Bleeding in early pregnancy is a common problem and there are usually no consequences for the pregnancy. Sometimes, however, it can mean there will be a miscarriage or, less commonly, an ectopic pregnancy (pregnancy outside the womb (uterus), usually in the fallopian tube). The only way to be certain is to have an ultrasound scan which will detect a heart beat in the fetus from between 6 and 7 weeks of pregnancy. However, when we are calculating dates, we count from the first day of your last period, and assume that you conceived two weeks after that date. That may not be so in all pregnancies, particularly if you have an irregular menstrual cycle.
What happens if you bleed before six weeks?
Bleeding at the time of your first missed period is called implantation bleeding and is quite common. Whether it is due to the embryo implanting or not is uncertain, but it happens around the time that implantation is taking place. A blood test for your HCG (pregnancy hormone) and progesterone (pregnancy-maintaining hormone) can be helpful in this situation. If the HCG is at the expected level for your stage in pregnancy (there is a wide range of normal values) and the progesterone is 45 or greater, there is a 90% chance that your pregnancy will continue. If either hormone is less than expected then there is a 50:50 chance that you will lose the pregnancy. The HCG rises very quickly and should double within 48 hours in a healthy pregnancy so a repeat test will confirm this. A smaller rise means that you are more likely to lose the pregnancy or that it is an ectopic pregnancy.
What if the heart beat is present?
Once the fetal heart beat has been seen on an ultrasound scan and is a normal rate (100 beats per minute or greater), there is a 95% chance that the pregnancy will continue, even if you are still bleeding. Once you get to 10-12 weeks of pregnancy with a live fetus the risk of miscarriage is less than 2%. However, because it is stressful when you bleed and continue bleeding in early pregnancy, I suggest you come for weekly scans till 12 weeks to reassure you and make it more bearable.
What are the causes of miscarriage?
Most times the cause is not obvious. The risk of miscarriage increases with maternal age (50% in women over 40) and paternal age. In these instances the miscarriage is most likely to be caused by a genetic problem in the fetus (e.g. Down Syndrome). Other medical conditions in women such as polycystic ovarian syndrome and thyroid disease increase the chance of miscarriage, although the cause is uncertain.
In men, damage to the DNA in sperm also leads to a higher miscarriage rate and the importance of this is that the problem can often be fixed by modifying lifestyle factors alone (for more information see www.fertilityfirst.com.au)
Do you need to have a curette?
If your pregnancy is no longer viable, then as long as the bleeding is not heavy or too painful it is safe to wait, as most studies show that two out of three women will completely miscarry by themselves without needing further treatment. The difficult part is waiting for it to happen, knowing that the fetus has died. This can take two to three weeks and is less likely to happen by itself if your cervix is still closed and the sac is still present (this is called a missed miscarriage). There is a small risk of infection but, in practice, this is very unlikely.
The alternative is to have a curette (or D & C, dilatation and curette) which is a short surgical procedure performed under a general anaesthetic as a day case. The neck of the womb (cervix) is dilated and a plastic catheter is inserted into the uterus and the contents are removed and may be sent off for further testing or discarded. As with any surgery, there are risks with this procedure, although the risk is low and it is usually straightforward and quick.
What if you’ve had more than one miscarriage?
Because miscarriages are common (about 20% of pregnancies), most doctors will not recommend further investigations until you have had three or more pregnancy losses. The investigations are mostly blood tests and are expensive. If you are older (35 or more) it may be sensible to think about doing the testing after two pregnancy losses as you have less time to spare. I am happy to discuss this with you.
What treatment is available?
Sadly, very little. Intensive monitoring in early pregnancy (weekly visits with ultrasound scans) has been shown to improve success rates and will help you to cope. One of the uncommon causes of repeated miscarriage is a clotting abnormality (detected by the investigations) and this may be treated by daily doses of low dose aspirin and heparin (a blood thinning agent which can only be injected).
Should you give up?
Only you and your partner can decide this. The statistics are on your side. In young women (25-29) the chance of having a healthy pregnancy is 55% even after four pregnancy losses. The success rate decreases with age but it is also important that you don’t stop too soon and later regret not ‘giving it your best shot’..
Where can you get help?
If you are bleeding and concerned, please ring me at my rooms or page me after hours (ph. 9214 1015). If you don’t have private insurance, there is an Early Pregnancy Assessment Service at St George Hospital which runs daily from 8.30-9.00am in the Women’s Health Clinic for women with problems in early pregnancy. If it is more urgent, you will need to go to your local Emergency Department.
If your problem is repeated miscarriage please come and see me prior to getting pregnant where possible, so that we can organise any necessary investigations and discuss how we will manage your next pregnancy.
There is no public clinic in the St George/Sutherland area although we hope to establish one in the next 12-18 months if funding becomes available.