Cessation of Menstruation during Pregnancy: Overview

Vaginal bleeding during pregnancy can often be frightening for women. However, such bleeding does not always indicate a serious problem. This type of bleeding occurs routinely, especially in the first 12 weeks of pregnancy. A significant proportion of women who experience bleeding during pregnancy go on to give birth to healthy babies. Despite this, women who frequently experience bleeding problems at different stages of pregnancy may need to take this situation seriously. A critical approach is important both from the gynecologist and from the pregnant woman.

When visiting a doctor, young women often ask themselves whether it is possible to be pregnant and have their period at the same time. Indeed, during pregnancy, some women experience bloody discharge, which they mistake for menstruation. There cannot be a full-fledged menstruation during pregnancy. However, bloody discharge during pregnancy is not uncommon. Its appearance indicates that there are certain failures or pathological conditions in the woman's body. This could be a hormonal imbalance, a threat of miscarriage, or even an ectopic pregnancy. Adverse outcomes of vaginal bleeding include low birth weight, preterm birth, stillbirth, and perinatal death.

The appearance of bloody vaginal discharge after conception should worry any woman. Some women confuse it with menstruation, especially if it coincides with its expected timing. However, it should be remembered that menstruation is not possible during pregnancy. The endometrium, a layer of cells that lines the inside of the uterus and comes out with blood during menstruation, helps the placenta develop during pregnancy and remains in the body. The cycle of monthly renewal of the endometrium stops during pregnancy. In case of any bloody discharge, you should consult a gynecologist.

Causes of vaginal bleeding

1. Most often, women experience bloody discharge during the first trimester. If they are just small spots on panties, this may indicate that the placenta has been implanted in the uterus. Sometimes a woman may also observe slight bleeding after intercourse, which is explained by the transformation of uterine cells that occur during pregnancy. However, there are also more serious causes of bleeding in the first trimester of pregnancy, among which are:

A. Miscarriage: Vaginal bleeding in the first 20 weeks of gestation occurs in approximately 20% of women with confirmed pregnancies; about half of these cases result in spontaneous abortion [1].

Spontaneous termination of pregnancy occurs due to internal failures that cannot be predicted in advance. If a young woman leads an unhealthy lifestyle - drinks alcohol, or other toxic substances, or does a lot of physical labor, all this can increase the risk of spontaneous abortion. Discharge will mean that the process of rejection of the embryo has begun.

B. A sharp decrease in hormone levels: A decrease in the amount of estrogen in the body of the expectant mother can occur due to stress, a viral disease, or an inflammatory process. It leads to endocrine disorders, which are expressed by the appearance of bloody discharge on the days when the woman should have had her period. This condition can last 3-4 months, it significantly increases the likelihood of miscarriage.

C. Sometimes the cause of discharge is the death of one of the embryos during a multiple pregnancy. If the pregnancy is multi-egg, that is, several eggs were fertilized, the development of other embryos can continue. However, the risk of death of other embryos in this situation is quite high.

D. Infections.

E. Subchorionic hemorrhage, which occurs between the uterus and the placenta.

F. Ectopic pregnancy.

G. Gestational trophoblastic disease: This is an extremely rare condition that can simulate pregnancy by causing a tumor to form containing abnormal fetal tissue.

H. Torsion of appendages.

Bloody discharge that occurs in the early stages of pregnancy can be distinguished from menstruation by several signs.

A. They often have a light pink or brown tint and are not particularly abundant.

B. During menstruation, women usually have a light discharge at first, which then becomes heavier and turns a deep red color.

C. Towards the end of menstruation, the intensity of vaginal bleeding decreases, and the shade of the discharge becomes less bright.

Treatment of vaginal bleeding in early pregnancy is aimed at eliminating the underlying cause of diseases:

• In case of rupture of the fallopian tube during ectopic pregnancy: immediate laparoscopy or laparotomy
• In case of ectopic pregnancy without rupture of the fallopian tube: administration of methotrexate or salpingotomy or salpingectomy laparoscopic or laparotomic access
• Threatened abortion or inevitable abortion: expectant management for hemodynamically stable patients
• Incomplete or failed abortions: dilation and curettage or evacuation of contents from the uterine cavity
• Complete abortion: obstetric observation [2].

2. Bleeding may also occur at later stages. Bleeding in late pregnancy (≥ 20 weeks gestation but before delivery) occurs in 3% - 4% of pregnancies and should be evaluated promptly because it may be associated with complications that threaten the safety of the mother or fetus. Most often it is caused by reasons such as:

The following symptoms are alarming:

• Hypotension
• Tense, painful uterus,
• Distress syndrome (absence of heartbeat, bradycardia, variable or late decelerations detected during monitoring), cessation of contractions, and absence of uterine tone [2].

Unfortunately, in practice, many young women underestimate these symptoms, believing that menstruation during pregnancy is possible, and do not worry about the discharge. They do not consult a doctor until the situation becomes critical. A timely response can save not only the unborn child but also the life of the mother. If bleeding occurs during pregnancy, a woman should contact a gynecological clinic.

There are cases when it is necessary to do this urgently. We are talking about those situations in which bloody discharge from the vagina is accompanied by pain and spasms, fainting or dizziness. Also, a pregnant woman should be alerted by heavy bleeding with clots.

The following symptoms are alarming:

• Hemodynamic instability (hypotension, tachycardia, or a combination of both)
• orthostatic changes in pulse or blood pressure;
• Fainting or near fainting
• Peritoneal symptoms ( Shchetkin-Blumberg symptom, rigidity, symptom of protection)
• Fever, chills, mucopurulent vaginal discharge [2].

Ectopic pregnancy or causes of heavy vaginal bleeding (eg, inevitable or incomplete abortion, rupture of a hemorrhagic corpus luteum cyst) can lead to hemorrhagic shock. In the early stages of examination in case of if such complications arise, it is necessary to determine the blood type and screening or blood test for compatibility and also set up I/O access [2].

The appearance of bloody vaginal discharge during pregnancy does not always mean that you can lose the baby. Therefore, with such symptoms, a pregnant woman should not panic and get upset. Many women who experience light bleeding then have a normal pregnancy and give birth to healthy children. However, in about a third of women, such bleeding becomes more intense over time and eventually leads to unfavorable consequences [3].

1. Everett C. Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. BMJ. 1997;315(7099):32-34. Available from: https://doi.org/10.1136/bmj.315.7099.32
2. Bunce EE. Wake Forest School of Medicine, Heine RP. Vaginal Bleeding During Early Pregnancy Reviewed. 2023. Available from: https://www.msdmanuals.com/ru/professional/authors/bunce-emily
3. Walfish M, Neumann A, Wlody D. Maternal haemorrhage. Br J Anaesth. 2009;103: i47-i56. Available from: https://doi.org/10.1093/bja/aep303