Apologies if it's too long for words.....
Header] Why bleeding needn't mean disaster
[Standfirst] “Seeing red” can be one of the most distressing things to happen in your pregnancy – yet it often doesn’t herald any major problems.
“I was in court with a client when I started bleeding,” recalls lawyer Anjali. “I was four months pregnant – in fact I’d just started thinking I could relax a bit; I went to the loo and found I was having what looked like a heavy period. I had to stuff paper towels into my knickers and go and tell the client I was a bit poorly – poor thing, he had no idea what was going on – before one of my colleagues rushed me into hospital to be checked out.”
Bleeding in pregnancy is surprisingly common. It happens to at least one in four women in their first few months, and quite a few after that; and it’s almost always alarming. After all, your pregnancy kicks off when your period fails to arrive and any spotting, or worse, is bound to trigger fears that everything’s coming to an abrupt halt. But plenty of women go on to have healthy full-term babies even if the medics never establish why they had one or more bleeding episodes along the way.
“Up to 12 weeks bleeding can be entirely normal,” says Dr Maggie Blott, consultant obstetrician at the Royal Victoria Infirmary in Newcastle upon Tyne. Dr Blott doesn’t believe in “breakthrough bleeding” around the time when you’d have a period if you weren’t pregnant. Instead, she cites other reasons why you’d bleed at roughly around this time. “It’s quite common around six to eight weeks when the embryo implants in the uterus, because the whole of the uterus lining is prepared for implantation and when the embryo implants in one spot the rest of the lining may be lost.” You do need to get it checked, she stresses – especially if you’re having abdominal pain as well, which could suggest an ectopic pregnancy (where the fertilised egg implants in the fallopian tubes rather than the uterus – and needs to be treated urgently to prevent further damage to you).
“I did bleed dead-on around the time when I’d have had my period,” says Elena. “There wasn’t much of it but I can remember sitting on the toilet thinking 'oh, that's it then' and feeling a bit sad and deflated. I imagined screaming ambulances, but I got a very low-key response from the out-of-hours doctors: one said ‘rest’, the other said ‘carry on as normal’ and both of them had the attitude that if I was miscarrying, there was nothing they could do till the following Monday, when I could go in for a scan if I was still bleeding.”
Dr Patrick O'Brien, consultant in obstetrics at University College London Hospital, explains why so many women get a similar response. “Yes, you should be checked, but unfortunately there’s usually nothing we can do to stop the bleeding at this stage.” Emily, who’s now 30 weeks pregnant, found herself bleeding one Saturday morning at about eight weeks in. “I rang NHS Direct, and eventually a doctor did get back to me, saying ‘well, if you are going to lose it, you will lose it’, to rest, and that if it didn’t stop I should go to Accident and Emergency. I ended up having an emergency scan on the Monday, and it was only then that I really was reassured. I didn't have cramps and now know that this was probably implantation bleeding, but it was very horrible at the time.”
A scan can’t stop the bleeding but it will check how both you and the embryo are doing, and where the placenta is – if it’s low down in the uterus, a further internal examination could trigger more bleeding. Some doctors start with a speculum examination instead, which won’t disturb a low-lying placenta but will also check the state of your cervix, and whether it’s open and/or “eroded” (the lining has extended to the outer side. “You should be asked for a detailed history of your pregnancy, whether you’ve had any pain, and so on,” adds midwife Sue Macdonald. “Take along any stained pads or clothing to be checked as well. If you’ve lost a lot of blood you may be in shock, which might mean you need a drip, and your ‘input and output’ (all the fluids going into and out of your body) will also be monitored.”
For some women, of course, this sadly is the end. If it does look as if you are miscarrying, most hospitals will offer three choices: to let things happen naturally; a dilation and curettage (D and C) operation, either now or later; or medication to induce contractions. “Women make their decision for themselves. It depends on how you are,” says Dr O’Brien.
In the second trimester – 12 to 24 weeks – bleeding tends to be much less common. “A small amount isn’t that worrying, although obviously you should speak to your midwife about it,” says Dr Blott. “If it’s heavy, go to hospital – to an early pregnancy unit, if there is one. And if you have severe abdominal pain, which could mean that the placenta is coming away, it’s urgent.” A low-lying placenta or a cervical erosion can both cause bleeding at different times – but, as Sam found, sometimes women bleed for reasons nobody can establish. “I had bleeding with both my two boys and I was given all sorts of reasons at different points, from a polyp to placental abruption to cervical erosion. After my first dramatic bleed at around 11 weeks I had some bleeding, like a period, every three or four weeks – and each time I’d panic a bit. I used to go down to the hospital first thing, straight to A and E and have a scan at the early pregnancy unit. I got quite into the habit of it, going down in the morning to save myself an overnight wait, and collecting scans of both the babies stage by stage. By about the sixth or seventh month it was much less frequent, and by then I could feel the baby move, too, so I was much less worried. And funnily enough it didn’t happen at all with my third baby, who was a girl.”
If you do bleed at this point, you don’t necessarily have to follow the traditional advice to put your feet up, says Dr O’Brien. “These days, we don’t think rest or exercise make much difference, although if you do notice that over-exertion makes you bleed more it’s obviously a good idea to stop. And although your iron intake will be routinely checked anyway, it’s sensible to take extra iron if you’re losing blood.” If you’re rhesus negative and you bleed you should also be offered Anti-D to prevent your body forming antibodies against any foetal blood which may have got into your bloodstream during the bleed.
Bleeding after in the last trimester is, as Dr O’Brien puts it, “a whole different ball game. If the baby is likely to be affected, we may have to think about delivering it.” “The quantity of the blood isn’t linked to the seriousness,” adds Dr Blott. “If you’ve got any bleeding, see your midwife or obstetrician straightaway, even though it’s usually nothing to worry about.” This is the stage where Olivia was rushed into hospital with full-scale placenta praevia (where the placenta covers the whole opening to the cervix). “I’d known about it from early on, but at 20 weeks blood absolutely poured out of me, literally as if someone had turned the tap on. It didn’t hurt at all, but it actually bounced off the floor with a pinging noise. My husband rushed me to hospital, swathed in towels – fortunately it had died down slightly – and I was kept in overnight, with steroid injections to mature the baby’s lungs in case they needed to do an emergency Caesarian. I was allowed home – which looked a complete bloodbath, because my husband hadn’t been able to clear up – but after another bleed a couple of weeks later I had to go back and stay in hospital as immobile as possible – until the baby was delivered, absolutely fine, by Caesarian a couple of weeks before his due date.”
Bleeding, agreed all the women interviewed for this article, is bound to scare you stiff. As Sam put it, “No matter what, blood is meant to stay inside you, and you know something’s not quite right if you’re losing it”. But the important thing is that they all took these pregnancies to term. “Yes,” concludes Dr O’Brien, “you should always take it seriously. But remember that for most women who bleed in pregnancy, it all settles down and both they and the baby are fine.” If it happens to you, it’s likely that you’ll have a happy ending too.
[box insert] Becky’s story
I was five weeks in when I first noticed that I was spotting. A scan showed that it wasn’t ectopic, there was a heartbeat and everything looked OK; and they sent me home, saying I might or might not lose the baby.
This carried on for a few weeks. A second scan at the early pregnancy unit showed a healthy baby with a heartbeat, and no obvious cause for the bleeding. Then one day at a routine hospital appointment, I suddenly started gushing blood – sorry, there’s no other way to put it – and they rushed me into the delivery suite for lots of embarrassing and terrifying internals while I watched the doctor’s gloves get progressively bloodier. Eventually another scan showed that I had a haematoma, a bleeding bruise or clot, on my placenta.
So over the next few months I was walking round feeling like a time bomb but having to try and think positively at the same time. Every day I spotted, most days I bled moderately and on a few occasions I gushed, yet every scan showed a healthy baby. My midwife explained that there was an increased chance of premature labour or premature induction, and also a chance that I would in fact lose the baby if the bleeding got to a level that meant the baby wasn’t getting what it needed from my placenta. However, I had a long bleeding-free stretch towards the end, they decided to let me go as far as I could naturally – and unbelievably I actually ended up induced, two weeks late (and the size of a not so small country) after all the earlier worries. And when I pushed my baby out and saw how perfect he was all the worries from the previous months just washed away.
I now make a point of trying to reassure people who bleed in pregnancy, because I can so empathise with that feeling of terror when you see red. It really, really doesn’t have to mean the worst.