Bleeding During Pregnancy: When Should You Worry?

A pink trace on the toilet paper at seven weeks. A bright red stain on your underwear at thirty weeks. Either way, your heart starts racing. Bleeding during pregnancy is never normal, but what it means depends entirely on when it happens, how much there is and what comes with it.

In the first trimester it is common and often has no consequences, but it must be checked. Later on, it always calls for a prompt examination. Here is how to make sense of it, when to call 141, and what to expect once you get there.

Is bleeding during pregnancy always serious?

No, but it is always a reason to see a doctor. According to France’s national health insurance (Assurance maladie), about 25% of pregnant women bleed in the first trimester. When the ultrasound shows a pregnancy properly implanted in the womb, 93% of those who bled carry on to term. Quebec’s Mieux vivre guide gives the other side: taking all bleeding together, about half of women who bleed in early pregnancy have a miscarriage. The two figures do not contradict each other; they describe different situations, and the ultrasound is what tells them apart. After 20 weeks, bleeding affects 3 to 4% of pregnancies, according to the MSD Manual, and it must be assessed without delay.

The UK’s NHS describes three levels, which are useful for explaining what you see over the phone or at the emergency department:

• spotting: a few pink, red or brown marks;
• light bleeding: you need a pad;
• heavy bleeding: it soaks through a pad, sometimes with clots.

The bleeding can be continuous or come and go. And sometimes no cause is found, even after every test.

In the first trimester: the possible causes

The cause is often harmless, but an ectopic pregnancy must always be ruled out quickly.

Implantation bleeding is often mistaken for a period: our article on the early signs of pregnancy helps you tell the difference.

A haematoma, which the sonographer may call a “detachment”, causes a lot of anxiety. According to the Assurance maladie, it usually resolves on its own and the pregnancy generally goes well, with simple ultrasound monitoring.

Miscarriage and ectopic pregnancy each have their own article: understanding miscarriage and what comes after, and recognising an ectopic pregnancy. With the second, time matters: pain on one side of the abdomen or at the tip of the shoulder, with or without bleeding, needs to be seen at the emergency department the same day.

In the second and third trimesters: always get checked

Once the first trimester is over, any bleeding is abnormal. The Assurance maladie treats it as an emergency: you go straight to the maternity unit. Two causes dominate, and they look quite different.

Placenta praevia. The placenta is attached too low and partly or completely covers the opening of the cervix. It causes bright red, painless bleeding, which can be heavy and can recur. Its position is noted at the second-trimester scan. If you are told you have a low-lying placenta, keep the NHS figures in mind: in 9 out of 10 women concerned, the placenta has moved away from the cervix by around 32 weeks, and placenta praevia affects only about one birth in 200. The timing of these scans is set out in our article on pregnancy ultrasound scans.

Placental abruption. The placenta starts to come away from the wall of the womb. The bleeding is often light and dark, or even absent, but the pain is sudden and constant, and the abdomen becomes hard as wood. You may feel faint, have palpitations or abnormal blood pressure, out of proportion to the small amount of visible blood. This is an absolute emergency. Among the risk factors, the NHS lists high blood pressure, a blow to the abdomen and smoking.

As your due date approaches, blood-streaked mucus can come with the loss of the mucus plug (the “show”) and signal the start of labour, according to the NHS. This bleeding stays light and mixed with mucus. To know when to leave for the hospital, read our article on the signs that labour is starting. If in doubt, the maternity unit would always rather see you.

More rarely, bleeding comes from a rupture of the womb, especially after a caesarean, or from the baby’s blood vessels running across the cervix (vasa praevia). One more reason never to wait.

What will happen at the emergency department?

It starts with questions: how many weeks pregnant you are, the amount and appearance of the blood, any pain, previous pregnancies. Then come the tests, adapted to the stage of pregnancy.

In the first trimester:

• a gynaecological examination, often with a speculum;
• an ultrasound, through the abdomen or vaginally, to check that the pregnancy is in the womb and that the embryo’s heart is beating;
• a blood test if needed, in particular measuring the pregnancy hormone (hCG) when an ectopic pregnancy is possible;
• sometimes a urine test.

If the embryo is still small, the result may remain uncertain. The Assurance maladie then plans a new scan at least 7 days later, sometimes 14. This wait is hard, but it avoids jumping to conclusions.

In the second and third trimesters:

• monitoring of your pulse, blood pressure and general condition;
• fetal monitoring, a continuous recording of the baby’s heartbeat;
• an ultrasound to locate the placenta and check the baby’s wellbeing;
• a blood test, including your blood group.

The MSD Manual stresses one point: no internal vaginal examination until the ultrasound has checked where the placenta is.

What happens next depends on the cause: going home with follow-up, admission to hospital with strict rest, or delivery if the mother’s or baby’s health requires it. If you are Rhesus negative, you will be offered an injection of anti-D immunoglobulin.

In Morocco, these tests are done at the obstetric emergency department of a public hospital or at your private clinic. Find out now which nearby maternity unit is open day and night, with help from our article on choosing a maternity unit in Morocco.