Vaginal bleeding

As many as half of all pregnant women may experience spotting or vaginal bleeding at some point during their pregnancy, especially in the first trimester. Vaginal bleeding in pregnancy has many causes — some are serious and some aren't. The significance and possible causes of bleeding are different in each trimester.

First trimester. Many women have spotting or bleeding in the first 12 weeks of pregnancy. Depending on whether it's heavy or light, how long it lasts and if it's continuous or sporadic, bleeding can indicate many things. It may be a warning sign, but it may also be due to the normal events of pregnancy.

You may notice a small amount of spotting or bleeding very early in pregnancy, about a week to 14 days after fertilization. Known as implantation bleeding, it happens when the fertilized egg first attaches to the lining of the uterus. This type of light bleeding usually doesn't last long.

Bleeding in the first trimester can also be a sign of a miscarriage. Most miscarriages take place during the first trimester, although they can occur any time during the first half of a pregnancy. But bleeding doesn't necessarily mean you're having a miscarriage — at least half the women who bleed in the first trimester don't have miscarriages.

Another problem that can cause bleeding and pain in early pregnancy is ectopic pregnancy, in which the embryo implants outside the uterus, usually in a fallopian tube. An uncommon cause of bleeding in the first trimester is molar pregnancy, a rare condition in which an abnormal mass — instead of a baby — forms inside the uterus after fertilization.

Second trimester. Although miscarriage is less common in the second trimester than in the first, a risk still exists. Vaginal bleeding is the primary sign of miscarriage.

Moderate to heavy bleeding in the second trimester may also indicate a problem with the placenta — placenta previa, in which the placenta lies too low in the uterus and partly or completely covers the uterus, or pla-cental abruption, in which the placenta begins to separate from the inner wall of the uterus before birth. Both of these conditions are more frequent in the third trimester.

If bleeding occurs between 20 and 37 weeks, it may be a sign of preterm labor.

A cervical infection, inflamed cervix or growths on the cervix also can cause vaginal bleeding. Cervical bleeding is usually not a risk to the baby, but if it's caused by cervical cancer, it's very important that the diagnosis be made promptly. Occasionally, light bleeding from the cervix may be a sign of cervical incompetence, a condition where the cervix opens spontaneously, leading to preterm delivery.

Third trimester. Vaginal bleeding in the third trimester may be a sign of a problem with the placenta. In placental abruption, the placenta begins to detach from the inner wall of the uterus. The bleeding from this condition may be scant, heavy or somewhere in between.

In placenta previa, the cervix is partly or completely blocked by the placenta, which is normally located near the top of the uterus. The main sign of placenta previa is painless vaginal bleeding, typically near the end of the second trimester or the beginning of the third. The blood from placenta previa is usually bright red and may be scant but is usually fairly heavy. The bleeding may stop on its own at some point, but it nearly always comes back days or weeks later.

Light bleeding from weeks 20 to 37 may indicate preterm labor. Bleeding in the last weeks of pregnancy may be a sign of impending labor. The mucous plug that seals the opening of the uterus during pregnancy is passed out a few weeks before or at the start of labor. The discharge may have a small amount of blood in it (see Bloody show).

When to seek medical help for vaginal bleeding

Sometimes, bleeding in pregnancy is caused by a minor condition or normal process that requires no treatment. Other times, bleeding is a sign of a serious problem. Be sure to have any bleeding during pregnancy evaluated by your health care provider. That's especially true after the first trimester.

Call your health care provider if you have slight spotting or bleeding, even if it goes away within a day. Contact him or her immediately or go to a hospital emergency room if you have:

• Any bleeding in the second or third trimester

• Moderate to heavy bleeding

• Any amount of bleeding accompanied by pain, cramping, fever, chills or contractions

You may need to be admitted to the hospital to find the cause of the bleeding. Treatment will depend on the cause.

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