Is Spotting or Bleeding During Pregnancy Normal?

How many women experience bleeding or spotting during pregnancy?

Roughly 25% of women will experience bleeding or spotting in the first trimester of pregnancy. If you are having bleeding or spotting, you are definitely not alone. There are many of us who have gone through this too. Somewhere between 8-15% of all recognized pregnancies will end in miscarriage, but this includes missed (or silent) miscarriages where bleeding may not be present. This means that many women who experience bleeding or spotting go on to have healthy babies!

So we learned that bleeding or spotting in pregnancy is common and not always cause for alarm. However, bleeding and spotting in pregnancy is not normal. If you are experiencing bleeding or spotting, you should always call your provider.

What causes bleeding or spotting in pregnancy?

Implantation bleeding

Implantation bleeding usually occurs 10-14 days after conception. It is a small amount of spotting or bleeding that stops on its own. 

Miscarriage 

Miscarriage is the spontaneous loss of pregnancy before week 20. Bleeding or spotting can be a sign of miscarriage. However, a miscarriage may be found on testing without any bleeding or spotting occurring.

Molar pregnancy

Molar pregnancy is rare. It occurs when cells call trophoblasts grow abnormally. Trophoblasts should form the placenta, but in a molar pregnancy the trophoblasts grow irregularly. This can lead to a variety of complications, some of which are serious. Bleeding can be a sign of molar pregnancy.

Infection or growth on the cervix

STIs and UTIs can cause bleeding in pregnancy. The infection will need to be diagnosed and treated by your provider. A growth on the cervix can also cause bleeding or spotting.

Subchorionic Hematoma (SCH)

SCH occurs when blood collects between the uterus and the amniotic sac. This may cause bleeding or spotting in pregnancy, but some people will never have any symptoms. A SCH may resolve itself on its own, or it may lead to further complications. SCH should be evaluated by your provider to determine if any additional monitoring or activity restriction is needed.

Ectopic pregnancy

In ectopic pregnancy, the fertilized egg implants somewhere outside the uterus, like the fallopian tube. This can become a medical emergency if not treated.

Incompetent cervix

The cervix is supposed to remain closed until it is time to give birth. With an incompetent cervix, the cervix begins to open too early, leading to preterm labor. Spotting can be an early sign.

Preterm labor

Vaginal bleeding can be a one of the symptoms of preterm labor. It is important to call your provider if you think you are experiencing preterm labor.

Placental abruption

Placental abruption is when the placenta separates from the uterine wall. This can cause bleeding. If placental abruption needs to be treated promptly, as it can be harmful to both baby and mom.

Placenta previa

Placenta previa is when the placenta is fully or partially blocking the cervix. This can resolve by itself with time and growth. However, bleeding after 20 weeks gestation is the primary symptom placenta previa. With placenta previa, the mother is monitored very closely to reduce risk of complications, and the baby will be delivered by c-section

Uterine rupture

Uterine rupture is rare. This occurs when the uterus tears along the scar from a previous c-section. Uterine rupture should be treated right away.

What should I do if I have spotting or bleeding during pregnancy?

Even if your bleeding or spotting is light and goes away quickly, you should still let your provider know. As far as specific recommendations, I’m going to quote professionals and share with you these Recommendations from Mayo Clinic:

1st trimester

During the first trimester (weeks one through 12):

• Tell your health care provider at your next prenatal visit if you have spotting or light vaginal bleeding that goes away within a day
• Contact your health care provider within 24 hours if you have any amount of vaginal bleeding that lasts longer than a day
• Contact your health care provider immediately if you have moderate to heavy vaginal bleeding, pass tissue from your vagina, or experience any amount of vaginal bleeding accompanied by abdominal pain, cramping, fever or chills
• Inform your health care provider if your blood type is Rh negative and you experience bleeding because you might need a medication that prevents your body from making antibodies that may be harmful to your future pregnancies

2nd trimester

During the second trimester (weeks 13 through 24):

• Contact your health care provider the same day if you have light vaginal bleeding that goes away within a few hours
• Contact your health care provider immediately if you have any amount of vaginal bleeding that lasts longer than a few hours or is accompanied by abdominal pain, cramping, fever, chills or contractions

3rd trimester

During the third trimester (weeks 25 through 40):

• Contact your health care provider immediately if you have any amount of vaginal bleeding or vaginal bleeding accompanied by abdominal pain

Should I go to the Emergency Room if I’m experiencing bleeding?

There are some times where a visit to the Emergency room (ER) is completely warranted. If you are experiencing heavy bleeding (soaking through more than 1 pad in a hour), you should go to the ER.You should also go to the ER if you are having severe pain, dizziness, or chills. If you have not yet had an ultrasound and you are concerned about ectopic pregnancy, you should go to the ER.

Another reason you may need to go to the ER is if your provider is unable to see you for your concern in a timely manner. For example, bleeding in early pregnancy could be a sign of ectopic pregnancy, which is a medical emergency. This is typically ruled out via ultrasound – checking to see if the gestational sac is in the uterus where it should be. A gestational sac should be visible in the uterus if your beta-hCG level is higher than 1,500 mlU per mL. If you call your provider and they can get you in quickly for an appointment, you don’t need to go the ER. They can order beta-hCG levels and complete a scan to rule out ectopic pregnancy. On the other hand, if they aren’t able to see you soon enough, you may need to go to the ER. This is because if an ectopic pregnancy continues to go untreated, it can become an emergency.

It is important to realize that in some cases, the ER may not be able to do anything for you. I’ve read the stories of many women who went to the ER at 5 weeks pregnant with bleeding and were shocked when there was little that could be done or seen.They were disappointed that they left without any answers and were simply told to wait and see. At 5 weeks, an ultrasound may show early development of a gestational sac. That’s all. The ER could draw blood for hCG levels, but even that isn’t very meaningful. hCG levels vary among healthy pregnancies, and you will only know if everything is progressing well if you retest that hCG level in 48 hours. Ultimately, there is very little else that can be done at this stage. If you were worried about miscarriage, you will have to continue to wait for reassurance. In this case, it would have been better to follow up with your regular provider instead of spending time and money at the ER.

What about pelvic rest or progesterone for preventing miscarriage?

Pelvic rest or bed rest may be a good intervention in the second or third trimester if recommended by your provider for a specific concern. Unfortunately, bed rest is not shown to be helpful during the first trimester to prevent miscarriage. Pelvic rest, however, may be beneficial. Pelvic rest means avoiding putting anything in your vagina (tampons, having sex, etc) and it may also include avoiding heavy lifting. There is limited evidence (meaning the scientific community isn’t very certain) that lifting weights greater than 200 pounds or frequent lifting of 45 pounds could increase the likelihood of miscarriage. So, if your job requires frequent lifting or occasionally lifting very heavy weights, you may need light duty or take a leave for a time. You should ask for specific recommendations from your provider.

There is little evidence supporting the use of progesterone for threatened miscarriage. Some have continued to recommend it in the first trimester, especially to those with recurrent miscarriages, as the use of progesterone is very safe. I will say, that even knowing the limited evidence, I chose to take progesterone preventatively when my provider offered it. There is very little risk, and I was desperate for anything that might help.

Are you currently going through a pregnancy after loss, and feeling nervous? Consider reading this article about how I’m coping with pregnancy after loss.

Citations:

1. Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management. Am Fam Physician. 2019 Feb 1;99(3):166-174. PMID: 30702252.
2. Linnakaari R, Helle N, Mentula M, Bloigu A, Gissler M, Heikinheimo O, Niinimäki M. Trends in the incidence, rate and treatment of miscarriage-nationwide register-study in Finland, 1998-2016. Hum Reprod. 2019 Nov 1;34(11):2120-2128. doi: 10.1093/humrep/dez211. PMID: 31747000.
3. Tenore JL. Ectopic pregnancy. Am Fam Physician. 2000 Feb 15;61(4):1080-8. PMID: 10706160.