Q. Do mild cramps, bleeding and lower back pain indicate miscarriage?

Answered by
Dr. Dattaprasad Balasaheb Inamdar
and medically reviewed by iCliniq medical review team.
Published on May 16, 2018 and last reviewed on: Jan 24, 2019

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.

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome to icliniq.com.

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,

  1. You can continue all the medicines you are taking. Regarding Aspirin, you need to confirm with your doctor.
  2. Addition of injection of Progesterone might possibly be of help.
  3. Though strict bed rest is not recommended, try to avoid strenuous physical activity.
  4. Only time will tell whether this pregnancy is destined to continue or not. We can be hopeful and have positive attitude towards situation. I have seen miracles happening with positive attitude.

Hi doctor, I have another question for you. I have been getting persistent crampy pain and dull ache in my lower right side. Yesterday, I have had intense cramping in that area. They felt like menstrual cramps but much more intense, unpleasant and unlike menstrual cramps or those I have had with my previous miscarriages, they were only on one side of the uterus. I could not tell precisely if it was the uterus or the ovary. However, after each cramping episode which lasted around five minutes, I have had more fresher dark red bleeding.

Finally, last night at 1 am after one more cramp I have had blood and a water-like discharge coming out. It felt a bit like urinating but I am sure it was from the vagina. I could not see whether it was a clear fluid or very watery blood, but it seemed like a lot, may be 30-40 ml. After this the left cramping gradually subsided. But, still I have a dull ache and discomfort in my lower left side. In my last week scan, the placenta looked very good. With my previous 2 miscarriages, I had organized cramps in my whole uterus that became more frequent and severe over 2 hours, then peaked for 30 minutes to unbearable intensity which made me almost faint and then stopped and I passed the whole tissue at once.

This time it was nothing like this. Just occasional intense cramping, burning pain on one side in a very specific location. For now the cramps and period-like feeling are better. There is a dull pain on the left that continues to bug me. I have an ultrasound scan appointment tomorrow. Can it be my water breaking at 9-10 weeks? Last week the gestational sac was around 34 mm minus the baby at 24 mm. I have calculated the volumes involved and there should have been around 18-20 ml but I think I got out more than that. Besides after this the cramping subsided so no miscarriage continued and I still feel pregnant. Can it be an ectopic pregnancy in my left tube? I know that at my earliest ultrasound there was a luteal cyst on my right ovary and a hemorrhagic cyst on my left. Is that possible to ovulate on both sides? Could the fluid have come from a tubal pregnancy? Or could it be an ovarian cyst breaking? Any ideas what the watery thing was?

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

All of your symptoms suggest watery discharge to be originating from gestational sac. But we can think positively and wait till tomorrow's scan. Regarding other doubts, ovarian cyst and ectopic pregnancy do not cause watery vaginal discharge. Pain of threatened miscarriage can be unilateral or bilateral; it is not going to alter diagnosis or fate of pregnancy. If you have strong doubt regarding existence of simultaneous ectopic pregnancy (also called as heterotopic pregnancy) you can ask the sonologist to look specifically for it.

Hi doctor,

I guess it is most likely to be the amniotic fluid. Is there any chance of survival or should I expect a termination? Could this be caused by a problem with the embryo even when appearing normal and having a normal heart rate? Such as a chromosomal issue, would the body expel it this late? The only hint to this would be at 7 weeks the yolk sac was measuring 6 mm which is quite large. The doctor did not measure it again at 9 weeks but it looks similar in size of 6-7 mm at most. Could it be instead related to the fact that I have an arcuate uterus seen on ultrasound? Or it would not cause this kind of miscarriage? Basically what should I do next? I have tested for thrombophilia and APS already (only heterozygous for MTHFR a18). I have been trying for almost two years and this would be my fourth miscarriage, I am just not sure I can keep this up. My uterus which was perfectly fine two years ago is now full of small diffuse fibroids. I am assuming this might be due to all the pregnancy hormones and the fertility medicines.

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

Please try to de-stress yourself and try not to think what might have happened to pregnancy. Things will be clear in tomorrow's scan and there is no need to think and worry about that right now.

Regarding your query, if amniotic fluid has completely drained out, there is very little chance of re-accumulating it and of continuing pregnancy.

  • Regarding cause, it can be genetic. May rarely be due to fibroids or adenomyosis. It depends on size, location of fibroids and whether embryo implanted on fibroid and still rare is a possibility of inadequate progesterone (very unlikely in this case).
  • Arcuate uterus definitely does not cause miscarriage and does not need treatment.
  • Regarding fate of future pregnancy, there is still a good chance of more than 50% of continuing pregnancy despite so many miscarriages. So, there is no need to get depressed. We can safely wait till tomorrow's scan result.

Hi doctor,I had a great surprise yesterday and the baby is still in with a heartbeat and growing correctly. I have not lost any amniotic fluid. However, I have many issues in my uterus that have not been detected at my scans. I have what appears to be a 3.6 cm fibroid on the left side of my uterus which is positioned exactly where that left side pain and cramping is. I am attaching a photo of it; it is in the upper image to the right. The doctor did not mention what it is but I have read online about the red degeneration and I am suspecting this is what I have. There is also a big hematoma I think subchorionic but cannot remember well, is it visible in the picture with the baby? The problem is ever since prodding and poking at the doctor's the pain on the left has become very intense (8/10) and continuous.

I have started having occasional 30 minutes contractions and cramps in the whole uterus around 6/10 and I am feeling overall extremely unwell. I have started bleeding fresh blood again and filled a large pad overnight. I could barely sleep because of the pain. The doctor recommended me to take antispasmodic (Drotaverine) but I have been taking it for a few days now and it is not helping much. Neither does Paracetamol. I have read online that when fibroids undergo red degeneration can bleed and release prostaglandins into the uterus which can cause contractions and eventually miscarriage. I have read that Ibuprofen is effective against this but there are also conflicting studies whether it causes miscarriage or not. The truth is with how increasingly horrible I am feeling I cannot imagine not ending up miscarriage. Should I take Ibuprofen, is it an option? I cannot speak to my doctor as he is out of town and I feel my situation is progressing quite quickly. I cannot get out of bed and my pain is not subsiding only increasing. Please advise me.

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

It is good to see the baby is alive and well.

Regarding fibroid, even if it is undergoing red degeneration, treatment is simply pain killers and antispasmodics. Paracetamol is the safest pain killer you can take right now. Try to avoid Ibuprofen or NSAIDs (non-steroidal anti-inflammatory drugs) as far as possible.

  • Red degeneration normally does not cause vaginal bleeding. So cause of bleeding and pain could be subchorionic hematoma. The ultrasound picture (attachment removed to protect patient identity) you have attached does not look like fibroid, but single film may not give true picture and degenerating fibroid can look differently.
  • Whatever may be the case, treatment in your case is sufficient progesterone support and adequate pain relief. Unfortunately, we cannot advise stronger pain killers, so you have to continue with maximum possible dose of Paracetamol and tolerate some pain.
  • If bleeding is too heavy or bothersome, it is better to get hospitalized.

Hi doctor,

Thank you so much for helping me with your advice. I will avoid NSAIDs as much as possible. My doctor was not sure that it was a fibroid either but could not figure out what else it might be so settled on fibroid. It was not seen on any other ultrasound (which were performed by a different specialist) so it might be a newer structure. The doctor also wondered if it was not in fact a septum and what appeared as a possible fibroid was in fact a decidualized separate chamber. From your experience does it look like anything you might recognize? Perhaps can it be an old hematoma?

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

From the pictures (attachment removed to protect patient identity), first possibility I can think is that of chorioamniotic separation or subchorionic hematoma. Second and less common possibility is that of degenerating fibroid.

  • In either case treatment remains same, which is mainly adequate progesterone support and pain relief in the form of Paracetamol tablets with or without antispasmodics. As you are taking both, it is sufficient.
  • Other medicines you can continue according to your doctor's advice, especially Aspirin tablets.
  • And one last important thing, whatever happens, just do not lose hope and always keep positive attitude.

Hi doctor, I just wanted to update you and thank you once more for your support. I am currently 13 weeks. I have continued to bleed and cramp all throughout this time. Yesterday, I had the anatomy and NT scan and everything was perfect with the baby, trisomy risk is very low and all looks normal. There is a 6x3 cm hematoma near the chorion but not affecting the placenta. I have also had some first trimester blood work done 4 days ago and these are the results that were not normal and I want to ask you about:On the coagulation panel, APTT was 20.1s (normal 23-32s). INR normal. Fibrinogen 367 (normal 180-350) and PT 10.1s (normal 10-16s). Do these results suggest a high risk to the pregnancy? Should I seek a doctor that will give me anticoagulant therapy like heparin or such? From my understanding aspirin does not affect APTT so there is no point in taking it especially since I am still bleeding, is that correct? Progesterone was at 32.3 ng/ml (which is low normal for second trimester and high normal for first trimester), although I have been taking 400 mg of progesterone daily, mostly orally since I was bleeding. Is this a normal result for my GA (I was 12w4d at the time of the test)? Should I take more progesterone like 800 mg daily and try to use it vaginally when just spotting or better ask a doctor for IM injections?

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome to icliniq.com.

It is good to know that your pregnancy is continuing (though eventfully).

  • Regarding APTT (activated partial thromboplastin time), value of APTT alone has no significance and it has to be interpreted in conjunction with INR. As you said that INR is normal, you need no treatment for APTT alone.
  • Regarding second query about progesterone supplementation, we normally prefer giving intramuscular progesterone (Injection Hydroxyprogesterone caproate 250/500 mg weekly) along with vaginal (or rarely oral, as in your case, oral is better because of vaginal bleeding) Progesterone. You can ask your doctor for that.
  • You need not worry about hematoma, as it is not affecting placenta.

Regarding decision to continue aspirin, your doctor is best judge.

Hello doctor, I am back with a new pregnancy problem and a few questions. Exactly two weeks ago I have been in hospital for two days due to severe cramps that did not stop. On the ultrasound, the hematoma was measuring 6x2.5 cm. The baby was right on track measuring 14 weeks and 1 day and with normal amniotic fluid around. Back from the hospital I continued to take Aspirin 75 mg, vaginal Progesterone 800 mg, Drotaverine (No-Spa) 240 mg/day, Paracetamol when needed, Butylscopolamine 10-30 mg/day as needed and Nifedipine 20-40 mg/day as needed. These are all medications that I was taking previous to my hospitalization as well. I was also given two new medications: 5mg Diazepam a day and Progesterone depo shots, first three of them every three days and now I will have one per week. I took these as prescribed for the last two weeks. During these two weeks I have had cramps but no bleeding until two days back. Then I started having light red-orange bleeding. I had two (relatively small) bleeds 13 hours apart and four more small bleeds around 2-4 hours apart each and then again nothing, just light orange pinkish brown bleeding when wiping. I did not consider these bleeds to be necessarily watery although the blood was not think and intensely red. It looked like lighter reddish orange blood. Yesterday at the follow-up ultrasound, the hematoma was lower near the cervical opening and smaller at 4x3 cm. The doctor told me it was on its way out and that I could expect more bleeding. However the baby although still measuring correctly at 16 weeks and with a good heartbeat, has almost no amniotic fluid left - the doctor wrote on the report oligohydramnios and that the amniotic fluid was at the low limit of normal. The baby was barely moving. I could not see any black around the baby at all on the screen but of course I am no expert, the doctor said there were some fluid pockets but small. The doctor looked at my cervix which is long at 4cm. She used the speculum and asked me to cough to see if I was losing fluid but there was nothing to suggest a leak. She gave me tests for D-dimer, Toxoplasma and Listeria to do and I am awaiting results. However, when I came back from this examination I have had a ton of watery reddish-orange-brown blood pour out of me then it stopped again and I have only had some orange brown blood when wiping this morning. My questions are what are the odds that I lost so much amniotic fluid with those bleeds that were more bloody than watery? I had some of those bleeds intermittently sometimes 10+ hours in distance. If the fetus bladder was full yesterday and full 3 weeks ago, does that ascertain that it has kidneys? And that it is peeing normally? I did not expect it kept a full bladder for 3 weeks, is that even possible? What else could have caused the fluid to drop so much in 2 weeks? Could it be the medications that I have been taking? I stopped them all after yesterday apart from Aspirin and Progesterone. I was normally drinking 2 L of water per day now I have decided to drink 3-4 L to try and increase the amniotic fluid. Is this a good idea? Should I increase or decrease my salt intake in order to help the amniotic fluid? What are the possible treatments that I can do to help with these issues - Heparin shots or amnioinfusions? My doctor wants me to have another anatomical scan before trying anything and also receive the results for D-dimer. What is your opinion of this, what is the most likely cause and what do you think I should do next? Does my baby have a chance at survival? It just seems like problems keep coming up.

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

You are really a brave person. Otherwise, it is very difficult to keep morale while having so many problems. Just keep up your morale and it will help you sail the journey of pregnancy. From the history you gave, following is my reply to your queries.

  • From your description, it appears to be leakage of amniotic fluid. As subchorionic hematoma is also draining along with fluid, it is not appearing watery, but looking rather reddish. It is not necessary for amniotic fluid to pour like water or drip, leakage can occur intermittently.
  • Fetus has full bladder essentially rules out kidney anomalies, but it does not rule out anomalies of urethra. You are right that baby will not hold urine for three weeks, plus if there is anomaly of urethra, bladder would be over distended which would be easily recognized on ultrasound.

None of the medicines you are taking normally cause severe oligohydramnios (amniotic fluid deficiency) and there is no need to discontinue them. In fact Nifedipine acts as uterine relaxant and may help in preventing miscarriage, so please do not stop on your own without your doctor's advice.

  • Drinking lots of water is a good idea and you can continue not just for oligohydramnios but for your better health too. If you are comfortable with, you can drink 3-4 liters water a day. It helps to increase amniotic fluid temporarily (but long term effect is doubtful).
  • Salt intake has little effect on amniotic fluid volume. Just continue salt intake with which you are comfortable. Once you start drinking extra water, little extra salt will obviously need to avoid hyponatremia (which normally does not occur with functioning kidneys). Normally your body adapts to the fluid intake and signals to appropriately alter salt intake. You need not alter salt intake forcefully.
  • Heparin or amnioinfusions are unlikely to help at this stage. Your doctor is right, it is better to wait for anatomical scan and D-dimer report before drawing any conclusion. None of the treatment has proven result for leakage of amniotic fluid at less than 20 weeks.

So simplest measures you can take to prevent miscarriage and treat oligohydramnios are drinking adequate water (3-4 liters should be sufficient), avoid strenuous work. Strict bed rest is normally recommended, but you can take rest as much as possible. Take adequate amount of antioxidants like fresh fruits, vegetables and dry fruits.

If you find that difficult, you can take supplements containing antioxidant vitamins, especially Vitamin C (500mg daily), Vitamin A (min. 1000IU daily) and Vitamin E (400mg daily).

Regarding prognosis, amniotic fluid leakage at <20 weeks does not have favorable prognosis. But remember one thing, that having bleeding so many times during early pregnancy, with too much pain and fibroid also was not having very favorable prognosis, and still you have pulled yourself till this stage through positive attitude, same can help you now and in future too.

Hello doctor,

I just want to update you that unfortunately I am no longer pregnant. 2 weeks after being diagnosed with oligohydramnios, I had an amnioinfusion procedure which confirmed that the membranes were indeed ruptured and I immediately lost almost all added fluid, within a few hours. After this the AFI was constantly at 0. The doctors, I have consulted 5 of them, were very adamant that I should have an induction abortion. Because chance of survival of the baby was nil and I was putting myself in danger of infection such as losing my uterus or even my life. I was not as convinced about the nil odds but given that I had no support from any doctor to continue expectant management I finally made the difficult decision to be induced. I lost my baby last Friday at 19 weeks 2 days by Misoprostol induction. I am still depressed and feel a lot of guilt about giving into the doctor's advice, even if it was likely the right thing to do. The placenta came out as well so they did not have to surgically intervene. I am currently on Ergometrine to help with cleaning the uterus. I am still bleeding bright red but small amounts and yesterday I passed 3 x 2-3 cm pieces of grayish tissue which I am assuming are leftover pieces of placenta. I have no bad cramping and I can finally walk and be out of the bed. I have few questions that I want to ask you. Are there any additional test should I get to investigate the cause of the bleeding and PPROM? I have already done thrombophilia and APS panels, ANA and the contrast MRI which showed an arcuate uterus but not a septum. Should I add any medication to my next pregnancy or stop taking any? May I have triggered this bleeding by taking a very long car trip at 7 weeks pregnant, 1-2 weeks before starting to bleed? I have been on bumpy roads for as much as 10 hours a day for 4 days and felt it as a discomfort in my uterus but did not actually bleed until a week after finishing the trip. Could the prolonged 6 week bleeding and the permanent clots cause the membranes to rupture? My cervical swab was negative for any infection or bacteria and my C-reactive protein was always <0.5 mg/L. Is it normal to pass pieces of grayish tissue after the induction abortion or should I immediately see a doctor? I know they told me the placenta was complete and if there were any small pieces I would pass them on my own but they didn't ask me to do any ultrasound follow-up. Thank you again very much for all your help. I wish I had better news. I am just so worried this horrible experience will not repeat itself and I need to understand why it happened to me so I can better prepare for it or prevent it.

Dr. Dattaprasad Balasaheb Inamdar

Infertility Obstetrics And Gynaecology
#

Hi,

Welcome back to icliniq.com.

Felt sad about your loss of pregnancy. But remember one thing that whatever had happened was in the best interest for you.

Whatever your doctors told is true with very low chance of continuing pregnancy and baby's survival with continuous severe oligohydramnios. It was not justified to put your life at risk and there is no need to regret for the decision.

Following are the answers to your queries. The investigations already done appear to be sufficient. With such history, I would have liked to do one test for syphilis.

  • I do not know how common the disease is in your country, so you can take your doctor's help whether to do it or not. Please keep in mind that syphilis is not only sexually transmitted, it can be transmitted through skin contact with a person having secondary stage syphilis.
  • The medicines you received appear more than sufficient. Regarding Baby Aspirin, in next pregnancy dose can be reduced. If it was 75 mg, it can be reduced to 50 mg. Aspirin is effective in doses between 46 mg and 310 mg.
  • Regarding Prednisolone, there is no harm in continuing Prednisolone at least till 12 weeks, but it has no proven benefit too. So your doctor can decide whether to continue it or not in next pregnancy. In my opinion, you do not need additional medicines.
  • It is not advisable to go on a very long trip on bumpy roads with such a history. There is no casual association between such a travel and abortion. But to be on safer side, you can try to avoid it in next pregnancy.

Early bleeding in pregnancy (first trimester) is associated with increased risk for preterm labor and IUGR (intrauterine growth restriction).

  • But its link with mid trimester abortion is not proven. Also, it is just an indicator of forthcoming events in pregnancy and cannot always be prevented. So, there is no need to think about that.
  • It is normal to pass bits of tissue. If there is no excessive bleeding or no fresh (bright red) bleeding, not associated with fever or foul smell to vaginal discharge, there is no need to be alarmed.
  • Normally there is no need to check completeness of placental expulsion by ultrasound. Only if you continue to bleed for more than 3 weeks, you can visit doctor again to confirm that everything is fine.

Rest of at least 3 months is advisable before attempting next pregnancy to allow your body to recuperate from abortion.

And last but not least, do not get depressed with the incident. Life should move on. Whatever happened has happened in your best interest and there should absolutely be no feeling of guilt.

Wish you good luck. I am sure you will have some good news in future.

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