What should I do about vaginal bleeding in early pregnancy? Early vaginal bleeding in the third trimester is one of the common clinical symptoms that 10% to 20% of mothers-to-be may encounter in early pregnancy. Vaginal bleeding is usually more likely to occur in the 4th to 10th week of pregnancy, and the vast majority of bleeding is not heavy. The embryo transfer pregnancy is a joyous event, but a small amount of vaginal bleeding scares these mothers-to-be. We need to identify the cause of bleeding through proper observation and examination, and treat and manage it in a reasonable and scientific way. During the process of embryo implantation and planting in the uterine cavity, it may be accompanied by the rupture of small blood vessels in the uterine meconium after trophoblast invasion, which is manifested as a small amount of vaginal bleeding during early pregnancy. This kind of bleeding also need not worry, it will also terminate on its own, if the amount of blood is more, you can check through the gynecological speculum to understand, doctors are generally easy to identify whether the blood is flowing from the uterine cavity, or the surface of the cervix oozing out. Of course, we should be alert to some abnormalities of pregnancy, such as ectopic pregnancy or spontaneous miscarriage, including embryonic development arrest may cause early pregnancy bleeding, which is due to congenital deficiency or incorrect location of implantation, embryo does not develop normally, HCG secretion is insufficient, and cannot produce enough progesterone by itself, the endometrium does not have the support of progesterone and estrogen in normal proportion, and the meconium peels off and bleeds. Such bleeding is often progressive and cannot be stopped. The amount of bleeding is compared to menstrual blood, and the amount of bleeding in a normal pregnancy usually does not exceed the amount of one’s usual menstrual period. What indicators do we analyze in case of bleeding? If the bleeding is minimal or a small amount, we can observe it first, without having to make a big fuss about it. If the bleeding is heavy and more than that, the doctor will usually assess the cause of the bleeding by the following tests 1.Assessment based on blood beta-HCG level HCG is mainly produced by trophoblast cells of embryo, and HCG can be detected in blood from the 7th day of fertilization, so pregnancy can be detected in advance by blood test. However, when the gestation period is <5~6 weeks, or when the blood β-HCG is <1500~2000 IU/L, the gestational sac is still too small and more difficult to find under ultrasound, therefore, in very early pregnancy, only dynamic monitoring of β-HCG levels can be used to initially assess the development of the embryo and to speculate the cause of vaginal bleeding. In normal pregnant women, serum beta-HCG levels double on average about 48 hours before the 10th week of pregnancy. If the 48-hour increase in blood beta-HCG levels is less than 66% or does not double every 72 hours, it means that this pregnancy may have a poorly developed embryo and there is a risk of miscarriage or ectopic pregnancy. The gestational weeks we mentioned are counted from the first day of the last menstrual period, or 18-20 days before embryo transfer. Note that the HCG doubling test will usually be done in the same laboratory, at the same time every other day, and before 40 days of pregnancy to be more accurate. 2.Assessment combined with serum progesterone level Before 6 weeks of pregnancy, progesterone is mainly produced by the corpus luteum in the ovary; after 6~8 weeks, it comes from the trophoblast around the corpus luteum and gestational sac of the ovary; after 8 weeks and until delivery, it basically comes from the trophoblast of the placenta; after 12 weeks, due to the formation of the placenta, progesterone is maintained at a stable level, after which the chance of spontaneous abortion decreases greatly. According to statistics if progesterone >25ng/ml, it is generally a case of well-developed embryo; if progesterone is below 5ng/ml, then there is a higher chance of miscarriage; if progesterone is between 5 and 25ng/ml, further observation is needed. Theoretically, progesterone below normal may be due to insufficient luteal function or poor development of the embryo itself. In fact, the range of normal progesterone during early pregnancy is very wide and it is difficult to say absolutely. Therefore, we need to combine your HCG and ultrasound results to determine the cause of bleeding and whether to apply progesterone. 3.Vaginal ultrasound assessment After 5~6 weeks of pregnancy, your doctor can use vaginal ultrasound to observe the possible causes of vaginal bleeding and whether the fetus is normal. Early ultrasound can help us to: (1) determine if the pregnancy is intrauterine and exclude ectopic pregnancy; (2) see if the yolk sac, fetal bud structures and fetal heartbeat can be seen in the developing intrauterine sac; (3) evaluate the possible causes of bleeding initially by the presence of submeconium blood accumulation or hematoma in the placental area. Compared with abdominal ultrasound, vaginal ultrasound can detect the placenta and fetal development earlier and determine the potential cause of early pregnancy bleeding more accurately and promptly. We sometimes encounter a few women who fail to make a clear diagnosis in time because they are overly afraid of vaginal ultrasound, and as a result, they wait until the ectopic pregnancy ruptures and bleeds profusely before coming to the hospital in an emergency, almost losing their lives. If β-HCG is >1500~2000 IU/L and the intrauterine gestational sac is not visible on vaginal ultrasound, ectopic pregnancy should be highly suspected, regardless of the presence or absence of bleeding. In women with regular menstrual cycles, the gestational sac in the uterine cavity can be observed by vaginal ultrasound at about 5 weeks of pregnancy, and after 6 weeks of pregnancy, most mothers-to-be can see their baby’s heartbeat. If there is a delay in seeing the fetal heartbeat, or if you once saw a heartbeat and then did not see it again, vaginal bleeding is a signal from the embryo to tell us that the TA has stopped growing and developing. What should I do if I have vaginal bleeding in early pregnancy? (1) If our period is delayed for a long time and there is a small amount of vaginal bleeding, unlike the usual period, we can first test the urine HCG test strip to screen for pregnancy. “If necessary, the HCG doubling test can be done. If you are not sure, you can take progesterone orally first and do ultrasound for 7~10 days of observation. (2) If the vaginal bleeding is incessant during early pregnancy and lasts for several days, and if the HCG level rises by 1500-2000 units/L, then remains flat or decreases again, a vaginal ultrasound is recommended to see if there is an intrauterine gestational sac and if there is a fetal heartbeat. If there is no germ or fetal heart in the gestational sac and no fetal heart is seen after 7 to 10 days of observation with symbolic oral progesterone, the uterus can be cleared. If there is no gestational sac in the uterus and at the same time a mass or gestational sac is seen in the fallopian tube area, the patient can be admitted to the hospital for observation or laparoscopic surgery to investigate the ectopic pregnancy. (3) If the vaginal bleeding in early pregnancy is high, close to or equal to menstruation, but the ultrasound reveals a normal intrauterine gestational sac and fetal heartbeat, it is possible to maintain adequate rest, take oral progesterone to preserve the fetus, and add a little low dose of estrogen if necessary, which is theoretically beneficial to maintain the repair of the uterine meconium and reduce and prevent bleeding. If there is a change in the fetal heartbeat and a stoppage, it means that the fetus has an irreversible bad outcome and is eliminated naturally, so there is no need for hard “preservation”. At this time, it is meaningless to use progesterone or herbal medicine blindly to protect the fetus. (4) If the vaginal bleeding is accompanied by HCG maintaining a low level of several hundred units/L and no suspicious gestational sac is seen inside or outside the uterus, conservative drug treatment can be considered, such as oral mifepristone combined with methotrexate (MTX) as a single injection or a course of 4 injections on alternate days to dynamically observe the decline of HCG. (5) After embryo transfer in IVF cycle, because of the hyperendocrine state in the body, the endometrium is not a physiological pregnancy environment, the chance of vaginal bleeding is higher, the dose of progesterone to preserve fetus is relatively large, also a little estrogen 1~2mg/day can be added to stop bleeding. If vaginal bleeding is minimal, vaginal progesterone preparations can still be used, and then switched to oral or intramuscular progesterone if vaginal discomfort is felt. Early pregnancy bleeding brings great psychological burden to the mother-to-be. Remember that scientific and reasonable treatment is the most correct attitude. There is no need to blindly keep the baby and do not take it lightly. Once you have abdominal pain and vaginal bleeding increases significantly, please go to the hospital promptly.