Per-vaginal bleeding* is perhaps the most worrying thing mothers-would-be can ever think of (next to abdominal pain). The mere mention of the word conjures grotesque images of miscarriage, the herald of the end of all hopes and dreams sounded by abdominal pangs. Don't stress! Miscarriage is defined as foetal** loss before 23 weeks (it depends on the source), whereas stillbirth, any loss after this. What I want to do here is to reassure all mothers-to-be that it's perfectly fine. There are multiple explanations towards this and there is no need to panic until the baby comes (I always find parenthood a little bit scary, but that's just me). Most of the time, there is nothing worth panicking about. In this article, I elaborate on the following categories:
BENIGN (things you don't need to worry too much);
RED FLAGS (things you probably should be worried).
As always, this article only intends to serve as a guide, not a definitive clinical opinion. It is aimed at mothers-to-be who are worried and wish to acquire additional information before having an appointment with the GP or obstetrician. Moreover, this article operates on the premise of 'normal pregnancies', meaning that we're assuming the foetus is okay. I don't want to complicate matters by discussing about problems such as molar pregnancies.
BENIGN
Let's start with a gross yet comforting picture.
(This picture is extracted from Wikipedia, not from a real patient) Cervical Ectropion, which shows the squamo-columnar junction of the cervix, where the 'slit' in the middle indicates the cervical os. This patient is likely to be multiparous (having undergone labour already) since the os is markedly increased in size and scope. Nulliparous patients (no experience of labour prior) are likely to have a round, smoother os.
Cervical Ectropion: This is perhaps the most comforting cause of antepartum haemorrhage (bleeding before labour; ante-: before; partum: labour; haemorrhage- bleeding***). It is also very common in pregnancy. [1] First, we have to understand what the squamo-columnar junction means. It is the junction between the columnar cells in the cervix and the stratified squamous (non-keratinised) cells in the vagina. The difference in cell type can be traced back to the mother's development in her mother's womb. The cervix and vagina originate from different primordial structures. [2] From the diagram above, patients with cervical ectropion experience a 'spillover' of such columnar cells over the junction, as indicated by the crimson patches against the background of salmon red. This is due to high levels of oestrogen during pregnancy. [3] Columnar cells are much more fragile than stratified squamous cells. If there is trauma, these columnar cells are more susceptible to damage. This leads to bleeding. For those of you who are thinking what causes the trauma - well, I have to be delicate here. You see, mothers-to-be remain people during the course of pregnancy and do have certain needs. They can be assuaged by coitus, which is in itself a form of blunt trauma, hence leading to bleeding. [4] Other forms of sexual activity, such as masturbation (with a dildo, for instance), can also result in the same effect.
This is usually very benign and requires no treatment. However, if the bleeding persists, it might mean something more sinister. It can mean higher risk of cervical cancer and its precursor, cervical intraepithelial neoplasia (CIN) since there is greater exposure to oestrogen. [5]
Infections: There are two types of infections here - sexually-transmitted infections (STIs) and urinary tract infections (UTIs). The female urethra (conductor of urine from urinary bladder to environment) is shorter than the male counterpart, thus the risk of contracting UTIs is higher. UTIs are relevant because microbes can travel from the urethra to the vaginal introitus (aka opening) relatively easily. This happens especially when high standards of personal hygiene are not perfectly maintained.
STIs can be transmitted through unprotected sexual intercourse. There are loads in this category and probably should be elucidated elsewhere. However, just to give you some background, here's a very disgusting picture to sober you up:
(Source acknowledged in the caption); Left - Gonorrhoea Cervicitis, Right - Chlamydia Cervicitis.
Gonorrhoea is the term used by lay people. In medicine, we either use the adjective 'Gonococcal' (Gonorrhoea + cocci, which refers to the morphology of the microbe), or refer to the microbe by its full name: Neisseria gonorrhoea. The species of Chlamydia we are referring to here, specifically, is Chlamydia trachomatis. There are loads of species within the genus, including Chlamydia pneumoniae, which underwhelmingly causes atypical pneumonia.
Apart from bleeding, there is also vaginal discharge and pain. If left untreated, there is a risk of migration of the microbe through the cervix. This leads to a condition called pelvic inflammatory disease (PID). Gonococcal disease is found to anchor higher risk of development. [6] Moreover, PID is a risk factor for both ectopic pregnancy and preterm labour. [7] Chlamydia infection also increases the risk of miscarriage. [8]
Miscellaneous Pathologies: There is also a giant bundle of possible pathologies. They can be related to drug use or family history. Per-vaginal bleeding can also be due to a predisposing condition - something you've got diagnosed in the past. These are usually not considered first unless something special shows up on history-taking. For instance, if you have a clotting disorder (such as von Willebrand Disease, or Haemophilia A), then excessive bleeding can be precipitated. A systemic autoimmune aetiology can also lead to bleeding (e.g. Systemic Lupus Erythematosus), due to immune attacks launched against the uterine lining or blood vessels (vasculitides, such as microscopic polyangiitis, granulomatosis with polyangiitis - but very rare in this context). These are more benign since they are either already managed by your doctor, or there are established ways to prevent them from interfering with the pregnancy too much. For example, Blood Journal has published a set of guidelines for managing pregnant women with haemophilia and von Willebrand Disease. [9]
RED FLAGS
Alright, it's always hard to start this one. There are 5 major conditions which can lead to bleeding and there can already be associated signs. Note that this is only an 'overview', since it is impossible to explain all conditions in detail.
Cancer
In medicine, we prefer the term 'malignancy' since the word 'cancer' is really quite vague. For malignancy, we can differentiate it from benign lesions that don't really cause havoc unless they grow too big. All gynaecological cancers have the potential to cause bleeding, since they invade vascular structures. Here are some warning signs of note:
- Constitutional Symptoms (non-specific, bodily symptoms) (night sweats, low-grade fever, malaise- weakness and exhaustion, anorexia - not wanting to eat, and so forth);
- Hard mass over the lower abdomen. It's not usually palpable in early cases. Pay attention to three things: blood (manifested in the forms of haematuria and rectal bleeding as well as vaginal bleeding), pressure (urinary obstruction, constipation), and pain (due to straining);
- Family History and Sexual History (HPV and HIV infections elevate the risk of cervical cancer; Ovarian cancer, endometrial cancer and breast cancer are significantly correlated with genetics, where the risk for first-degree relatives is markedly higher than the normal population); [10-12]
- Previous history of oral contraceptives (the combined type, not the one only containing progestogen);
and so forth.
If in doubt, do have an appointment with your GP or obstetrician. This section only deals with malignancies which are not directly relevant to the pregnancy. Molar pregnancies are not discussed.
The FIGO^ Staging of Cervical Cancer (extracted from https://nethealthbook.com/cancer-overview/cervical-cancer/staging-cervical-cancer/)
^international federation of gynaecology and obstetrics.
Pregnancy-Related Red Flags:
Placenta Praevia: in short, this concerns a low-lying placenta. It is not that uncommon to happen before the third trimester. However, normally, the placenta goes up as the foetus assumes a presentation known as 'cephalic vertex'. Presentation refers to the part which first presents at the maternal pelvis. Normally, the foetal head (vertex being the 'pole' of the head) is the part in question. In patients with placenta praevia, by the final few weeks before pregnancy, the placenta still lies low. This can cause very heavy bleeding if irritated. That's why vaginal exams are strongly discouraged unless this can be ruled out by the clinician. This condition can be very important in terms of delivery and subsequent medical management for the mother. For instance, corticosteroids and C-Section are recommended. [13-14]
Placenta Praevia - extracted from www.teachmeobgyn.com
Ultrasound Scan of Placenta Praevia - the clinician's preferred imaging modality of diagnosis; extracted from: https://step2.medbullets.com/obstetrics/120369/placenta-previa.
As a side note, there are two types of ultrasound relevant in obstetrics and gynaecology: transabdominal and transvaginal; the former is much more convenient (since the gel can be easily applied to the tummy and the scan can go right away). The latter provides better resolution and is more sensitive to pathologies.
Vasa Praevia: This is relatively rare- its prevalence at 0.60 per 1000 pregnancies. [15] It means that the blood vessels of the foetus run too closely to the internal cervical os - aka the exit point. They are lying too low. In this case, there is a high chance of vaginal bleeding. Moreover, the membranes may rupture prematurely, endangering the life of the foetus. The third sign is the slowing of the foetal heart. It is a very serious concern and necessitates immediate C-section and foetal resuscitation (because of the low heart rate). This is stated in the guidelines published by the Royal College of Obstetrics and Gynaecology, thus applicable in the UK only. [16] Seek help from a medical professional if in doubt (also when there is family history or previous obstetric history of this condition, since the risk is accordingly higher).
Placenta Abruption: This happens when the placenta detaches from the womb. It is another serious condition which requires immediate delivery since the placenta provides nutrients and oxygen to the foetus. Once this route is compromised, the foetus is likely to experience very severe physiological consequences, such as dropping heart rate and retarded development. This condition is sometimes tricky to diagnose because the 'obviousness' of the disease is dependent on the position of the placenta. If the placenta is higher up in the womb, the bleeding won't be vaginal. Instead, the mother presents with anaemic symptoms, including palpitations (feeling the heart going 'bop bop, bop bop'), shortness of breath (can't breathe well), dizziness and exhaustion. [17]
Placenta Abruption (extracted from Wikipedia)- the left one is called 'revealed', where it's more obvious since there is vaginal bleeding. The right one, however, is 'concealed' where the only way of perceiving it (this is crucial since the mother needs to 'feel' it before seeking medical help before the next antenatal check-up) is the development of anaemic symptoms and the decrease of foetal movement (e.g. the baby isn't as active). [18]
Uterine Rupture: This is a very significant issue, usually when contractions kick in during labour. It's a condition where all three layers of the uterine wall (endometrium, myometrium and perimetrium) are divided. A 'crack' emerges. A very grave risk factor is previous C-Section and uterine surgery - that's also the reason why mothers who got a C-Section for their last pregnancy MUST have a C-Section for subsequent pregnancies. The condition entails acute abdominal pain, heavy vaginal bleeding and injury towards the urinary bladder. [19, 20] Seek immediate medical attention if there is searing pain over the abdomen with a tearing sensation.
Uterine Rupture (Again from Wikipedia because I love the diagram); there is a similar condition called Uterine Dehiscence which basically means a pre-rupture state: the middle layer (myometrium) is rupturing, but the membranes are still intact. [21] C-Section is, as mentioned above, a huge risk factor for both.
Conclusion:
No matter what happens, don't panic. Pregnancy is a wonderful thing and although it implies the assumption of hefty parental responsibilities (my scepticism remains), it is a miracle to us all. If you ever experience vaginal bleeding before labour, rest assured - everything is likely to turn out fine if you seek medical attention promptly and follow medical advice.
*The eagle-eyed amongst you might have noticed that I used two different terms: per-vaginal bleeding and vaginal bleeding. This is only a dash of influence from my pedantic side. Per-vaginal bleeding refers to bleeding coming from the vagina. Vagina bleeding is broader and includes per-vaginal bleeding. It can also refer to bleeding from other parts of the body, e.g. the anus, which gets mistaken as vaginal bleeding (in medicine, we call this 'factitious bleeding').
**'Foetal' is the preferred lay term for everything that is related to the life-form residing within the mother's womb, in the UK, Ireland and the Commonwealth. The preferred scientific and US term is 'fetal'. The same applies to derivates such as foetus/fetus. This is not another example of Anglo-American divide. 'Fetal' is the correct historical term since it comes purely from Latin. 'Oe' usually represents an ancient Greek origin that's been adapted into Latin.
***Unrelated but I want to clarify the difference between haemorrhage and haematoma. Haemorrhage means bleeding, whereas haematoma means bleeding with clotting, so that it presents more like a solidified lesion. They are similar but also distinct.
[1] Matiluko AF. (2009). Cervical ectropion. Part 1: appraisal of a common clinical finding. Trends in Urology, Gynaecology & Sexual Health.
[2] Paxton S, Knibbs A, & Peckham M. (2020). The Leeds Histology Guide. Histology.leeds.ac.uk. Retrieved 13 November 2020, from https://www.histology.leeds.ac.uk/female/vagina.php.
[3] Wingeier M, La Marca-Ghaemmaghami P, Zimmermann R, & Ehlert U. (2015). Is salivary estriol detectable in very early pregnancy?. Psychoneuroendocrinology, 61, 53-54. https://doi.org/10.1016/j.psyneuen.2015.07.536.
[4] Tarney C, Han J. (2014). Postcoital Bleeding: A Review on Etiology, Diagnosis, and Management. Obstetrics And Gynecology International, 2014, 1-8. https://doi.org/10.1155/2014/192087.
[5] Casey P, Long M, & Marnach M. (2011). Abnormal Cervical Appearance: What to Do, When to Worry?. Mayo Clinic Proceedings, 86(2), 147-151. https://doi.org/10.4065/mcp.2010.0512.
[6] Reekie J, Donovan B, Guy R, et al. (2017). Risk of Pelvic Inflammatory Disease in Relation to Chlamydia and Gonorrhea Testing, Repeat Testing, and Positivity: A Population-Based Cohort Study. Clinical Infectious Diseases, 66(3), 437-443. https://doi.org/10.1093/cid/cix769.
[7] Huang C, Huang C, Lin S, et al. (2019). Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. PLOS ONE, 14(8), e0219351. https://doi.org/10.1371/journal.pone.0219351.
[8] Baud D. (2011). Role of Chlamydia trachomatis in Miscarriage. Emerging Infectious Diseases, 17(9), 1630-1635. https://doi.org/10.3201/eid1709.100865.
[9] Leebeek F, Duvekot J, & Kruip M. (2020). How I manage pregnancy in carriers of hemophilia and patients with von Willebrand disease. Blood, 136(19), 2143-2150. https://doi.org/10.1182/blood.2019000964.
[10] Liu G, Sharma M, Tan N, & Barnabas R. (2018). HIV-positive women have higher risk of human papilloma virus infection, precancerous lesions, and cervical cancer. AIDS, 32(6), 795-808. https://doi.org/10.1097/qad.0000000000001765.
[11] Win AK, Reece JC, Ryan S. (2015). Family history and risk of endometrial cancer: a systematic review and meta-analysis. Obstet Gynecol.125(1):89-98. doi: 10.1097/AOG.0000000000000563. PMID: 25560109.
[12] Fasching P. (2018). Breast cancer in young women: do BRCA1 or BRCA2 mutations matter?. The Lancet Oncology, 19(2), 150-151. https://doi.org/10.1016/s1470-2045(18)30008-1.
[13] Jauniaux E, Alfirevic Z, Bhide A, et al. (2018). Placenta Praevia and Placenta Accreta: Diagnosis and Management. BJOG: An International Journal Of Obstetrics & Gynaecology, 126(1), e1-e48. https://doi.org/10.1111/1471-0528.15306.
[14] Morris EP. (2010). Consent Advice No. 12: Caesarean Section for Placenta Praevia. Royal College of Obstetrics and Gynaecology. Retrieved 13 November 2020, from https://www.rcog.org.uk/globalassets/documents/guidelines/ca-12-alt_layout-1.pdf.
[15] Ruiter L, Kok N, Limpens J, et al. (2015). Incidence of and risk indicators for vasa praevia: a systematic review. BJOG: An International Journal Of Obstetrics & Gynaecology, 123(8), 1278-1287. https://doi.org/10.1111/1471-0528.13829.
[16] Jauniaux E, Alfirevic Z, Bhide A, Burton G, Collins S, & Silver R. (2018). Vasa Praevia: Diagnosis and Management. BJOG: An International Journal Of Obstetrics & Gynaecology, 126(1), e49-e61. https://doi.org/10.1111/1471-0528.15307.
[17] Varouxaki N, Gnanasambanthan S, Datta S, & Amokrane N. (2018). Antepartum haemorrhage. Obstetrics, Gynaecology & Reproductive Medicine, 28(8), 237-242. https://doi.org/10.1016/j.ogrm.2018.07.001.
[18] Winje B, Roald B, Kristensen N, & Frøen J. (2012). Placental Pathology in Pregnancies with Maternally Perceived Decreased Fetal Movement - A Population-Based Nested Case-Cohort Study. Plos ONE, 7(6), e39259. https://doi.org/10.1371/journal.pone.0039259.
[19] Raghavaiah NV, Devi AI. (1975). Bladder injury associated with rupture of the uterus. Obstet Gynecol. 46(5):573-6.
[20] Hawkins L, Robertson D, Frecker H, Berger H, & Satkunaratnam A. (2018). Spontaneous uterine rupture and surgical repair at 21 weeks gestation with progression to live birth: a case report. BMC Pregnancy And Childbirth, 18(1). https://doi.org/10.1186/s12884-018-1761-x.
[21] Pollio F, Staibano S, Mascolo M et-al. (2006). Uterine dehiscence in term pregnant patients with one previous cesarean delivery: growth factor immunoexpression and collagen content in the scarred lower uterine segment. Am. J. Obstet. Gynecol. 194 (2): 527-34.
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