Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse. Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus. Miscarriage: Mild painless vaginal bleeding (often referred to as “spotting”) is usually due to hormonally induced eversion of the glandular cells that line the inner cervical canal, such that erosion develops on the outer part of the cervix that protrudes onto the vagina. The everted glandular tissue is fragile and susceptible to contact trauma, brought about sexual penetration or the insertion of vaginal suppositories. Since such local bleeding does not involve the developing conceptus located inside the uterus it is almost always innocuous. The diagnosis of a local cause of bleeding requires visual inspection of the vagina and cervical inlet a speculum examination. Thereupon, provided that the pregnancy has advanced beyond 5-6 weeks, a concomitant sonogram could confirm the presence of an unaffected pregnancy. Patients are advised to be more careful in inserting vaginal suppositories and to avoid sexual penetration until the bleeding has stopped for at least 1 week.Sometimes bleeding occurs behind the conceptus inside the uterus (retrochorionic bleeding). Some blood will usually track down through the cervix and into the vagina. A speculum examination will often reveal blood tracking into the vagina through the cervical canal and a sonogram will reveal the presence of a retrochorionic blood clot. Although such retrochorionic bleeding can become an inevitable miscarriage, it often abates and over time the blood clot in the uterus absorbs, and the pregnancy continues normally. Treatment involves careful observation, avoidance of aspirin and other non steroidal anti-inflammatory medications, bed rest and avoidance of vaginal penetration until the condition stabilizes, is essential.While mild painless vaginal bleeding is usually innocuous, bright red bleeding that increases in amount and is accompanied by escalating pain is another matter altogether. It often suggests an impending inevitable miscarriage. Before the 7th week of pregnancy a normally rising blood hCG (pregnancy hormone) titers is a comforting indicator that the pregnancy is more than likely progressing normally. Likewise, the detection of a normal heartbeat detected by ultrasound examination done after the 7th week of pregnancy is a very reassuring finding. However, even such findings by no means exclude the possibility of an inevitable miscarriage.The causes of a miscarriage are multiple and diverse. However in most cases it is due to the developing conceptus being chromosomally/genetically abnormal. However, early miscarriages that reoccur more than twice in a row (Recurrent Pregnancy Loss-RPL) often suggest of an underlying implantation problem that could be due to a poorly developed uterine lining (endometrium) or immunologic dysfunction involving activated immune cells known as uterine natural killer (NK) and/or T-cells. Treatment requires an accurate diagnosis of the cause and selective therapy. An ectopic pregnancy must be excluded: .Bleeding in the first 2-3 months of pregnancy especially if associated with the sudden onset of acute abdominal pain that is aggravated by movement and is accompanied by right shoulder tip pain, and light headedness or fainting could point to a bleeding ectopic pregnancy (one that is located in a Fallopian tube, outside the uterus) . The condition can be life endangering and warrants an immediate trip to the hospital as it often requires emergency surgery. Molar pregnancy: Molar pregnancies are due to rapid overgrowth of the trophoblastic tissue that forms the placenta. Although infrequent they can cause early vaginal bleeding in pregnancy. Bleeding from molar pregnancies is often present with typical bleeding which resembles “red currents floating in a red jelly”. Bleeding from a molar pregnancy can either painful or painless. The condition is often associated with severe vomiting in early pregnancy, disproportionate enlargement of the uterus, and very elevated blood levels of hCG. Ultrasound evaluation, often reveals a rather characteristic snow-storm like image. Patients with a vaginal bleeding are often told to stay in bed. While this might reduce visible blood loss, there is no tangible evidence that it will prevent a miscarriage. Unfortunately, there is no definite treatment for this kind of bleeding in the early stages of pregnancy. Alas, in most cases only time will provide the answer.
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