Early pregnancy (early pregnancy) refers to the period before the end of the 12th week of pregnancy, during which the embryo develops rapidly. In addition to various early pregnancy reactions such as nausea, vomiting, breast tenderness, frequent urination, and mild abdominal pain, vaginal bleeding may occur during early pregnancy, ranging from brown blood, pink discharge, or red blood seen on the underwear, to menstrual blood. Vaginal bleeding may or may not be accompanied by pain in the abdomen. Usually bleeding during early pregnancy is a sign of embryonic damage. About half of the patients who bleed during early pregnancy will have a miscarriage or ectopic pregnancy and half will continue the pregnancy until delivery. The bleeding during early pregnancy may be due to an embryo implantation process that injures the small blood vessels of the uterine meconium, which can be saved; it may be an early sign of ectopic pregnancy, which should be diagnosed and treated early; or it may be preterm miscarriage, inevitable miscarriage, or embryonic abortion. The diagnosis of inevitable miscarriage can be made quickly by speculum examination, while preterm miscarriage and ectopic pregnancy may require a period of observation. In order to protect the pregnant woman and the fetus as much as possible, clinicians should identify the cause of bleeding as early as possible and deal with it promptly. Identifying the cause of bleeding during early pregnancy Bleeding during early pregnancy is not easy to identify if it occurs shortly after conception, for example, within 2 weeks of fertilization. In this period, the blood chorionic gonadotropin (HCG) and progesterone are not high, and the embryo will not be visible on ultrasound when the blood HCG is below 1500-2000 IU, so it can only be observed first. In case of implantation bleeding, it is often self-limiting and will stop on its own after some time. Three weeks after fertilization is the period of rapid development of the embryo after implantation. Bleeding during this period can be diagnosed by the following methods: 1. Opening the speculum for examination can reveal bleeding due to cervical causes, which can diagnose refractory abortion. 2. The cause of bleeding can be found by testing three indicators: blood HCG, blood progesterone and ultrasound: when the blood HCG rises above 1500 IU, the fetal sac can be found by vaginal ultrasound. When the blood HCG rises above 2000 IU, the fetal sac can be found by abdominal ultrasound. If the fetal sac is found outside or inside the uterus, the presence of ectopic pregnancy can be determined. It can be said that an ectopic sac seen on ultrasound is the gold standard for the diagnosis of ectopic pregnancy. If the sac is located in the uterus, ultrasound can also determine the location of the embryo implantation, for example, is it an angular pregnancy (which is often indicative of uterine adhesions or uterine malformations)? Is it a cesarean scar pregnancy? Is there intrauterine bleeding outside the gestational sac? Does the development of the embryo correspond to the date of menopause? All these conditions will help to clarify the cause of bleeding during early pregnancy. Early pregnancy (early pregnancy) refers to the period before the end of the 12th week of pregnancy, during which the embryo develops rapidly. In addition to various early pregnancy reactions, such as nausea, vomiting, breast tenderness, frequent urination and mild abdominal pain, vaginal bleeding may occur during early pregnancy, ranging from brown blood, pink discharge or red blood on the underwear to menstrual blood. Vaginal bleeding may or may not be accompanied by pain in the abdomen. Usually bleeding during early pregnancy is a sign of embryonic damage. About half of the patients who bleed during early pregnancy will have a miscarriage or ectopic pregnancy and half will continue the pregnancy until delivery. The bleeding during early pregnancy may be due to an embryo implantation process that injures the small blood vessels of the uterine meconium, which can be saved; it may be an early sign of ectopic pregnancy, which should be diagnosed and treated early; or it may be preterm miscarriage, inevitable miscarriage, or embryonic abortion. The diagnosis of inevitable miscarriage can be made quickly by speculum examination, while preterm miscarriage and ectopic pregnancy may require a period of observation. In order to protect the pregnant woman and the fetus as much as possible, clinicians should identify the cause of bleeding as early as possible and deal with it promptly. Identifying the cause of bleeding during early pregnancy Bleeding during early pregnancy is not easy to identify if it occurs shortly after conception, for example, within 2 weeks of fertilization. In this period, the blood chorionic gonadotropin (HCG) and progesterone are not high, and the embryo will not be visible on ultrasound when the blood HCG is below 1500-2000 IU, so it can only be observed first. In case of implantation bleeding, it is often self-limiting and will stop on its own after some time. Three weeks after fertilization is the period of rapid development of the embryo after implantation. Bleeding during this period can be diagnosed by the following methods: 1. Opening the speculum for examination can reveal bleeding due to cervical causes, which can diagnose refractory abortion. 2. The cause of bleeding can be found by testing three indicators: blood HCG, blood progesterone and ultrasound: when the blood HCG rises above 1500 IU, the fetal sac can be found by vaginal ultrasound. When the blood HCG rises above 2000 IU, the fetal sac can be found by abdominal ultrasound. If the fetal sac is found outside or inside the uterus, the presence of ectopic pregnancy can be determined. It can be said that an ectopic sac seen on ultrasound is the gold standard for the diagnosis of ectopic pregnancy. If the sac is located in the uterus, ultrasound can also determine the location of the embryo implantation, for example, is it an angular pregnancy (which is often indicative of uterine adhesions or uterine malformations)? Is it a cesarean scar pregnancy? Is there intrauterine bleeding outside the gestational sac? Does the development of the embryo correspond to the date of menopause? etc. All these conditions can help to clarify the cause of bleeding during early pregnancy. For bleeding after 3-4 weeks of fertilization, in addition to ultrasound to find the cause, the changes in blood HCG and progesterone must be monitored dynamically. Usually after 3 weeks of fertilization (i.e. more than 5 weeks from the first day of the last menstrual period), the blood HCG doubles significantly and the progesterone will be above 25ng/ml. Observing the dynamic changes in the blood indicators at this time helps to understand the cause of early pregnancy bleeding. The so-called dynamic changes should be reviewed in about 2-3 days. Normally the blood HCG should increase at least 1.66 times every 48 hours and should double every 72 hours, if it does not reach this rate, it indicates slow intrauterine development of the embryo or ectopic pregnancy. If the HCG drops rapidly in an exponential manner after vaginal bleeding, it mostly indicates that the embryo has been shed or has died. Progesterone is also a good indicator to monitor the development of the embryo: after 5-6 weeks of early pregnancy (from the first day of the last menstrual period), progesterone should reach 25ng/ml (25X3.18=79nmol/L) or more. 20ng/ml is a slightly lower level, which can be reversed if the adverse factors are corrected at this time. Progesterone below 15ng/ml is a dangerous indicator, when the trend of embryonic dysplasia is mostly irreversible. If the progesterone is below 10ng/ml, the embryo is almost impossible to save. It is also important to note that low progesterone is sometimes the cause of embryonic dysplasia, but more often it is the result of embryonic dysplasia. If there is a drop or disappearance of HCG before the location of the embryo is detected by ultrasound, it is usually a biochemical pregnancy as the saying goes. Those with biochemical pregnancy can no longer identify an ectopic or intrauterine pregnancy. In early pregnancy, there are deeper causes than implantation bleeding, preterm and inevitable miscarriage, and ectopic pregnancy, such as high blood pressure, abnormal glucose metabolism, abnormal thyroid function, abnormal coagulation mechanisms, infections, and immunologic factors. When possible, these indicators should be tested to perhaps detect the cause of abnormal embryonic development, such as high blood sugar, hypertension, hypothyroidism, etc. It is also beneficial to make purposeful adjustments before the next pregnancy Be careful to deal with For patients who bleed during early pregnancy, they should be advised to: 1. reduce their activities (it does not mean that they must always be bedridden to come); 2. watch carefully what falls out and keep flesh-like tissues for the doctor to see. 3. go to the emergency room when there is obvious abdominal pain, or bleeding more like the amount of menstruation, or dizziness, to avoid delaying resuscitation with internal bleeding of ectopic pregnancy. 4. if There are no symptoms mentioned above (abdominal pain, heavy bleeding, dizziness, etc.). Blood tests for progesterone, blood HCG and ultrasound must be done regularly, usually at least once every 3 days. HCG drops During regular blood sampling for progesterone and blood HCG, if the blood HCG drops rapidly, the embryo may have been shed and the blood HCG should be checked weekly until it is tracked to normal levels. Rising HCG If blood HCG rises slowly, monitor closely and check progesterone, blood HCG or ultrasound every 3 days or so. If an ectopic pregnancy is detected during this period, treat it quickly. If intrauterine pregnancy has been confirmed, observe the development of the embryo in the uterus. If there is bleeding in the uterine cavity outside the fetal sac, the volume of bleeding is not large and can be observed with the possibility of absorption. If the blood progesterone is below 15ng/ml, the embryo is more dangerous. If the blood HCG continues to rise slowly with less than 20% rise in 3-day interval, it also indicates that the embryo is underdeveloped. When various indicators are combined to determine that the embryo has stopped developing, embryonic abortion should be cleared as soon as possible. Progesterone: If progesterone rises slowly, progesterone can be applied to preserve the fetus. Progesterone can make the endometrium more suitable for embryo development and can inhibit uterine contraction to play the role of foetus. Progesterone can be administered orally, intramuscularly, or intravaginally. Commonly used methods: 1.Dydrogesterone tablets, 2 tablets orally in the morning and 2 tablets orally in the evening, 10mg each; 2.Progesterone pills, 2 pills orally in the morning and 2 pills orally in the evening, 100mg each; 3.Progesterone injection, 40mg each time intramuscularly once a day; 4.Progesterone extended release gel (chenoprogesterone), one vaginal tablet daily. The progesterone dose should be adjusted by intermittent progesterone check during the medication. The progesterone is a very important part of the progesterone program, and some people are worried about progesterone causing embryonic malformations, which is not based on facts. The progesterone currently used is a natural ingredient and is not different from endogenous progesterone. Progesterone is the classic method of fetal preservation and its long-term and widespread use has proven its safety and effectiveness. Some people ask if progesterone is used for ectopic pregnancy, won’t it be a problem? In fact, there is no trouble. The use of progesterone for ectopic pregnancy does not delay the diagnosis of ectopic pregnancy, nor does it increase the trouble of handling it. 2. Chinese medicine: there are ready-made medicines and tonics, which should be prescribed by Chinese medicine practitioners after identification. 3.Other: For bleeding caused by abnormal embryonic development due to hypertension, hyperglycemia and abnormal nail function, it should be corrected as much as possible, and it is better to mend than not to mend. Finally, I would like to repeat that 50% of the cases of bleeding in early pregnancy can be turned around, so don’t be too nervous. The best attitude is to take things as they come and let nature take its course.