Mailbag 29: “What does the Fox say” – With Dr. Nathan Fox

This is a transcription of a portion of a Healthful Woman podcast.

Anita’s Question

Our next question is from Anita. “My question is, is it always necessary to go to the doctor/hospital if you bleed in your first trimester? Backstory: for my first pregnancy, I had a cramp and bled on Super Bowl Sunday when I was about five weeks pregnant. Since it was Sunday, my OB sent me to the ER, and I spent the whole day there. The result was a ‘threatened miscarriage’ and a $12,000 bill. That pregnancy was otherwise uneventful, and I birthed my daughter. In my second pregnancy, I had bad cramping and some blood on a Tuesday night, and my doctor didn’t have openings on Wednesday, and has a closed office Thursday and Friday. So, again, I spent the entire day in the ER and left with a diagnosis of ‘subchorionic hematoma,’ and again, a $12,000 bill. Again, normal pregnancy and healthy boy. Listening to your podcasts, I know that both bleeding and subchorionic hematomas are common and overall uneventful. So, I’m wondering, the third time around, if I bleed, can I say I don’t want to go to the ER? God forbid it’s a miscarriage. What’s the rush anyways?”

Dr. Fox’s Response

Anita, great question. First is, maybe we’ve got to change your healthcare plan so you don’t get $12,000 bills when you go to the emergency room. That notwithstanding, this is a really interesting question.

First-trimester bleeding, in general, is not a medical emergency. Meaning, the life and health of the mother is typically not threatened when there’s first-trimester bleeding. And usually, for the pregnancy, while it might indicate an impending miscarriage, it often does not. Whether it does or does not, there’s usually little that we as doctors can do about it. There are exceptions, meaning there are people who can have hemorrhage during the first trimester, in which case it can be a medical emergency, but it’s probably pretty uncommon that we have an opportunity to intervene.

So, from a medical perspective, you are correct that people with first-trimester bleeding often do not need to be evaluated quickly. One exception is when we don’t yet know what’s going on with the pregnancy. If someone has first-trimester bleeding and hasn’t been seen in the office yet, I don’t know that they don’t have an ectopic pregnancy, which can be an emergency for the mother. But if we already know there’s a pregnancy inside the uterus, whether or not we’ve seen a heartbeat yet, and they subsequently have bleeding, I know it’s not an ectopic pregnancy.

So if we already know the pregnancy is inside the uterus, it’s generally not a situation where it’s a medical emergency to go to the emergency room. Sometimes people are just really worried, understandably. They want to know: is this pregnancy still viable? Is there a heartbeat? Am I miscarrying? It’s very anxiety-provoking to have bleeding in the first trimester, and that’s a completely reasonable thing to feel.

What to do logistically, whether to go to the ER, go to the doctor immediately, or wait a few days, depends on several factors. If we don’t know yet whether the pregnancy is inside the uterus, I’ll want to see that patient in the very near future, because there’s a possibility of an ectopic pregnancy, and that’s something you don’t want to sit on. If I already know the pregnancy is inside the uterus and there’s bleeding, it depends on the anxiety level of the mother. Generally, if she’s not bleeding heavily, I’ll give her the option to go to the emergency room, but usually encourage her to wait until the next day to see us in the office, because it typically takes less time and she usually won’t get a $12,000 bill. But sometimes it’s just too much anxiety or stress, or she isn’t able to come into the office for several days. It really has to be case by case.

If someone had bleeding where they’re not hemorrhaging, and we already know it’s not an ectopic pregnancy, you are correct that there’s nothing medically that we would typically need to do immediately. It’s case by case: when can she come in, how soon can we see her, how anxious is she, what else is going on. One other factor is blood type, since if we don’t yet know it, we need to get that within a couple of days to figure out whether she needs a RhoGAM shot.

For you, Anita, since you’ve already had children, your blood type is already known. So if we already know the pregnancy is inside the uterus and you have bleeding, you probably don’t need to go to an emergency room unless it’s really, really heavy. Some of that will depend on how soon your doctor can see you in the office and how much concern you have at the time.

Learn More on the Healthful Woman Podcast

Dr. Fox answers several other questions in this episode, including moderate alcohol use in pregnancy and where to find the studies behind it, whether pregnancy really suppresses the immune system and what that means for deli meat and listeria, what to do about a history of fast labor when you live farther from the hospital, and how to interpret a placenta pathology report with confusing findings. To learn more, listen to Mailbag 29 on the Healthful Woman podcast, produced by Maternal Fetal Medicine Associates.

Maternal Fetal Medicine blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!