Metrorrhagia in the First Trimester of Pregnancy

Dr. Claude Allouche, Gynecologist

Ahuza Clinic, Raanana
Tel: 058 726 02 64

Introduction

Gynecological bleeding during the first trimester of pregnancy is relatively common, affecting about 25% of pregnant women. While they can often be benign, these instances always require medical evaluation to determine whether they are associated with serious complications. The course of the pregnancy largely depends on the location of the embryo (intrauterine or ectopic) and its viability.

Pregnancy and Cessation of Menstruation

The cessation of menstruation (amenorrhea) is usually the first sign of pregnancy. For most women, this cessation continues throughout the pregnancy. However, in 25% of cases, gynecological bleeding may occur during the first trimester. In most instances, these bleedings are observed during a normally evolving intrauterine pregnancy, with 93% of such pregnancies continuing to term.

In some cases, bleeding may be associated with more serious situations, such as:

• Ectopic pregnancy
• Miscarriage
• Hydatidiform mole

Causes of Bleeding in the First Trimester

1. Intrauterine Pregnancy with Bleeding

When an intrauterine pregnancy is confirmed, it is reassuring to note that, even with bleeding, the majority of pregnancies progress favorably. Typical characteristics include signs of pregnancy such as nausea, vomiting, and breast tenderness, in the absence of abdominal or pelvic pain. These vaginal bleedings are often moderate and repetitive, but they are not always a sign of imminent miscarriage.

Indicative Symptoms:

• Painless vaginal bleeding
• Absence of abdominal or pelvic pain
• Presence of pregnancy signs (vomiting, nausea, breast tenderness)

Additional Examinations:

A consultation with a gynecologist is necessary. After a clinical examination, the doctor will perform a pelvic ultrasound to assess the state of the pregnancy. This ultrasound allows measurement of the embryo and analysis of its heart activity. Four scenarios may be observed during the ultrasound:

• Early pregnancy loss: The embryo is absent, or if visible, measures more than 7 mm without heart activity.
• Uncertain evolution: The embryo is too small for its gestational age, requiring further ultrasound monitoring (7 to 14 days after the initial ultrasound).
• Presence of a hematoma between the placenta and the uterine wall or chorion, requiring ultrasound monitoring.
• Normal ultrasound: No obvious signs of anomaly, the cause of bleeding remains unknown.

Follow-up and Treatment:

Treatment will depend on ultrasound results:

• Evolving pregnancy: If the ultrasound confirms normal embryo development, no intervention is needed, but clinical and ultrasound monitoring will be implemented.
• Pregnancy loss: If the pregnancy has stopped, treatment aims to expel the fetus. Two options are available:
  • Misoprostol (oral medication)
  • Uterine aspiration (surgical treatment)

The choice of treatment is discussed with the patient, who is informed of the benefits and drawbacks of each option.

2. Ectopic Pregnancy

Ectopic pregnancy is a medical emergency in which the embryo implants outside the uterine cavity, most often in a fallopian tube. It occurs in about 2% of pregnancies and can be dangerous if not diagnosed and treated quickly.

Clinical Signs:

The main symptoms of ectopic pregnancy are:

• Delayed menstruation
• Unilateral abdominal pain (often dull with more intense episodes)
• Light vaginal bleeding, often dark in color

In some cases, symptoms may be less typical, especially if genital bleeding occurs instead of menstruation or if there is more abundant, red bleeding.

Diagnosis and Treatment:

Diagnosis relies on:

• Pelvic ultrasound (transvaginal and abdominal), which shows an empty uterine cavity and a mass in a fallopian tube.
• Beta hCG measurement, which remains elevated despite the absence of an intrauterine pregnancy.

Treatment must be administered quickly to avoid serious complications, such as rupture of the fallopian tube. It may include medical treatment or surgical intervention.

3. Miscarriage

Miscarriage is the spontaneous expulsion of the embryo or fetus before the 22nd week of amenorrhea. Early miscarriages occur before the 14th week and represent the majority of cases.

Symptoms:

• Disappearance of pregnancy signs (nausea, vomiting, breast tenderness)
• Bright red vaginal bleeding with clots or brownish tissue
• Intermittent mid-abdominal pain similar to contractions

Diagnosis and Treatment:

Diagnosis is confirmed by ultrasound, which evaluates whether the expulsion is complete or incomplete:

• Complete expulsion: No treatment is needed, but a follow-up examination is required.
• Incomplete expulsion: An intervention is necessary, with two possible options:
  • Waiting for spontaneous expulsion (1 to 2 weeks)
  • Medical treatment (misoprostol) or surgical (aspiration)

4. Hydatidiform Mole

A hydatidiform mole is a benign proliferation of trophoblastic cells, often without an embryo or with an abnormal embryo. It is rare in the West.

Symptoms:

• Gynecological bleeding
• Intense pregnancy signs (vomiting, breast tenderness)
• Uterus larger than expected for gestational age

Diagnosis and Treatment:

Ultrasound reveals a fluffy appearance of the uterus with ovarian cysts and a very high hCG level. Treatment involves aspiration of the uterine contents with follow-up of hCG levels until normalization.

What to Do in Case of Bleeding During Pregnancy?

If you experience bleeding during pregnancy, medical consultation is essential to assess the cause and severity. An evaluation, including a gynecological examination, ultrasound, and, if necessary, blood tests, will be performed.

Medical Emergencies

It is crucial to seek emergency care if you experience:

• Heavy bleeding
• Pelvic pain accompanied by bleeding
• Fever associated with bleeding

Precautions for Rh-Negative Blood Group

If you are Rh-negative, in case of bleeding during the first trimester, you will need to receive an injection of anti-D immunoglobulin to prevent maternal-fetal alloimmunization.

Source: Ameli.fr