Hi doctor, I am 30 years old and according to LMP, I am 9 weeks and 6 days pregnant now. I had three previous miscarriages (two chemical pregnancies and one at 5-6 weeks). This pregnancy has been really well until a few days ago. Last week I had an ultrasound and the heart rate was 173. That night, I started getting cramp pain. I had mild cramps but noticeable. Cramp intensity was around 3-4/10 at the most. I cramped every day since then and yesterday I started bleeding. At first just brown blood then increasingly heavier. I went to the doctor as soon as I started bleeding (before the clots and red blood) and the baby was fine on the ultrasound, measuring 24-25 mm (so growing) and heart rate was 179. The doctor told me that there is no problem with the placenta which had no bleeding or tears and so this is not a threatened miscarriage. There was some free blood in the uterus which he said may be from further implantation of the placenta. However, I started gushing red blood with clots after an hour with 2-3 bouts of heavy bleeding through the night. This morning it seems to be much lighter but still bleeding. I still have mild cramps, some back aches and lower abdomen side aches. Overall, I feel like I have my period, I have a sensation of inflammation in the uterus, but without the typical period cramping. All through the pregnancy I have taken the following medicine, Prenatal vitamin once a day, Baby Aspirin 75 mg once a day, PTU 50 mg, 400 mg Progesterone vaginally, 3 mg Folic Acid, 2.5-5 mg Prednisone and HCG IM injections every 4 days (5000 IU). I have few questions that my doctor did not answer me. Can this bleeding be caused by implantation? Can takeover of progesterone production by placenta cause bleeding? When does the placenta actually takeover hormone production? Do I still have a chance of keeping this pregnancy? Do the mild cramps and backaches indicate impending miscarriage or are they somewhat normal with the bleeding? If they are normal, should I take Acetaminophen for them? Should I continue to take the Aspirin given that I am bleeding? I have had the APS and thrombophilia panel tests and all are clear. Should I take the Progesterone orally now, while I am bleeding? Is it as effective? And finally, is there any possible explanation for this type of bleeding with a healthy baby with heart beat? If it was immunological (for example NK cells) would that kill the embryo instead or just start a bleeding like this? Please explain.
Hi. The symptoms you are experiencing come under category of threatened abortion. The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge or bleeding appears through a closed cervical os during the first half of pregnancy. Risk of threatened abortion progressing to abortion is substantially reduced when fetal cardiac activity is seen on ultrasound; which is true in your case and is a reassuring fact. This bleeding is not an implantation bleeding. The implantation bleeding happens between 7-10 days after ovulation when baby is burrowing in endometrium which is actually before diagnosis of pregnancy or before a woman misses her period. Placenta takes over progesterone production between 7-11 weeks. But it is just a shift in hormone production and not associated with bleeding. As described above, you have a fair chance of continuing pregnancy (if not already lost), because of heart activity seen on ultrasound. Cramps during pregnancy (unless due to bowel/bladder disturbances) are not normal and indicate threat to pregnancy. Cramps do not always indicate impending miscarriage. Acetaminophen can be taken for relief of cramps; better medicine is injection of Progesterone along with antispasmodics. Aspirin rarely aggravates bleeding and can be continued despite bleeding in most cases. Progesterone when taken orally is less effective than vaginal progesterone, only exception being Hydrogesterone which is effective orally. Normally in such cases we start injection Progesterone 100 mg intramuscularly on alternate days, but there is insufficient evidence to support and refute its effectiveness. In most cases, such bleeding happens due to chorioamniotic separation or subchorionic bleeding that is bleeding between baby and uterine wall. If cause is immunological, abortion may happen with intrauterine demise of baby or it may start with bleeding; both are possible. So, summarizing facts in your case,