Dr Louise Wiseman explains what causes bleeding in the late stages of pregnancy – and when to seek help.
While it does not necessarily indicate a problem with mother or baby, you should always discuss with a midwife or doctor if you have any bleeding or pain during pregnancy or feel that your baby’s movements or their pattern has changed.
Dr Louise Wiseman looks at the possible causes of bleeding or spotting during the late stages of pregnancy, and when to seek help:
What causes bleeding in late pregnancy?
A pregnant woman should always tell her doctor or midwife straight away if she has any bleeding in pregnancy.
In some cases, it might be harmless, but in others, a medical emergency, so it is important to be properly assessed to find out the cause.
Is bleeding in late stages of pregnancy normal?
The medical word for bleeding in late pregnancy is “antepartum haemorrhage”. It describes bleeding that occurs any time from 24 weeks into the pregnancy, up until the time before the birth of the baby. The bleeding can be from anywhere in the genital tract; the vagina, vulva or cervix alongside being from the womb (uterus) or pregnancy itself.
Only three to five per cent of pregnancies are affected by antepartum haemorrhage. In about a fifth of babies born very early (preterm or premature), there is some bleeding in the time before delivery.
There is a broad range of problems that come under the umbrella of bleeding during pregnancy – from fairly innocent causes of minor spotting in pregnancy to genuine bleeding. All must be checked with your antenatal team to exclude the risk of a proper obstetric emergency that must be dealt with promptly. Deaths from maternal obstetric haemorrhage are thankfully uncommon in the UK and obstetric teams are highly skilled at working together to ensure a good outcome for mother and baby. To make sure this is so, there are strong guidelines for looking after women in late pregnancy to assess the cause of any bleeding and work out what to do in the safety of a hospital environment.
What is spotting?
The Royal College of Obstetricians and Gynaecologists have clear guidelines for the healthcare profession and these explain what spotting actually is: staining, streaking or blood spotting noted on underwear or sanitary protection. This is different to haemorrhage (heavier or continued bleeding) that is graded according to how much blood is thought to be lost. The concern is that with a certain amount of blood loss, the body goes into shock as there is less blood circulating and this can compromise the mother and baby.
Of course, spotting or a small bleed may settle without any intervention with care in a hospital, but this can be a sign of further bleeding to come, so the antenatal team takes all different types of bleeding seriously.
A woman bleeding in the late stages of pregnancy should never have a vaginal examination outside a hospital, as such an examination may cause further brisk bleeding.
Causes of spotting in late pregnancy
Alongside all the many changes in your body that occur during pregnancy, the womb and cervix prepare for delivery in a very specific way. The cervix area has to become thinner and more delicate to prepare for labour. This can mean it is more likely to bleed, for example, after sex. Hormonal changes of pregnancy can make the tissue of the cervix change to form what we call an “ectropion” or “erosion”. The glandular cells which usually line the inside surface or neck of the cervix travel downwards and sit on the outside surface of the cervix.
Some women have an ectropion even when not pregnant, and it is something doctors and nurses are used to seeing at the time of having a smear when they examine you with a speculum. It is seen as a kind of “raw” area. It is thought to be caused by higher oestrogen levels and can occur when taking oral contraceptives as well as in pregnancy. This is not associated with cancer.
This area can subsequently be more delicate and more likely to bleed e.g. after sex although the spotting may not be noticed for quite a while after intercourse has taken place.
Lesions or infections in the genital tract
As is the case when not pregnant, vulval or cervical lesions can potentially cause light bleeding or spotting within pregnancy. For example, polyps can be little extra growths on the cervix that may cause light bleeding.
Any vaginal infections need to be managed carefully by your obstetric team so as not to affect the pregnancy or baby in any way.
A ‘show’ is the natural mucus plug (that has sealed the cervix closed during pregnancy) coming away. This is completely normal when labour is due. Women see this sometimes as a blob of “jelly like substance” which may be tinged pink or with a small amount of red blood or brown, older blood. This tends to signify that labour will start, although it may be hours or even days before contractions actually come. Tell your midwifery unit if you think you have had a show. If this is earlier than expected for your dates there may be specific treatment in the hospital. For example, you may be given steroid injections to help baby’s lungs mature if it is likely the baby is coming earlier than expected and before 35 weeks.