Bleeding and/or pain in early pregnancy

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.

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.aepu.org.uk/find-a-unit/
• 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.

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.

A threatened miscarriage

If 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 miscarriage

Unfortunately, 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.

An ectopic pregnancy

When 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 Ectopic pregnancy.

A molar pregnancy

A 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.

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.

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.

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.

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.