The Alana Bleeding Clinic (ABC)
The Alana Bleeding Clinic (ABC)

At Alana, we offer a rapid consultation service for women who require specialist review for any obstetric or gynaecologic bleeding issue. Whether related to early pregnancy, menstruation or postmenopausal bleeding, the skilled practitioners at Alana will triage your concern, book your appointment, assess you, provide on-site ultrasonography and complete any intervention or management.  So let us take the stress from a bleeding situation and make your visit as easy as ABC….

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Introduction

Abnormal vaginal bleeding is concerning for women who suffer with this problem, whether they are pregnant or at any other time in their gynaecological life. Women who are in the early stages of pregnancy are naturally concerned about the well-being of their baby and for those women who know they are not pregnant, concerns regarding the cause of the abnormal bleeding is a considerable cause for stress.   The Alana Bleeding Clinic, has been developed to simplify and streamline the symptom of abnormal bleeding, so that you are seen quickly, diagnosed promptly and then managed efficiently to optimise your health.  The following information relates to the areas of bleeding during early pregnancy and at other times, so that you have more information to understand the problem of abnormal bleeding.

Bleeding in Early Pregnancy

Once you have become pregnant, you want the very best for your baby.  Bleeding is always concerning, but is in fact very common, with approximately 25% of women having bleeding in early pregnancy, and it is important to note that this does not necessarily mean you are going to miscarry. If you do suffer from bleeding in early pregnancy and/or have period-like pain we recommend that you seek advice and appropriate investigations.  If your GP refers you to the Alana Bleeding Clinic, we will see you (within 24 hours), will take a history and organise appropriate tests.  This may include blood tests such as your pregnancy hormone level (called a Beta HCG), your blood group and probably perform an internal pelvic ultrasound scan to determine where the pregnancy is located and to find out how the pregnancy is progressing.

The bleeding may simply be caused by the pregnancy nestling into the lining of your uterus, but if it is more heavy and ongoing it may represent a miscarriage. We will be able to provide you with advice and direction as to the best management and a range of options for your care.  These options may include one or more of the following:

Reassurance that the pregnancy is located inside the uterus. The pregnancy itself may be very early and therefore whether it is going to be a progressive pregnancy may not be able to be confirmed. In this setting, close observation and a repeat ultrasound will be organised in 1-2 weeks. You will need to monitor your bleeding and contact us if you have any concerns in the interim.

In 2-3% of women with bleeding and pain, the pregnancy may be located outside the uterus. This is called an ectopic pregnancy. Risk factors for an ectopic pregnancy include:

  • Previous infections in the pelvic (sexually transmitted infections like Chlamydia)
  • A previous ectopic pregnancy
  • Smoking
  • Younger (less than 20) or older (more than 40) age
  • Any previous damage or surgery to the tubes, pelvis or abdomen
  • Endometriosis,
  • A current intrauterine device (it is important to note that if you have an intrauterine device you are NOT more likely to have an ectopic than other women, but if you happen to become pregnant with the IUD in place, then the pregnancy is more likely to be an ectopic).

Most ectopic pregnancies occur in women without any risk factors and they may be a serious risk to your health, since if they rupture (burst), this may result in life-threatening bleeding. If you experience any shoulder tip pain, feel lightheaded, have passed out, or have extreme abdominal pain you should present to the Emergency Department of your nearest hospital for immediate assessment. When you experience these symptoms the ectopic pregnancy may have ruptured which causes bleeding from the fallopian tube. This requires urgent surgery to remove the ectopic pregnancy and therefore stopping the bleeding.

An ectopic pregnancy may be diagnosed when the pregnancy hormone is positive and the ultrasound reveals an empty uterus. If an ectopic pregnancy is indeed diagnosed, the option is to have a laparoscopy and removal of the ectopic pregnancy or medical management with methotrexate. Both treatment options have their own advantages and disadvantages and these are discussed in the associated information link on ectopic pregnancy. We will discuss these options with you if required.

Pregnancy of unknown location (PUL). This means that you are pregnant, as the pregnancy hormone (HGC) is positive but that the ultrasound is unable to detect its location. This may mean that the pregnancy is in a very early stage and is developing within the uterus, and will go on to develop into a normal pregnancy.  It is not possible to know if there is likely to be a variant of pregnancy such as miscarriage or ectopic pregnancy at this time. In there is a PUL, then we will need to follow you with both the HCG level and ultrasound.

Miscarriage. This means that unfortunately the pregnancy has failed to develop and has stopped growing. We will be able to diagnose a miscarriage if there is no heartbeat detected once the baby is beyond a certain measurement on ultrasound or if there has not ben proper formation of the baby from the outset. Most miscarriages occur due to a significant chromosomal problem. Since these major problems are not compatible with life, these are identified early and result in miscarriage usually prior to 12 weeks.

In the unfortunate circumstance that the pregnancy is not going to progress due to a miscarriage we will discuss management options, which include a careful ‘watch and wait approach’ to see if the pregnancy naturally expels itself – this is more likely in certain situations and less likely in others, treatment with medications to facilitate the process more rapidly or a simple surgical procedure called a “D&C”. This stands for a dilatation and curettage and is performed in theatre as a day procedure. We will help you decide which treatment option may be most suitable.

Abnormal Uterine Bleeding when not pregnant

Abnormal bleeding for a woman when she is not pregnant may be just as worrying as bleeding during pregnancy.  During the menstrual cycle the lining of the uterus called the endometrium is building up in preparation for a pregnancy, and if this does not occur this lining is being shed during your “period”. The amount of bleeding is usually small – less than 5 tablespoons (or 50ml) and bleeding more than this may cause anaemia or be a sign of other gynaecological or general health conditions. If bleeding occurs in between periods or is excessive (an easy way to assess this is the number of pads or tampons that you need to change during a cycle and if this is more than every second hour, you should talk to your GP about this as it may be a problem), this is considered abnormal uterine bleeding. If a woman has reached the menopause and has not had a period for more than 2 years, then any bleeding that occurs after this time is considered abnormal and requires an assessment.

Women are often concerned about what is causing their bleeding and most causes are simple, and not related to conditions such as cancer, although it is important to perform the appropriate tests to exclude these uncommon but important causes of abnormal bleeding.  Polyps, fibroids , changes in the cervix and a change in a woman’s hormonal responsiveness are more common causes of abnormal bleeding and are more easily treated.

There are many conditions that cause abnormal uterine bleeding.  If your bleeding is unusually heavy – for example you are changing a pad every 20 minutes, feel dizzy or faint, we recommend that you present to your nearest Hospital emergency department for immediate assessment.

At the Alana Bleeding Clinic we see women with abnormal bleeding who require assessment by a gynaecologist within the same week. Our consultation will include a detailed history, physical examination, pelvic ultrasound scan and any blood tests that are necessary. In suspected abnormalities involving the lining of the uterus (the endometrium) a biopsy is necessary. This biopsy will be obtained with a simple procedure called a hysteroscopy and targeted biopsy.

Frequently Asked Questions

Why do I have spotting or mild bleeding in early pregnancy?

It is common to have some bleeding in early pregnancy.  It may occur in 20% (or one out of five) mums to be, and it is unlikely to be harmful to your baby.  It usually happens at about the same time that your period would have been due, and may last for a couple of days.  The bleeding is usually light (no large clots) and is not accompanied by strong period pains.

There are many different causes for bleeding in pregnancy, and in the first trimester the bleeding may be caused by:

  • Breakthrough bleeding: which happens as the pregnancy hormones interfere with the hormones of your normal menstrual cycle.  This causes some the endometrial lining to be shed.  Spotting or light bleeding may come and go for several days.
  • Implantation bleeding:  which happens when the fertilised egg implants in the endometrial lining of the uterus. The endometrial lining has been prepared for the nestling of the fertilised egg during the menstrual cycle and has now got a very good blood supply.  The implantation may therefore be associated with some light bleeding.
  • Other causes:  which may include changes to your cervix by the pregnancy hormones; it softens the cervix and causes an area of cells covering the cervix to move towards the outside of the cervix.  These cells are more prone to bleeding, especially when touched during intercourse.  It is important to be up to date with your Pap smear screening tests as bleeding may also be caused by abnormal cells.  Bleeding can also be linked to vaginal or cervical infection which would require further investigation with a vaginal swab and may need treatment.  A harmless growth on the cervix called a polyp may also cause bleeding at any stage in the pregnancy.  A speculum examination (as is done with the Pap smear) will reveal this polyp, and usually nothing needs to be done about it during your pregnancy.

Bleeding in early pregnancy is common but it’s important to tell your doctor about it.  At Alana we will perform a physical examination which may include a speculum examination to see if the cervix is open or not and what the cervix looks like in general.  Depending on other symptoms we may take a vaginal swab if we think there is an infection.  We may also perform an (internal) ultrasound to measure the gestation and to determine where the pregnancy is located.

We would recommend testing your pregnancy hormone level (“quantitated HCG”) which also helps in dating the pregnancy, and we would test your blood group.

In general if the bleeding is light and settles down, and is not accompanied by bad period type pains, there is a good chance that all is well and that your baby is fine.

I  thought I was 7 weeks pregnant but the scan says I’m only 5 weeks and no heartbeat is seen, how is this possible?

To answer this question we firstly go back to basics to understand your cycle.

The pregnancy is calculated based on the average menstrual cycle which is 28 days.  The first day of menstrual bleeding marks the first day of the menstrual cycle.  This is called your LMP (or “last menstrual period”).  Right in the middle of this picture perfect 28 day cycle is when ovulation occurs (day 14 of the cycle) and roughly 2 days before and after is when you are most fertile.  In real life not everyone has this picture perfect 28 day cycle, it may be longer or shorter, but we know that ovulation occurs roughly 14 day before your next period.  This is why many fertility doctors recommend to have intercourse every 3 days if you really are trying to have a baby because the ovulation may occur a little earlier or later than you may think.

When calculating the weeks of pregnancy we include those two weeks from the first day of the LMP as this is the easiest part of the cycle to notice and to record.  We also will enquire about the length of your cycle and whether it is regular or irregular.  All of this is helpful in trying to establish the gestation.  For example, if your cycle is regular and 33 days long we would expect your ovulation to have occurred later (5 days) and an early pregnancy scan will most likely show a baby that measures 5 days less than you were expecting.

Now to answer your question, it may be that you ovulated later in the cycle or have a longer cycle.  The pregnancy is truly only 5 weeks, a follow up ultrasound in 10-14 days is likely to show your baby’s heartbeat and all is well.  The other possibility is that unfortunately the pregnancy is not developing as expected at 7 weeks gestation and a follow up scan may reveal a miscarriage.  We understand that this is an anxious time and to have to wait for 10 -14 days seems very long but it is important to have this time in between scans to determine accurately what is taking place.

How long do I have to wait after my miscarriage to try to conceive again?

We recommend you have at least one normal period after your miscarriage.  If the first bleed is not quiet as normal than wait until you have a normal menstrual period in your next cycle as it takes time for your body to clear the pregnancy hormone.  When you have had a normal period we know your cycle has returned to normal, the pregnancy hormone is out of your system and that your body is ready for a new pregnancy.  Record the first day of your menstrual period (LMP) as this is important in dating your next pregnancy. Physically you do not need more than one period but allow yourself enough time to emotionally be ready as well.  Some time is also necessary to allow yourself to grieve about your pregnancy loss.

We find that most women after a miscarriage are a little more anxious in their next pregnancy.  Your GP can refer you to Alana for an early pregnancy scan and we recommend it to be done at around 8 weeks from your LMP as at this stage you should really be able to see your baby’s heartbeat.

What are my chances of falling pregnant after an ectopic pregnancy?

It depends on a few things really as some ectopic pregnancies are caused by certain conditions like endometriosis or as a result of previous pelvic inflammatory disease (PID) commonly caused by Chlamydia infection.  In these conditions the remaining fallopian tube may be scarred as well and increase the likelihood of another ectopic pregnancy.  In general, the risk of recurrence is up to 8-10% after one ectopic pregnancy.  The recurrence risk is of course dependent on whether or not you have any underlying conditions.  Many women (and doctors) think that the ovaries are taking turns in releasing an egg (left than right etc.) but this is not true.  The other commonly held belief is that, for example, the right fallopian tube only can pick up the egg released from the right ovary, which is not true either.  We know that in reality the ovaries are located rather close to each other (not like in the anatomy pictures), and ovulation occurs more “randomly” from each ovary (sometimes at the same time!) and that the fallopian tubes can pick up the egg from the ovary on the other side.  This is because of a complex process attracting the fallopian tube to move towards the ovary where the ovulation (release of the egg) has occurred.

Therefore a previous ectopic pregnancy doesn’t half your chances of a next pregnancy.  Research has shown that around 65% of women with a previous ectopic pregnancy have an intrauterine pregnancy within 18 months.  This figure may go up to as high as 80% in two years, so that is promising.  If you do fall pregnant it is important to have an early pregnancy scan determining the location of the pregnancy, making sure it is inside the uterus.

If you have trouble falling pregnant than depending of your age and underlying conditions we would recommend you to see one of our Alana specialists as the other fallopian tube may be scarred and preventing you from conceiving naturally. There is an ultrasound test called a HyCoSy (“Hysterosalpingo Contrast Sonography”) which can determine whether your other fallopian tube is functioning normally.  During this ultrasound investigation a speculum is inserted to allow a thin plastic tube to be placed inside the uterus.  Through this tube a mixture of air and normal saline is injected and this shows up on the ultrasound scan.  You can see if the fallopian tube is open (“patent”) as there is spill seen around the end of the fallopian tube and ovary.  This test may reassure you if normal.  If the fallopian tube is blocked it is worthwhile seeing our fertility specialist at Alana (Dr Alejandra zurieta), she will discuss alternative ways for a pregnancy to occur (like IVF).

Related Information:

Recurrent Miscarriage

Early Pregnancy Care