomes a “low-lying placenta,” which can still cause bleeding when labor ensues. 

 

Abruptio placenta occurs when there is premature detachment of the placental membranes from their attachments. This usually happens during severe pre-eclampsia (hypertension of the mother, with or without edema, or urine findings), or sometimes, trauma to the abdomen. This is accompanied by prolonged hardening of the uterus, and is an obstetrical emergency, so the woman should be rushed to the hospital, as her life, and the baby’s, are already severely compromised. An emergency caesarean section is done to save both lives. 

 

Many times, vaginal bleeding during the last half of pregnancy could be accompanied by rhythmic, tolerable contractions. If persistent, the woman could be in preterm labor (or, premature labor); that is, the pregnancy has not yet reached at least 38 weeks.

From time to time, especially when the woman is nearing her due date, some uterine contractions are felt, which could be painful. These are called false labor pains, or Braxton-Hicks. She is advised to time the contractions in her watch, and if they come regularly, with increasing intensity and shorter intervals, it is best to see her doctor immediately. This may be accompanied by vaginal spotting or pink/red mucous discharge, as the small cervical capillaries break as the cervix dilates. 

 

If the woman is still below 38 weeks, her doctor might decide to give her medications, whether intravenously or orally, that could stop the contractions. Admission to the hospital might be needed. The baby could thus spend more time in the mother’s womb, gain more weight, and lungs given more time to mature before delivery. Bed rest is often recommended, as the patients themselves feel better and lighter when they are off their feet. The combined weight of the baby, placenta, amniotic fluid, and the weight gained during the past months could lead to back and shoulder aches during the last month. —KG, GMA News

Dr. Alice M. Sun-Cua is an author and practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.