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First trimester bleeding

Shieva Ghofrany: [00:00:00] Hi everybody. Tuesday I decided that we're gonna talk because a lot of people have been requesting the discussion about bleeding in pregnancy, but particularly first trimester. Um, so we're not really gonna talk about placenta previa or placenta abruption very much. We're gonna talk about first trimester bleeding, and the overarching theme here is it's very common. 

I never say it's normal. Like when patients say to me, I had some bleeding, is it normal? My pap response is bleeding is not normal because normal is what should happen, but it's very common and the likelihood is you're gonna be fine, but let's check it out. So one of my many isms is, it's likely nothing, but let's check it. 

with any complaint, and that includes first trimester bleeding, where it has to be evaluated. It's likely nothing, meaning nothing dangerous that's [00:01:00] going to harm you or the pregnancy, but it has to be checked out. So let's assume you've just found out you're pregnant. You don't yet know that the pregnancy is in your uterus, meaning you haven't yet had an ultrasound, so you've peed on the stick. 

You're positive pregnant. You're in that like, I'm four to five weeks pregnant. You don't yet have an appointment with your. And you spot or bleed, you should call the doctor because the likelihood is it's just a little bit of early first trimester bleeding, but the doctor needs to find out one of two things. 

One which is sad is sometimes that early bleeding or spotting is a miscarriage, but two, which is dangerous if not caught. So again, not a big deal provided we catch it is something called an ectopic pregnancy where the pregnancy can be growing outside of the uterus and. Tubes typically, and that pregnancy unfortunately can burst the tube and that can be very important and dangerous for us to know about so that we can make sure you're fine. 

So bleeding, [00:02:00] spotting early in the pregnancy before you've had an ultrasound, proving that it is intrauterine in the uterus. Please call your doctor. That's the first one, and and again, very common. Usually nothing bad, but has to be ruled out. Then let's say you've seen your doctor already, everything is okay, and you've had an ultrasound where they see the pregnancy and the uterus. 

They know that the heartbeat is there. They know you're measuring where you should be, so it's an appropriate, viable, intrauterine pregnancy. You're 8, 9, 10 weeks pregnant. You go home and one of three to four things can precipitate it. Either you had sex or you lifted something heavy or you exercised, or you had a big bowel movement, a big pooper, or you had a vaginal ultrasound, the probe that goes in your vagina. 

Any of those things might precipitate either. . Oh, right after that, I went and peed and I had a schmear of pink, or, oh my God, right after. Again, any of those things, sex, bowel movement, anything. A [00:03:00] lot of bright red bleeding, or a day or two after those things, you went to wipe and you noticed a lot of brown mucusy. 

Sticky, tacky, nasty old blood. Any of those things are very, what I call mechanical bleeding. Meaning when you go see your doctor, cuz you still should call to make sure everything's okay. And I tell patients all the time, when you have sex, when you exercise, when you have a big poop, you might notice a little bit of bleeding. 

Please call us, we'll tell you to come in and just prove everything's okay. And then we'll probably tell you to lay off sex. For a week or two just to let everything calm down. We can't tell you not to poop, and we can't tell you not to lift things that are, for example, a two year old child if you needed to. 

Um, the reason for that kind of bleeding is your cervix. Let's say this represents your cervix. That's the opening. The opening right there can either have a polyp sticking out of it or more like. It's just that the outside of the cervix is very, fryable is the term we use, meaning very delicate and filled with blood vessels from the pregnancy. 

The same mechanism that causes you to have [00:04:00] nosebleeds and gum bleeding when you're pregnant. You might notice when you brush your teeth, your gums bleed more, and that's because everything is more vascularized, more blood supply. So that cervix is fryable and anything that goes in and touches it or irritates it, or when you have a big bowel movement again, your bowel movement pushing up pushes up against the vaginal wall, which pushes up against your cervix, which then causes you to have the bleeding or spotting, so again, bleeding or spotting, precipitated by a bowel movement, exercise, sex lifting, something heavy vaginal ultrasound. 

Still get it checked out, but it is likely nothing. Another form of bleeding can be in the form of what we call S C h Subchorionic Hematoma, or some people refer to it as Subchorionic hemorrhage. I dislike the term hemorrhage because as you can imagine, it evokes, oh my God, tons of bleeding to patients when in reality it just means that underneath [00:05:00] the corion, so subchorionic hematoma, I'm gonna break those down in Latin, sub means under. 

Corion is that circle that the baby is surrounded in. So there's the chorionic S sac and the amniotic sack early on, before about 10 to 12 weeks. Those are separate. And then by 10 to 12 weeks those fuse. So when you see the amniotic sack, it's really the amnion and the corion. So subchorionic means underneath the corion. 

So imagine the baby's growing in the sack. You see the uterus with the sack. And underneath that, right in between the sac and the uterine wall, you can have some bleeding happen. Why we don't exactly know. There are different things that might precipitate it. Like just when the embryo implanted, it didn't exactly implant as well as it should have. 

So a little part of the sac starts to detach. Um, so subchorionic hematoma underneath the corion hematoma means collection of blood. Oma is collection. Is that d. No. Should you Google it? Hell no. Because when you Google it, you are [00:06:00] gonna read varying degrees, depending on the publication of risks of a miscarriage from a subchorionic hematoma. 

And the truth is this, is it possible to have a miscarriage after a subchorionic hematoma? It is. Is it likely? No. In the data I see anywhere from like 20 to 50% risk of a miscarriage with a subchorionic hematoma. And the truth is anecdotally, if you ask the majority of ob g. We will tell you, we see it all the time, meaning someone came in spotting or bleeding or even cramping, not necessarily after bowel movement or exercise or intercourse. 

We do a vaginal ultrasound and we can see a little bit of a collection of what looks like blood. You can never prove that's what it is, but it'll look like blood behind the coron. First of all, you don't always see it, so sometimes it's concealed and you can't say anything other than, look, I see the heartbeat and everything's. 

Second of all, you do sometimes see it. You can't exactly quantify it. Very skilled practitioners like our maternal fetal care doctors, and I guess more skilled OBGYN than [00:07:00] us sometimes can quantify what percentage of the corion looks like it might be disrupted. And depending on the percentage, if it's very high percentage is disrupted and it looks like the sack has really detached, then you're at more risk for a miscarriage. 

But that is not the most common. The most common situation is you see a little area, a little bit of bleeding. The patient has had some bleeding. You tell them to be restful, not because that's gonna actually stop the chance of a miscarriage because the likelihood is the miscarriage will not occur anyway. 

But because psychologically it feels better for patients to think that they have something that they can modulate. Like their physical activity, sex, exercise. There are oftentimes where unfortunately you see the Subor hematoma without any bleeding or spotting, and the reason I say unfortunately is then as the physician we're in this conundrum of what do we do with that information? 

I don't really wanna tell someone. By the way, there's a little area here and this is what might happen when I know it's gonna cause anxiety, and I know that there's a decent chance that this is just gonna [00:08:00] reabsorb and that the bleeding's never even gonna come out. Having said that, if we don't tell a patient and then they bleed, and then it turns out, They hear, oh, we kind of knew that could have happened. 

They seem to be more upset. So for the most part, I myself do tell my patients if I see it, even if they haven't had bleeding. But that is not necessarily the standard, and it is not wrong for your doctor to kind of choose not to tell you when it is something again, that is very common. That will likely not manifest in anything clinical, and there's nothing you can do. 

There's nothing really that you can do to change whether or not you're gonna bleed. Even if you bleed after activity, it doesn't mean lack of activity would've precluded the bleeding. It's just that the activity kind of precipitated it to come out sooner. Meaning, let's say you are gonna bleed. You have sex and then the bleeding comes out right away. 

The fact is you were probably gonna bleed later, but it just precipitated it come out sooner and psychologically, that's not always good, but that's why some doctors don't necessarily openly tell their patients about it. And I would advocate that that is okay, [00:09:00] depending on. You knowing your patients well and knowing who might be more anxious and who might not. 

Again, it's not what I tend to do, but that is not the right or wrong answer. Um, so again, spotting and bleeding in the first trimester is very common. It is not normal. The vast majority of time. It is nothing concerning, but it is something that you need to get checked out. A third or fourth, I forgot how many we've talked about, um, which can affect you later, is placenta previa, which is. 

If this is the inside of your cervix and your placenta inside your uterus is sitting on top of the cervical opening, that's what's called a placenta previa, meaning in front of what happens there. The most of the time. We should not even use the term placenta previa at the first trimester ultrasound because it's really a third trimester diagnosis, meaning you've gotten past 26 to 28 weeks, you're in that third trimester, your placenta is still on top of your cervix. 

Then we should call it placenta preview. Earlier than that, all we should say [00:10:00] is, oh look, the placenta sitting on top of your cervix, it's likely going to move. If we're looking at it from the side, for example, this is your placenta. As your uterus grows, the placenta is gonna grow away from where your cervix is, and so the likelihood of it staying as a placenta previa, even if you see it there at the 10 or 12 week ultrasound, not very high, and the word placenta previa is fraught with a lot of other clinical implications, like not being able to deliver vaginally, not being able to have sex, not being able to exercise. 

So again, when it is seen before 26 to 28 weeks, if you look at the guidelines and data, we shouldn't call it a placenta preview. We shouldn't stop you from sex or exercise. All of this is assuming that you're not bleeding. If you are bleeding, it is a prudent for you to be more restful. Okay? And then another reason, which is not common would be if you had a bleeding disorder. 

That either was known or had never been discovered otherwise. Those are not very common. Those are fairly rare. But if you had liver disease where your liver was unable [00:11:00] to create the right components to stop you from bleeding, that could happen. Something called bon willebrands factor deficiency, which is actually pretty common, but not a common reason for bleeding during pregnancy. 

Um, among other bleeding disorders that again, are not. All right, so that is it. I hope you are well. I hope you have a great Tuesday. Um, if you do have bleeding and spotting something important to remember that your doctor will always look at, but it's good for you to know as well that your blood type, if it's rhh negative, like a negative or B negative, or a B negative or O negative, means that you need a shot of something called ro gam. 

Actually, that's a good video. I haven't done anything about Ro gam. I'm gonna do that soon too. All right, talk to you later. Bye.