Hi, Welcome back. I’m Dr. Hughey, and today I’ll review the obstetrical symptoms of vaginal bleeding, decreased fetal movement, contractions, fluid loss, headache, and that ominous catch-all, “I just don’t feel very well.”

What these all have in common, is that they are common, usually innocent, and occasionally life-threatening. The other thing they all have in common is that they are a “today” emergency…in other words, whenever you encounter any of those symptoms, they should be evaluated today, not tomorrow or next week, or at the next prenatal visit.

Vaginal Bleeding

During the first trimester, some vaginal bleeding is seen in as many as half of all pregnancies. It may take the form of bright red bleeding, dark brown discharge, or a pink smudge, but all of it is bleeding, and all of it is abnormal.

In about half the cases of vaginal bleeding during the 1st trimester, the bleeding goes away and nothing bad happens. Explanations for the bleeding might include cervicitis, vaginal or cervical trauma, or most commonly, a small separation of the placenta from its attachment to the inside of the uterus. These small separations are usually not dangerous and resolve spontaneously.

In the other half of cases of vaginal bleeding, the pregnancy will be lost. Most of these losses are from chromosome or placental abnormalities that are inherent to the pregnancy. Rarely, these losses are from other causes of miscarriage, among them trauma, infection, environmental hazards or exposure to toxic materials.
Whenever a pregnant patient in the first trimester notices vaginal bleeding, this is an issue that needs investigation today. They will need an examination, to identify the source of bleeding, and an ultrasound scan. The scan can confirm fetal viability and proper location of the pregnancy, as well as identify area of subchorionic bleeding.

Tubal ectopic pregnancy usually presents with an initial maternal complaint of vaginal bleeding, and early diagnosis and management of ectopic pregnancy is generally the safest for the mother.
Inevitable miscarriages are also best diagnosed early, to give the mother the most number of options, such as awaiting nature’s spontaneous but sometimes inconvenient and hazardous resolution. Or, intervening with a D&C to terminate the non-viable pregnancy in a controlled environment, at a time of the patient’s choosing.
Failure to evaluate vaginal bleeding during the 1st trimester may lead to life-threatening clinical surprises, such as maternal hemorrhagic shock, the need for blood transfusions, and emergency surgery.

In the second and third trimester, vaginal bleeding is usually, but not invariably due to some degree of placental abruption. Less often, it is a symptom of undiagnosed placenta previa, or bloody show associated with preterm labor. All of these are today conditions, requiring evaluation today.

Decreased Fetal Movement

Fetal movement is usually appreciated by the mother between the 16th and 20th week of pregnancy, although they will frequently note that they had been feeling the movement earlier, but they weren’t sure that was what it was.

Once fetal movements are well established during pregnancy, mothers will notice that the fetus is more active at some times and less active at other times. Many women associate late evening with considerable fetal activity, but there is much variation from fetus to fetus and in the same fetus, from day to day. The most consistent factor, however, is that every day, there is significant fetal movement.

Whenever a woman notes that the fetus is much less active than usual, this is a danger sign, and something that needs evaluation today.

Usually, such evaluation leads to reassurance that the fetus is simply less active or the mother less sensitive to the fetal movements. Often, by the time the mother arrives for her testing, and after a glucose-rich snack, the fetus is very active.

However, for a fetus who is trying to manage on less oxygen or nutrient, reducing or eliminating its’ movements is one way to conserve energy. This situation can be revealed through such tests as fetal non-stress or contraction stress testing, or biophysical profiles. Should pathologically-reduced fetal movement be detected, such interventions as blood pressure control, nutritional modification, cardiac therapy, and early delivery can be life-saving.
Some obstetricians use some form of kick-counting to objectively evaluate fetal movement. My personal favorite kick count method was to have the pregnancy woman start counting discrete fetal movements each morning. By the time she reached ten, she was done for the day. But if noontime arrived and she hadn’t felt ten movements, she was to call my office for a non-stress test that afternoon. While this was my favorite, be aware that there have not been studies demonstrating any one method of kick counting to be superior to any other. For that matter, there are no studies that show kick-counting to be superior to the mother’s subjective sense that the fetus is not moving around as much.

Because of the lack of a confirmed, reliable metric for evaluating fetal movement, I would recommend that you urgently evaluate any woman who notes the subjective decrease in fetal movement. That means today.

Preterm Contractions

Every uterus contracts, whether it is pregnant or not. Every pregnant uterus contracts, but the contractions are usually mild, infrequent, and particularly in early pregnancy, are imperceptible without special monitoring equipment.

As pregnancy advances, the normal uterine contractions become somewhat more frequent, somewhat stronger, and for some women, somewhat perceptible. For example, most women at 32 weeks of pregnancy will demonstrate an occasional contraction (That means once an hour or less) that she may or may not be aware of. For a few women, these contractions are painful and annoying, but remain infrequent. All of this is normal.

What is abnormal, is frequent (every 20 minutes or less), regular, painful contractions that persist for more than an hour or two. Women with these complaints need to be evaluated today to determine whether this is the beginning of preterm labor or not.

This determination is important for two reasons:

First, preterm labor may be an indicator of a problem facing the fetus, such as infection. These underlying problems often require treatment to achieve a happy outcome.
Second, should preterm labor be identified, it is usually possible to

delay the labor process long enough to benefit the fetus with steroid administration to accelerate maturation.

Failure to evaluate the maternal symptoms of abnormal contractions can lead to the life-threatening, unstoppable, non-remediable, premature delivery of an infant.

Leakage of Fluid from the Vagina

There are several innocent and one dangerous condition that leads to the symptom of fluid loss from the vagina. It is important that you determine which is which today.

During pregnancy, there is a normal increase in vaginal secretions, particularly close to full term. This increase in secretions may be perceived by the pregnant woman as a loss of fluid from the vagina. These secretions will not pool in the upper vagina, will have an acidic pH, and when dried will not form observable crystals on a glass slide.
During pregnancy, there is normally a considerable amount of pressure from the uterus pressing on the maternal bladder. Particularly with fetal movement, this pressure may cause some urine to be lost involuntarily. While some women will recognize this as urine loss, others will be unable to determine whether it came from the bladder or vagina. Such urine loss will not show pooling in the upper vagina, and will not show ferning. If the woman were to take a single PHENAZOPYRIDINE pill (also known as Pyridium and usually used to relieve symptoms of a urinary tract infection), within a couple hours, the bright orange-red color of the Pyridium will appear in the urine and not in the vaginal discharge.

Some vaginal infections may cause a watery vaginal discharge. Visual inspection of the vagina in these cases usually will reveal significant inflammation and purulence.

But the most dangerous of the possible causes for fluid leaking from the vagina is premature rupture of membranes. If this has occurred, it is important to evaluate the woman today for a number of reasons. If the umbilical cord has prolapsed at the time of rupture of membranes, immediate delivery by cesarean section may be life-saving. If enough amniotic fluid has been lost to result in oligohydramnios, then this lack of sufficient buffering amniotic fluid may lead to intermittent umbilical cord compression, a potentially life-threatening and injury-causing condition. While infection may be a cause of premature ruptured membranes, it can also be a result of the membrane rupture. In some cases of premature labor, the only symptom noticed by the woman is premature rupture of membranes. For all these reasons, women leaking fluid from their vaginas during pregnancy need evaluation today.

Headache

If it weren’t for pre-eclampsia, there would probably be no special significance to a mild headache occurring during pregnancy. But pre-eclampsia is an issue, and the woman may have no other presenting symptoms than headache.

Because headaches are so common, I have often recommended that a pregnant woman with a mild headache take a couple of Tylenol, lie down and rest for an hour, and then call me back with the results. Usually, the headache has gone away and I don’t worry about it.
But in the event the headache persists, or any time the headache is severe, it is important to have the woman come in today for evaluation.

Taking her blood pressure and dipsticking her urine for protein are usually enough to rule in or rule out pre-eclampsia. In the case of a sinus headache, in addition to a normal blood pressure and no proteinuria, the woman will point to her frontal or maxillary sinuses as the source of the pain. She will usually have an accompanying upper respiratory infection, and the diagnosis is uncomplicated. Another not-very-threatening cause for headache during pregnancy is a tension or stress headache. She will have pain and tenderness in the muscles involved, in addition to a normal blood pressure and urine.

A special case is the headache that is more severe than she has ever experienced in the past. These severe headaches can be associated with pre-eclampsia, but are also seen with intracranial bleeding, meningitis, and encephalitis.

Headaches that don’t resolve within an hour of simple measures, and all severe headaches, need evaluation today,

Malaise

Occasionally a pregnant woman will say, “I don’t know what’s wrong, but I just don’t feel well.”

I would recommend that you see that woman today. This is not a common complaint, but an obstetrician may hear this several times a year. In the majority of cases, there is nothing serious…the patient may be coming down with the flu, or suffer from fatigue, or depression, or have some unresolved family issues. But for some of these women, their vague symptom of malaise is the presenting complaint for such serious and potentially life-threatening problems problems as pre-eclampsia, HEELLP syndrome, intrauterine fetal demise, increasing intracranial pressure, placental abruption, chorioamnionitis, and pneumonia, to name a few.

So those are the six potentially life-threatening symptoms that require evaluation today…Bleeding, Decreased fetal movements, Preterm contractions, Loss of fluid, Persistent headache, and a vague sense of malaise.