About this information

This information is for you if you want to know more about bleeding and/or pain in the first 3 months of pregnancy. It may be helpful if you are a relative or friend of someone who has bleeding and/or pain in early pregnancy.

What does vaginal bleeding and pain mean for me?

Vaginal bleeding and/or cramping pain in the early stages of pregnancy are common and do not always mean that there is a problem. However, bleeding and/or pain can be a warning sign of a miscarriage or, less commonly, of other complications of early pregnancy.

What should I do if I have bleeding and/or pain in the first 3 months?

If you have any bleeding and/or pain, you can get medical help and advice from:

• your GP or midwife, who may advise you to go to hospital
• your nearest Early Pregnancy Assessment Service: details of the unit nearest to you can be found at: www.earlypregnancy.org.uk
• NHS 111: call 111 when you need medical help fast but it’s not a 999 emergency; the service is available 24 hours a day, 365 days a year, and calls are free from landlines and from mobile phones
• your nearest A&E department if you are bleeding heavily or if your pain is severe.

What will happen when I attend hospital?

You will be asked about your symptoms and the date of your last period. You will also be asked about previous pregnancies and your general health. You may need to have:

• a urine sample tested to confirm that you are pregnant
• an ultrasound scan. You may be advised to have either a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed on your abdomen) or occasionally both. A transvaginal scan may be recommended as it gives a clearer image. Neither scan increases your risk of having a miscarriage.
• a speculum and/or a vaginal examination to check the neck of the womb for any apparent cause of bleeding and/or pain.
• a test for chlamydia
• blood test(s) to check your blood group and/or the level of your pregnancy hormone (βhCG).

You should be offered a chaperone (someone to accompany you) for a vaginal examination and a transvaginal scan. You may also wish to bring someone to support you during your examination or scan.

What could be causing bleeding and/or pain at this stage of pregnancy?

A threatened miscarriageIf you have had bleeding and/or pain but your ultrasound scan confirms that your pregnancy is progressing normally, this is known as a threatened miscarriage. Many women who bleed at this stage of pregnancy go on to have a healthy baby. You may be offered a follow-up scan.

An early miscarriageUnfortunately, bleeding and/or pain in early pregnancy can mean that you have had or are having a miscarriage. Sadly, early miscarriages are common. In the first 3 months, one in five women will have a miscarriage, for no apparent reason, following a positive pregnancy test.

However, most miscarriages occur as a one-off event and there is a good chance of having a successful pregnancy in the future. For further information on miscarriage, see the RCOG patient information Early miscarriage (www.rcog.org.uk/en/patients/patient-leaflets/early-miscarriage).

An ectopic pregnancyWhen a pregnancy starts to grow outside the womb, it is called an ectopic pregnancy. In the UK, one in 90 pregnancies is ectopic. Your symptoms, scan findings and blood tests might lead to suspicion that you have an ectopic pregnancy.

An ectopic pregnancy can pose a risk to your health. If this is suspected or confirmed, you may be advised to stay in hospital. For further information, see the RCOG patient information An ectopic pregnancy (www. rcog.org.uk/en/patients/patient-leaflets/ectopic-pregnancy).

A molar pregnancyA molar pregnancy is an uncommon condition where the placenta is abnormal and the pregnancy does not develop properly. It affects only one in 700 pregnancies. A molar pregnancy is usually diagnosed when you have an ultrasound scan. For further information, see the RCOG patient information Gestational trophoblastic disease (www.rcog.org.uk/en/patients/patient-leaflets/gestational-trophoblastic-disease-gtd).

A pregnancy of unknown location (PUL)If you have a positive pregnancy test and your pregnancy cannot be seen clearly on ultrasound scan, it is known as a pregnancy of unknown location (PUL).

Reasons for this may be:

• that your pregnancy is in the womb but it is too small or too early to be seen. Modern pregnancy testing kits are extremely sensitive and can detect the pregnancy hormone just a few days after conception. However, a pregnancy may not be seen on ultrasound until approximately 3 weeks after conception (at least 5 weeks from your last period).
• that an early miscarriage has occurred, particularly if you have had bleeding that has now settled. Pregnancy tests can stay positive for a week or two after a miscarriage.
• an ectopic pregnancy that is too small to be seen. As many as one in five women with a PUL may have an ectopic pregnancy.

I have been told that I have a PUL – what happens next?

It is important that you are followed up to get a diagnosis and to confirm whether your pregnancy is continuing or not. You will be given an appointment to attend your early pregnancy unit for follow-up.

You are likely to be asked to come every 2–3 days for a blood test to check the level of your pregnancy hormone (βhCG). The results should help show where the pregnancy is developing. They will also help to guide your follow-up:

• in a normal pregnancy, βhCG levels rise significantly
• in an ectopic pregnancy, the level will usually rise slightly or stay the same
• once a miscarriage has occurred, the level will fall significantly.

You may also be booked for another ultrasound scan, usually within 1–2 weeks. If an ectopic pregnancy is suspected, a member of staff may contact you with your results and give you advice.

This uncertainty will be difficult but it often takes time to come to the right diagnosis. Sometimes this is reached within a few days but it may take up to 2 weeks. The team looking after you will discuss your options at each step.

What symptoms should I be aware of while I am being monitored?

It is important that you are aware of the signs of an ectopic pregnancy (below) and that you seek urgent medical help if you have any of them. Fortunately, most women with a PUL do not have an ectopic pregnancy.

• you will have a greater chance of a vaginal birth in future pregnancies
• your recovery is likely to be quicker, you should be able to get back to everyday activities more quickly and you should be able to drive sooner
• your stay in hospital may be shorter
• you are more likely to be able to have skin-to-skin contact with your baby immediately after birth and to be able to breastfeed successfully
• you will avoid the risks of an operation
• your baby will have less chance of initial breathing problems.

What are the disadvantages of VBAC?

Successful VBAC has fewer complications than ERCS. If you do have a successful vaginal birth:

Contact your Early Pregnancy Assessment Service or A&E department immediately if you have any of the following:

• heavy bleeding
• severe pain in your abdomen
• pain in your shoulders
• dizziness
• fainting

Key points

• Bleeding and/or pain is common in early pregnancy and does not always mean that there is a problem.
• Bleeding and/or pain in early pregnancy can sometimes be a warning sign of a miscarriage.
• If you have bleeding and/or pain in the early stages of pregnancy, you should seek medical advice.
• You may be advised to have tests including an ultrasound scan to check your pregnancy.
• If you have heavy bleeding, severe pain in your abdomen, pain in your shoulder, dizziness or fainting, you should contact your Early Pregnancy Assessment Service or nearest A&E department immediately.

Further information

Association of Early Pregnancy Units (AEPU): www.earlypregnancy.org.uk

Miscarriage Association: www.miscarriageassociation.org.uk

National Institute for Health and Care Excellence (NICE): Ectopic Pregnancy and Miscarriage: www.nice.org.uk/ guidance/cg154/ifp/chapter/About-this-information

NHS 111 service: www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/ NHS-111.aspx

Making a choice

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee. It is based on the NICE Guideline Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management, which you can find online at: www.nice.org.uk/guidance/CG154.

This leaflet was reviewed before publication by women attending clinics in Liverpool, Chester, Prescot, Wrexham and Inverness, by the RCOG Women’s Network and by the RCOG Women’s Voices Involvement Panel.

The RCOG produces guidelines as an educational aid to good clinical practice. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. This means that RCOG guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of management.

A glossary of all medical terms is available on the RCOG website at: www.rcog.org.uk/en/patients/medical-terms.