Bleeding in early pregnancy: spotting, warning signs and where to go in Singapore

Bleeding in early pregnancy is common, and most of the time the pregnancy carries on. SGH's early pregnancy unit says most women with bleeding or pain go on to a normal pregnancy, and KKH says the same of threatened miscarriage, where bleeding happens while the baby is still developing. Light spotting with no pain can usually be watched at home after you've told your doctor. Heavy bleeding, soaking pads, severe or one-sided tummy pain, shoulder-tip pain, feeling faint, or a fever needs a hospital the same day: in Singapore that's KKH's 24-hour Urgent O&G Centre for pregnancies under 22 weeks, or your nearest emergency department. Below are the causes, what colour and amount tell you, and which unit at KKH, SGH or NUH to go to.

Spotting or bleeding: what the colour and amount tell you

Doctors split it into spotting, a few drops or a smear when you wipe, and bleeding, a flow you need a pad for. When you call or arrive, KKH's doctors will ask about the colour of the blood, how much there is (from just a smear to soaking through pads), whether you have pain, and whether you had sex recently, so note these down before you go.

KKH explains the colour. Bright red blood is fresh bleeding. Brown blood is old blood trickling out, which is common after a bleed that has already stopped. If brown spotting turns bright red, or gets heavier, see a doctor.

It's also normal to notice more blood when you stand up after lying down. KKH says blood pools in the vagina while you lie down and drains when you get up, so a gush in the morning doesn't always mean the bleeding is getting worse.

Why you might bleed in early pregnancy

Often no cause is found. When there is one, KKH lists these as the usual reasons:

• Implantation bleeding, as the embryo settles into the womb lining around the fifth week. Cleveland Clinic describes it as light and pink or brown, about 10 to 14 days after ovulation.
• A subchorionic haematoma, a collection of blood around the pregnancy sac that a scan can show.
• Low progesterone, a hormone the pregnancy needs.
• An infection.
• A threatened miscarriage, where you bleed but the pregnancy continues.
• A miscarriage, an ectopic pregnancy outside the womb, or, rarely, a molar pregnancy, where abnormal placental tissue grows. These are the causes that need a doctor quickly.

Subchorionic haematoma

KKH names it as a cause and says it may be seen on an ultrasound scan. Singapore pages say little more, so this part leans on an NHS leaflet from Chelsea and Westminster Hospital, which calls it the most common cause of bleeding in the first trimester. Most haematomas shrink on their own and the baby is born healthy, though they can come with a slightly higher chance of miscarriage. The same leaflet says there's no evidence that bed rest helps, and to call the early pregnancy unit if you're still bleeding 14 days after the scan or the bleeding gets worse.

Implantation bleeding or a period?

Implantation bleeding is light and pink or brown. Bright red or dark red blood, heavy flow or clots are more like a period or another cause; our side-by-side guide to implantation bleeding or a period compares them. If you're not sure whether you're pregnant, take a test; our guide to a faint line on a pregnancy test explains what a pale result means.

Signs of miscarriage and ectopic pregnancy

KKH lists these signs of miscarriage: spotting or bleeding, fluid or tissue passing from the vagina, lower tummy cramps, and a dull ache in the lower back. Persistent bleeding, or bleeding with pain, may point to an underlying problem and needs checking. Many women have cramps and spotting in the first trimester with no problem at all, and some miscarriages show no symptoms and are found on a scan.

KKH says miscarriages in the first 12 weeks happen in up to one in five pregnancies, and about half are linked to a problem with the baby's chromosomes. KKH is also clear that a miscarriage is not caused by any specific food, stress, strenuous activity, work, travel, exercise or sex. Our miscarriage risk by week guide shows how the odds fall once a heartbeat is seen.

An ectopic pregnancy grows outside the womb, usually in a fallopian tube. SingHealth puts it at about five to seven in every 1,000 pregnancies. Signs are irregular or light bleeding with pain low in the tummy, often on one side, though some women have no symptoms. You're at higher risk if you've had an ectopic pregnancy before, used an IUCD or had IVF. Sudden severe pain, shoulder-tip pain, or feeling faint or dizzy can mean the tube has ruptured. That's a medical emergency.

Where to go in Singapore

Which door you walk through depends on how many weeks pregnant you are and how bad the symptoms are. These are the units on each hospital's own pages.

At the visit, expect an internal check, a scan and often blood tests. If you're more than six weeks pregnant, KKH says an ultrasound may be used to check whether the baby is alive. Very early, the pregnancy may be too small to see, and you may need a repeat scan or blood test a few days later. If your blood group is rhesus negative, such as O negative, you may be offered an anti-D injection to protect future pregnancies.

What happens with a threatened miscarriage

If the scan shows the pregnancy is still growing, your doctor will call it a threatened miscarriage. Most women in this situation go on to have a healthy pregnancy, KKH says.

KKH may test your progesterone level. Above 35 nmol/L is generally a good sign. Below that is linked with a higher chance of miscarriage, but it doesn't mean the pregnancy will end. Progesterone tablets are an option, and if you've had at least one miscarriage before, KKH says there is some evidence they may lower the risk. If you haven't, there's no strong evidence they help, though you can still choose to take them.

KKH's practical advice while you're bleeding:

• Rest if you want to, but strict bed rest doesn't prevent miscarriage and raises the risk of blood clots.
• Avoid sex until the bleeding has completely stopped.
• Avoid strenuous work while the bleeding continues.
• Go back if the bleeding becomes bright red or heavier, or the pain gets worse.

Waiting for the next scan is hard. KKH runs an emotional support service with medical social workers on 6394 1028 or 6394 1029, Monday to Friday 8.30am to 5.30pm and Saturday 8.30am to 1pm. Your prenatal check-ups and scans guide shows what the usual scan schedule looks like from here.

Frequently asked questions

Is bleeding in early pregnancy normal?

Light bleeding is common. SGH says most women who bleed in early pregnancy go on to have a normal pregnancy. Tell your doctor about any bleeding, and go to hospital straight away if it's heavy or comes with strong pain.

How much bleeding is too much in early pregnancy?

Bleeding heavier than a normal period, or enough to soak through pads, needs a hospital now. So does any bleeding with severe pain, dizziness or a fever.

What does brown spotting mean?

KKH says brown blood is old blood trickling out, while bright red blood is fresh. Brown spotting after a bleed has stopped is common. If it turns bright red or heavier, see a doctor.

Where should I go for bleeding in early pregnancy in Singapore?

Under 22 weeks, KKH's Urgent O&G Centre is open 24 hours for walk-ins. KKH and SGH also run early pregnancy units for milder bleeding, by appointment or self-referral in office hours. For heavy bleeding or severe pain, the nearest emergency department is fine.

Does bleeding mean I'm having a miscarriage?

Not usually. Many women bleed in the first trimester and carry on to a healthy birth. A scan and sometimes blood tests tell your doctor whether the pregnancy is continuing.

Should I stay in bed if I'm spotting?

You can rest if it helps you feel better, but KKH says bed rest does not prevent miscarriage and raises the risk of blood clots. Avoid sex and strenuous work until the bleeding stops.

For the weeks ahead, our early signs of pregnancy and 6 weeks pregnant guides cover what's normal in the first trimester.